Links To “Type-1 Myocardial Infarction” Chapter From The Internet Book Of Critical Care

This chapter of the IBCC is outstanding. It is of most relevance to specialists in Cardiology, Emergency Medicine, and Critical Care.

For links to all the cardiology related chapters in the Internet Book Of Critical Care, please click on the cardiology section of the table of contents.

In this post I link to the chapter subheadings of Type-1 Myocardial Infarction Chapter From The Internet Book Of Critical Care [Link is to the IBCC Table Of Contents], November 5, 2021 by Dr. Josh Farkas.

The sections of the chapter that are most relevant to general clinicians are, I believe:

• Risk stratification
• Management
  • General supportive care

Here are the above two sections

risk stratification in acute MI

Risk stratification and hemodynamic status can be rapidly determined at the bedside as shown in the figure above.   This may be very helpful regarding disposition and management.  For example, the presence of severely reduced LV systolic function suggests that the patient may respond poorly to beta-blockers.

general supportive measures

general measures

• Discontinue NSAIDs (NSAIDs may impair renal function and myocardial remodeling, and mute the beneficial effect of aspirin).
• Target potassium >3.5 mEq/L  and magnesium >2 mEq/L  (avoids arrhythmia).
• Target hemoglobin >8 mg/dL.   (REALITY trial)
• Supplemental oxygen only for patients with hypoxemia, titrated to a target of normoxia (e.g., target saturation 92-97%).(AVOID trial)
• High-intensity statin (e.g., 80 mg atorvastatin daily).(11277825)

avoid opioids

• Reasons not to use opioid:
  • (1) Opioid runs the risk of masking ongoing ischemia without resolving it.  Urgent catheterization is indicated for patients who can’t be rendered pain-free with medical therapy (e.g., nitroglycerine and beta-blockade).
  • (2) Opioid administration may delay oral absorption of P2Y12 inhibitors.
• For patients who have already had catheterization, opioid can be helpful.

Here are the direct links:

CONTENTS

• Rapid Reference 
• Limitations of this chapter
• Nomenclature & types of MI
• Diagnosis
  • DDx of MI
• EKG findings in MI
  • Anterior OMI
  • Inferior OMI
  • RV OMI (RVMI)
  • Posterior OMI
  • High lateral OMI
  • OMI in LBBB or RV-pacing
  • OMI vs aneurysm
  • Hyperacute T-waves & de Winter pattern
  • Wellens patterns
  • Subendocardial ischemia patterns
• Risk stratification
• Management
  • General supportive care
  • Nitroglycerine
  • Beta-blocker
  • ACE inhibitor
  • PCI
  • Anticoagulation
    • Aspirin
    • P2Y12 inhibitors
    • Anticoagulation if no immediate PCI
• Right ventricular MI (RVMI)
• Approach to decompensation post-MI
• Podcast
• Questions & discussion
• Pitfalls
• Supplemental media

Going further

• OMI/NOMI paradigm:  Dr. Smith’s ECG blog, OMI manifesto, and who needs the cath lab.
• Evidence behind heparin in NOMI: by the NNT, PulmCrit and First 10 in EM.

Guidelines

• European Society of Cardiology (ESC) guidelines:*
  • 2017 ESC guidelines for STEMI.
  • 2020 ESC guidelines for NSTEMI.
• NICE guidelines from the UK:*  2020 MI guidelines.
• 2013 ACCF/AHA guideline for STEMI.
• 2014 AHA/ACC guidelines for NSTEMI.
• *This chapter was largely based on ESC & NICE guidelines.