Trauma Echocardiogram:  may see pericardial effusions (although these may also occur in the absence of pericarditis). If AF appears to trigger hemodynamic instability or ischemia, consider DC cardioversion. Note the serpiginous course of the rupture- pretty common. Early VT may not require ongoing antiarrhythmic therapy (especially if the patient can be successfully revascularized). 750-1000 mg Q6-8 hours). Stabilize the patient and consult cardiothoracic surgery. Post MI complications have high morbidity and mortality. There are a variety of possible complications which can occur following an MI. It is usually transient, benign and self-limiting but symptoms may be distressing. ECG in MI; Ischemic Heart Disease Workbook Review; Ischemic heart disease; Post-MI complications; Chapter 62 Organ Systems - Cardiology: Lipid Metabolism. 273819 PPT. Recurrent anginal chest pain (due to myocardial strain). Treatment as that of early post-MI pericarditis except that an oral corticosteroid course maybe required . Electrolyte abnormalities should be corrected (e.g. Additional complications include ischemic stroke, heart failure, renal failure, and cardiac dysrhythmias. Grand Rounds Troponin may re-elevate, but this is often difficult to discern in the context of previously elevated troponin values. VT which occurs later in the patient's course (e.g. September 2017 PCI has reduced mechanical complications, but these still occur (especially in the absence of successful revascularization). Typically seen in late-presenting patients who have not been revascularized. Only occurs with femoral access (not radial access, #RadialFirst). Table 1 - Clinical classification of types of myocardial Infarction Type 1 : Spontaneous myocardial infarction related to ischemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring, or dissectionType 2 : Myocardial infarction secondary to ischemia due to either increased oxygen demand or decreased supply, e.g. The IBCC chapter is located here. gastrointestinal bleed due to anticoagulation), Performing a non-angiogram CT scan has little or no value (because mere identification of the hemorrhage isn't very helpful (, (1) Supportive measures should be instituted without delay. Treatment for mechanical post-MI complications includes vasodilators and ACE inhibitors, as well as blood thinners in cases which have thrombi. October 2017 In tamponade, pericardiocentesis may be used as bridge to surgery. Treatment is the same as for non-MI Torsades de pointes (e.g. Post-procedure Complications Monitoring Programme 34th . May develop abruptly, or can be preceded with RBBB with either LAFB or LPFB (bi-fascicular block). @angioplastyorg @mmamas1973 @nolanjimradial pic.twitter.com/SkU42NoIdJ, — Richard Bogle (@richardbogle) November 28, 2017, Patient was referred to surgeons and did an echo on way to the OR ⤵️ pic.twitter.com/nBcRb0UpXY, VSD caused by a complication of MI pic.twitter.com/Zif2WxCyHd, — Echocardiography (@EchoCases) August 26, 2018, negative contrast effect = a washout of the contrast (agitated saline) in the right atrium in a patient with an ASD #echofirst #cardiotwitter pic.twitter.com/liGUMX0kM4, — Ivan Stankovic, MD, PhD (@Ivan_Echocardio) June 12, 2018. Surgery is generally preferred, but transcatheter closure is another option. (b) NSTEMI may be treated in the usual fashion (e.g. Description Complications of myocardial infarction include complications of both ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI), usually occurring within 24 hours. Presence of internal echoes or echogenic masses (clot) within pericardial effusion increases specificity. Following a myocardial infarction (MI), patients are at risk for a variety of cardiac complications. Occurs between one week to three months after MI. Most common scenario:  patient is improving after MI and then deteriorates. nitroglycerine) may favor blood flow to body (rather than RV). February 2017 This may occur in the free walls of the ventricles, the septum between them, the papillary muscles, or less commonly the atria. Infarct expansion is associated with high mortality and complications such as heart failure and LV aneurysm formation (2). beta-blocker to reduce myocardial oxygen demand, possibly nitroglycerine). Able to lie flat but crackles in chest. Some patients may present to the hospital with heart failure due to a ruptured chordae tendinae (following a silent or mildly symptomatic myocardial infarction). Hemodynamic deterioration with RV dilation may mimic PE. Often have poor prognosis. Pain It is seen in 20 per cent of patients following a Q-wave MI. All new aortic regurgitation (may suggest aortic dissection), ? with percutaneous coronary intervention). For recurrent arrhythmias refractory to therapy, see the chapter on. Often a large anterior infarct, but the rate may be similar among either anterior or inferior MIs. We looked at baseline (age, gender) and treatment characteristics, risk factors for cardiovascular disease and diagnosis (e.g. Following conversion to sinus rhythm, patients will often be treated with an amiodarone infusion to prevent recurrence. Syncope #FOAMed #FOAMcc pic.twitter.com/k8GQHhk9FB, — Lars Mølgaard Saxhaug (@LMSaxhaug) March 7, 2018. occur in a time-dependent manner, and can be directly related to the anatomy of the coronary artery blood supply. CXR:  pleural effusion and pneumonitis may be seen. Treat conditions which may be increasing sympathetic tone (e.g. Complications may occur due to ischemic or injured tissue and therefore may begin within 20 minutes of the onset of M.I., when myocardial tissue injury begins. Hemodynamic optimization (e.g. Incomplete or subacute rupture:  chest pain, vomiting, fluctuating hemodynamic instability. In-stent thrombosis may cause severe transmural infarction. Typically occurs with inferior or posterior MI, affecting the posterio-medial valve leaflet (figure above). Ischaemic complications Reocclusion of an infarct-related artery. Presentation most similar to papillary muscle rupture. Also known as Dressler's Syndrome, or post-cardiac injury syndrome (although … Rare, typically large anterior MI with occluded LAD. April 2016 Headache Flail mitral valve is defined as presence of abnormal mitral leaflet coaptation like the one seen here on this sub-xiphoid view #POCUS pic.twitter.com/xNpVT1kKWr, — J. Christian Fox (@jchristianfox) May 23, 2017, TEE showes papillary muscle rupture with torrential eccentric mitral regurgitation. MI Complications Left ventricular free wall rupture. Key is comparison to the last EKG and echocardiogram obtained (some patients may have persistent ST elevation, in which case this probably doesn't represent re-infarction). Echocardiography may reveal new wall motion abnormality. post-MI pericarditis. evidence of VSD (color doppler shows flow across septum), ? Post MI complications mnemonic Hey Awesomites! However, this can be missed if there is a narrow and eccentric regurgitant jet. January 2017 November 2016 First line therapy is high-dose aspirin (e.g. Rare, usually occurs within a week of MI. active extravasation). physical signs at admission, left ventricle function, ST deviation at admission ECG, infarct location) in this analysis. Papillary Rupture & Mitral Regurgitation: Transient MR occurs in 13-45% of patients and typically requires no treatment. Intra-aortic balloon pump may be considered (but shouldn't delay surgery). Indications for intervention may include clinical course (e.g. retroperitoneal hemorrhage), Medication effect (e.g. Arnaoutakis GJ, Zhao Y, George TJ, Sciortino CM, McCarthy PM, Conte JV. Presentation Summary : Post-Procedure Complications Monitoring Programme 36th Review Meeting. Learn the post myocardial infarction complications mnemonic DARTH VADER, to help you remember post mi complications. Less severe hematoma may present in a delayed fashion with falling hemoglobin and hematoma tracking over abdomen/flank. stop offensive medications, provide magnesium infusion). due to papillary muscle. Definitive control can generally be achieved by interventional radiology. Copyright 2009-. This is often acute and usually occurs 24-72 hours post-MI. Reflects diffuse necrosis resulting from a very proximal occlusion. January 2018 Nonetheless, “prevention is the ideal management strategy for mechanical complications post-MI,” they write. Note that if the rate is low (<100 b/m) this may represent. Rupture occurs because of increased pressure against the weakened walls of t… If the patient is hypertensive, treatment with a beta-blocker may be considered (especially if this would otherwise be a consideration). Also known as Dressler's Syndrome, or post-cardiac injury syndrome (although these terms include other causes such as post-CABG pericarditis). For decompensation after myocardial infarction, echocardiogram is critical to evaluate for a diverse range of complications. Beta-blockers should be considered if hemodynamics will tolerate them. To reveal clinical parameters which could be predictive of post-MI complications multivariate analysis was performed. Post-MI ischemic pain indicates that more myocardium is at risk of infarction. The above tweet is an Atrial septal defect (ASD), not a VSD, but it illustrates the concept of negative contrast. Treatment:  overall, similar to the management of a subacute myocardial rupture. Antihyperlipidimics; Apoproteins; Biochemical basics of lipid metabolism; Hyperlipidemias; Introduction to lipid metabolism; Lipid Metabolism Workbook Review; Lipoproteins Tenderness or fullness may be noted. Can generally be managed conservatively (without transvenous wire insertion). 2. ICU Early and Late Complications of Acute Myocardial Infarction - Timeline of Complications - Ventricular Arrhythmias - Bradyarrhythmias / Heart Block - Cardiogenic Shock - Stroke - Ischemic MR / Papillary Muscle Rupture - Ventricular Septal Rupture - LV Free Wall Rupture - Pericarditis (Dressler Syndrome) #Diagnosis #Cardiology #Timeline #Timetable #PostMI #Complications #Myocardial #Infarction … Post-MI pericarditis or aortic dissection may also cause pericardial effusion. Techniques will vary depending on the nature of the bleed, but may include coil embolization or placement of a covered stent. Indications to consider transvenous pacing may include: (b) New bundle-branch block (especially LBBB). Look for JVD, pulsus paradoxus, diminished sounds; Emergent echo if stable; Give IVF and consult cardiovascular surgery for pericardiocentesis and thoracotomy; Left ventricular aneurysm Postoperative MI is classified as type 5 MI (Table 1) (4). This chapter explores some problems that we should be on the lookout for in these patients. December 2017 The In Vivo Morphology of Post-Infarct Ventricular Septal Defect and the Implications for Closure. Intra-aortic balloon pump may be considered, but shouldn't delay surgery. Papillary muscle rupture (1%) presents within the first day, and presents with a holosystolic murmur, pulmonary edema, and cardiogenic shock. A proton pump inhibitor should be given to prevent gastric ulceration. including heart failure, angina, depression, and sudden death due to another MI or an arrhythmia. September 2016 If the patient hasn't been revascularized, this surgery should be a combined CABG plus mitral valve repair/replacement. Complications of acute M.I. Pericardial effusion is sensitive but nonspecific. We are the EMCrit Project, a team of independent medical bloggers and podcasters joined together by our common love of cutting-edge care, iconoclastic ramblings, and FOAM. Occurs in a minority but significant number of patients following fibrinolytic... Infarction in a separate territory (recurrent infarction). Complications due to an attack of myocardial infarction mnemonic: DARTH VADER (I loved his character in Star wars you know :p ) D- Dressler's syndrome A- Arrhythmia R- Rupture T- Tamponade H- Heart failure V- Valvular defects A- … ... (case collection progress and Complication rate) ... + Post-op MI. Congestive heart failure, LV dysfunction. A very uncommon complication of acute MI. Ventricular septal defect can present in a similar fashion. Post-MI Pericarditis (Post-cardiac injury syndrome), Hemorrhage (e.g. Reading Avoid beta-agonists wherever possible (e.g. (a) In-stent thrombosis requires immediate repeat PCI. This is an especially important consideration among patients who are intubated and may be unable to report these problems. coronary artery spasm, coronary embolism, anemia, arrhythmias, hypertension, or hypotensionType 3 : … Even small VSDs should be repaired (may suddenly enlarge). December 2015 pic.twitter.com/n7e9RxosWQ, — V.L.Sorrell, MD (@VLSorrellImages) March 27, 2018, 65 yr old with chest pain 1 week ago. It is reasonable to check electrolytes (especially magnesium & potassium)  & EKG to look for any underlying causes that may warrant therapy. Many complications are mechanical (eg, papillary muscle rupture, left ventricular free wall rupture, or ventricular septal defect) and are related to the location and extent of myocardial injury, while other post-MI complications are immunologic, inflammatory, or iatrogenic. There are three major mechanical complications of acute myocardial infarction (MI): – Rupture of the left ventricular free wall, which can lead to cardiac tamponade, – Rupture of the interventricular septum, which can lead to VSD, – The development of mitral regurgitation, April 2017 Abx 26. May cause pericardial effusion but rarely tamponading . With conservative therapy, most bleeds will tamponade eventually. Similar to atrial fibrillation in general. May be difficult to diagnose within the first 24 to 48 hours... Postinfarction angina. JACC Cardiovasc Interv 2017;10:1233-43. Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation. Delayed deterioration in the patient recovering from MI may result from a host of different problems (e.g. Often causes (or associated with) instability. Essentially, a contained rupture of the LV (clot and pericardium seal off the rupture). May see variety of findings (e.g. PRBC transfusion (type & cross-match, stay 2-4 units ahead). Subarachnoid Hemorrhage Prior infarction with other aggravating factor (e.g. May respond to atropine if occurring early in course of MI (within the first ~6 hours, patients may have bradycardia due to excess vagal tone). anemia, hemorrhage). May 2016 July 2016 Myocardial rupture is most common three to seven days after myocardial infarction, commonly of small degree, but may occur one day to three weeks later. November 2015. June 2016 Patients often have a junctional escape rhythm (narrow-complex, with heart rate 40-60 b/m). pericardial effusion (pericarditis, ventricular wall rupture), ? EKG Challenge medication effect, procedural complications, or merely the natural history of the disease). Radiation to trapezius ridge supports pericarditis. fluid, inotropes). The highest incidence of postoperative complications is between one and three days after the operation. Any suggestions on what to do and when to do it? Optimal treatment may be reperfusion (this is potentially an indication for PCI). BP 80/60, p90. Stroke Screening. Secondary prevention aims to prevent complications or reduce impact, and to prevent further cardiovascular events. Pericarditis. One of the most common complications (~1/200 procedures). Complications of Myocardial Infarction • Free wall rupture • Pseudoaneurysm formation • Ventricular septal rupture • Papillary muscle rupture • RV myocardial infarction … Initial management is based on ACLS algorithms (DC Cardioversion for unstable patients versus amiodarone for hemodynamically stable patients). November 2017 Lidocaine may be used as a second-line anti-arrhythmic (with typical dosing including a bolus of ~100 mg followed by 1-4 mg/min infusion). Doppler echo may show flow across ventricle. For new-onset AF in the context of MI, this could tip the balance a bit towards considering rhythm control (as opposed to rate control). Patients are mobilised early, usually within 48 hours of admission after an MI to avoid complications such as PE and DVT. Severe hemorrhage manifests with hypotension/shock. March 2017 For suspected retroperitoneal hemorrhage, obtain a stat CT angiogram (make sure the study is protocoled as an. Diagnosis is based on echocardiography (compared to a true aneurysm, the neck is generally narrower). Initial MI may be mild, so patients may present initially with ruptured papillary muscle. Here’s the CFD of the post-infarct VSD. Cardiac if patient in heparin infusion). Auscultation:  new holosystolic harsh murmur might be heard. Pearl:  Whenever a patient with heart failure is encountered with normal ejection fraction, be sure to investigate valvular function with color doppler. Certain complications tend to occur within 1-2 weeks after MI (mostly STEMI). Occasionally, patients may have a silent MI and present with one of these post-MI complications. 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