Psychosomatic diseases - myocardial infarction

Myocardial infarction
English name: myocardial infarction

As a result of acute coronary occlusion, blood flow interruption, causing serious and lasting ischemic myocardial necrosis. Clinical manifestation was sudden, dramatic and long-lasting retrosternal pain, the characteristics of the dynamic evolution of ECG and serum enzymes increased, can occur arrhythmia, heart failure, shock and other complications, often life-threatening. The most common disease in Europe and America in the United States about 150 million people each year occurred in myocardial infarction. China in the world is a low-incidence areas, but there is an upward trend in recent years.
The etiology and pathogenesis of myocardial infarction more than 90% was due to coronary atherosclerosis based on the thrombosis caused by less in the coronary artery spasm, a small number from the embolization, inflammation, and other deformities caused by occlusion of the lumen narrow, so that serious and myocardial ischemia lasting up to 1 hour or more to the occurrence of myocardial necrosis. Myocardial infarction often occurred in a number of incentives, including fatigue, agitation, bleeding, shock, dehydration, surgery or serious arrhythmia, such as.
Pathophysiology of coronary occlusion of 20 to 30 minutes later, that is, its blood supply due to severe myocardial ischemia and necrosis, known as acute myocardial infarction. Chunks of myocardial infarction involving the ventricular wall as the full-thickness transmural myocardial infarction, such as involving only the inner heart wall, less than half of ventricular wall thickness, known as subendocardial myocardial infarction. The role of intraluminal pressure in mind, the necrosis of the heart wall bulging out, can produce myocardial rupture, or the gradual expansion of the formation of tumor wall. Necrotic tissue of about 1 ~ 2 weeks after the beginning of the absorption and gradually fibrosis, 6 to 8 weeks to heal and scar formation, known as the old myocardial infarction. Pathophysiological changes and the site of infarction, extent and scope of closely related, can cause varying degrees of cardiac dysfunction and hemodynamic changes. Including a reduction in myocardial contractility, reduce compliance, uncoordinated myocardial contraction, left ventricular end-diastolic pressure increased, decreased cardiac output, blood pressure decreased faster rhythm or arrhythmia, the heart of the expansion can lead to heart failure and cardiogenic shock .
More than half of some clinical manifestations of acute myocardial infarction patients, in the onset before the 1 ~ 2 days or 1 ~ 2 weeks are premonitory symptoms, the most common are the original stable angina to unstable angina, or following to without angina, the sudden appearance of long angina. Pain typical of myocardial infarction symptoms include sudden onset of severe and lasting pain substernal squeeze, with rest and nitroglycerin can not be alleviated, often accompanied by irritability, sweating, a sense of fear or dying; a small number of patients had no pain, that is the beginning of the performance of to shock or acute heart failure; some patients is located in upper abdominal pain, be mistaken for gastric perforation, acute pancreatitis, such as acute abdomen, stroke-like episodes can be seen in older patients. Systemic symptoms: fever, elevated leukocyte, erythrocyte sedimentation rate faster; gastrointestinal tract symptoms: more common in patients with inferior wall infarction; arrhythmia: at 75% ~ 95% of patients, occurred in the onset of 1 to 2 weeks, and to 24 hours within the common, anterior myocardial infarction prone to ventricular arrhythmia, myocardial infarction-prone AVB; heart failure: The principal objective is acute left ventricular failure, in the onset occurred within the first few hours, the occurrence rate of 32% ~ 48%, expressed as difficulty in breathing, coughing, cyanosis, irritability and other symptoms.
Signs of heart may be light to moderate sector increased faster or slower heart rate, heart sounds weakened, may be the fourth or third phonocardiogram phonocardiogram, 10% ~ 20% of patients in the incidence of 2 to 3 days prompted apical systolic murmur papillary muscle dysfunction, but except for ventricular septal perforation, pericardial friction at this time there is often accompanied by the sound, if combined with heart failure and shock corresponding signs will appear.
Common laboratory tests the following: ① electrocardiogram. Myocardial infarction typical characteristic electrocardiogram changes in a few hours in the onset high Tsim T wave; a few hours later, ST elevation was Camponotus up with T-wave form of one-way curve; 1 ~ 2 days appeared pathological Q wave , 70% ~ 80% Q wave Yongcun; within two weeks, such as ST segment gradually return to potential, T-wave flat or inverted, upside down three weeks the most, and sometimes were coronary T-wave, a few months or years gradually restored, can also be permanent存在. According to the lead electrocardiogram changes can be judged, the site of infarction. ② serum enzymes. Content increased, including creatine phosphokinase and its isoenzyme, lactate dehydrogenase and aspartate aminotransferase. Interleukin after the onset may be increased to 1 ~ 20,000 / mm3, erythrocyte sedimentation rate faster sustainable 1 ~ 3 weeks. ③ check radionuclides. The use of myocardial necrosis and the blood supply cut off 201 thallium myocardial cells can not enter the characteristics of intravenous 20 1 thallium scan for hot spots or photographs, to show the site of myocardial infarction and scope.
Diagnosis and differential diagnosis according to typical clinical manifestations, characteristic electrocardiogram and serum enzymes evolve dynamic evolution, may make the correct diagnosis. Non-Q-wave infarction is based on ECG and serum enzyme Evolution ST Dynamic Evolution to diagnose. Older people suddenly failure, shock or serious arrhythmia, it is necessary to think of the possibility of this disease. A typical performance often required with the acute abdomen, pulmonary infarction, dissecting aneurysm, such as identification.
Treatment of early detection, early hospitalization, and to strengthen pre-hospital to deal with in situ. Treatment principles in order to rescue the dying of cardiomyopathy and narrow infarct size, the protection of heart function, the timely processing of various complications. ① care and general treatment. Acute phase of absolute bed rest for 1 ~ 3 days; oxygen; continuous observation ECG heart rate, cardiac rhythm and blood pressure and respiratory changes, guardianship of 3 ~ 5, if necessary, monitoring of pulmonary wedge pressure and gross venous pressure; low-salt, low fat,少量多餐maintain patency stool, 1 week to get out of bed activities, two weeks of activities in the corridor, was discharged three weeks, severe cases, appropriate to extend the length of stay in bed with. ② sedation analgesia. Dolantin with morphine or intramuscular injection, 4 ~ 6 hours can be repeated. Irritability to use dolantin and non Flanagan intramuscular or intravenous injection. ③ volume adjustment. Admitted to hospital as soon as possible after the establishment of intravenous access, three days before the slow rehydration, pay attention to balance out. ④ measures to reduce the infarct size. Thrombolytic therapy: will enable revascularization, myocardial reperfusion. Incidence of 6 hours, there are persistent chest pain, ST-segment elevation, and no contraindication thrombolysis may choose to join urokinase or streptokinase within 30 minutes of normal saline trickle-down, following the use of heparin anticoagulant therapy from 3 to 5 days . If the conditions can be used to coronary thrombolysis; nitroglycerin: the expansion of the drug directly coronary, the lifting of coronary spasm, increased collateral circulation, reduce the infarct size; incidence of the first few hours, β blockers can myocardial reduce oxygen consumption, reduce the infarct size; betaloc adjusted depending on the amount of illness. Diltiazem for non-Q wave myocardial infarction early treatment. ⑤ Antiarrhythmic. Lidocaine preventive for easy ventricular fibrillation, the incidence within 6 hours of the initial issuance of the young patients; if premature ventricular contractions or ventricular tachycardia (VT), the immediate use of intravenous lidocaine, premature after the disappearance of sustainable static point; the occurrence of ventricular fibrillation, as soon as possible the use of non-synchronous DC defibrillator. Ventricular tachycardia is not satisfied with the effect should also be adopted as soon as possible synchronous cardioversion; on slow arrhythmia, often available for intramuscular injection or intravenous atropine; Ⅱ - Ⅲ degree atrioventricular block may be temporary pacemaker placement; Room on Tachyarrhythmia with digitalis category verapamil drug control may be synchronized electrical cardioversion. ⑥ merger after acute myocardial infarction with cardiogenic shock and pump failure treatment. Pulmonary edema nitroprusside static point when the first choice, at the same time with morphine, furosemide, cedilanid and are required to monitor the blood volume, blood pressure, cardiac output and pulmonary wedge pressure hair, cardiogenic shock available dopamine, dopa phenol butylamine or aramine, such as to maintain blood pressure, can be added to sodium nitroprusside. Conditional to use intra-aortic balloon counterpulsation surgery can improve survival. ⑦ the prevention of acute myocardial infarction 2. Discharged before the use of 24-hour Holter monitoring, echocardiography, exercise test radioisotope found that there were symptoms or silent myocardial ischemia and serious arrhythmias, understanding of cardiac function, in order to estimate the prognosis, decisions and the implementation of coronary angiography , percutaneous transluminal coronary angioplasty or coronary artery bypass grafting in order to prevent re-infarction or sudden death. ⑧ living and work arrangements. Discharged from hospital after 2 ~ 3 months, as appropriate, to restore some or light work, after some patients to resume full-time work, but to avoid fatigue or excessive tension.
Prognosis prognosis and the scope of the size of infarction, collateral circulation generated, as well as timely treatment, and acute phase hospital mortality of 30% over the past year, the current dropped to about 10% more than in the first week of death, particularly in a matter of hours , the occurrence of serious arrhythmia, shock or heart failure, the mortality rate especially high, the long-term prognosis and cardiac function.
The prevention of (a preventive) treatment of hypertension, hyperlipidemia, diabetes, in order to prevent atherosclerosis and coronary heart disease incidence, coronary heart disease may be long-term oral administration of aspirin or dipyridamole against platelet accumulation, it may be the prevention of myocardial infarction role. Universal access to knowledge related to myocardial infarction, early diagnosis and timely treatment and strict monitoring and aggressive treatment complications is to improve the prognosis of the key

Clinical manifestations

Most patients received prior to the onset of day was a few weeks there is fatigue, chest discomfort, activities palpitation, dyspnea, irritability, premonitory symptoms such as angina pectoris. One new occurrence of angina, early-onset angina) or add to the original angina (angina pectoris evil) as the most prominent. Its symptoms are:

Pain was one of the first symptoms, and the nature of pain and angina pectoris the same, no obvious incentive for more often occurred in quiet, the extent of heavier and lasted longer, up to several hours or several days, with rest and with Nitroglycerin tablets can not be eased and more. Patients often irritability, sweating, fear, or have a sense of dying. A small number of patients had no pain, that is manifested in the beginning of shock or acute heart failure. Some patients is located in upper abdominal pain, be mistaken for gastric perforation, acute pancreatitis, such as acute abdomen, and some patients with pain radiation to the neck, back, top, be mistaken for bone and joint pain.
Systemic symptoms are fever, tachycardia, leukocyte and erythrocyte sedimentation rate increased faster and so on, the body temperature is normally around 38 degrees and rarely more than 39 degrees, lasted about a week.
Gastrointestinal symptoms are often accompanied by intense pain frequent nausea, vomiting and epigastric pain. Severe hiccups may occur.
Arrhythmia in 75% ~ 95% of patients, more than occurred in the onset of 1 ~ 2 weeks, and to begin the 24 hours up to see, can be accompanied by fatigue, dizziness, fainting and other symptoms.
Hypotension and shock during the blood pressure decreased pain common, not shock. Such as pain relief and systolic blood pressure is still lower than 10.67kpa (8mmHg), there is irritability, pale skin cold and wet, thin and rapid pulse, sweating profusely, volume reduction (per small? Lt; 20ml), delirious slow, and even hom service persons, compared with the performance of shock. Shock more than a few hours after the onset ~ 1 week the main fat.
Acute left ventricular heart failure is failure.