Usually patient presents with “typical” chest pain.

 ·       PLACE: Reosternal or precordial

·       QUALITY: Pressure, aching, squeezing, discomfort, crushing, swelling, bursting

·       RADIATION: May be skip areas with restrosternal pain, or pain only in the referral areas. e.g.

LAD-L arm/both arms RC-jaw/neck

CIRCUMFLEX- in between scapulae

·       SYMPTOMS: Dysnoea, diaphoresis, nausea, vomiting, apprehension, syncope, agitation, palpitation (arrhythmias)

·      TIME:3-30mins.Infarction>15mins(prolonged).Cansuddenly decrease with reperfusion.

Clinical diagnosis

ENZYMATIC CRITERIA FOR DIAGNOSIS OF ACUTE MI/NSTEMI

 1.      Troponin I > 1ng/ml check serial values at 4-6 hours

2.      Serial increase and then decrease of CKMB values, with a change of >25% betweenany two values.

3.      CKMB> 10-13 U/L (+/- 7 is considered as lab error, therefore > 21 is considered asdiagnostic in our lab) or >6% total CK activity.

4.      Increase in CKMB values >50% between any two values separated by 4h.

5.      If only a single sample, two fold increase over the normal value.

Suspect a false elevation if

 1.      Presence of a skeletal muscle disease/trauma

2.      An atypical time course of increase and decrease of the plasma CKMB levels e.g more prolonged.

3.      MBCK <5% of total CK activity (probable skeletal muscle source tongue, diaghragmetc. are relatively rich in CKMB)

4.      A marked elevation of CK 20-30 folds.

Indications for thrombolytic therapy :

 1.      Patients irrespective of age seen within 12h of an AMI with ECG criteria for the same(i.e ST segment elevation > 1mm in 2 contiguous Limb Leads or >2mm in 2 contiguous chest Leads.)

2.      New LBBB seen within 6h or chest pain.

3.      New RBBB, proven acute infarction, associated heart failure.

4.      Seen within 12h with ongoing ischemia, pain in sluttering episodes in the presence ofST segment elevation.

Contraindications to thrombolytic therapy

Absolute :

 1.      Altered consciousness.

2.      Active internal bleeding.

3.      Known CNS AV malformation/tumor.

4.      Recent head trauma.

5.      Known previous haemorrhagic stroke.

6.      Intracranial/Intraspinal surgery within the past 2 months.

7.      BP persistently higher than 200/120mm of Hg.

8.      Known bleeding disorder.

9.      Pregnancy

10.  Suspected aortic dissection.

11.  Previous allergy to Streptokinase.

12.  Major trauma/surgery within 2 weeks that can bleed into a closed place.

Relative :

 1.      Active peptic ulcer disease.

2.      H/o ischemic/embolic stroke.

3.      Current use of anticoagulants.

4.      Major trauma/surgery>2 weeks and <2months.

5.      H/O chronic uncontrolled HT (treated/untreated)

6.      Subclavian/IJV cannulation.

Thrombolysis regimens :

Streptokinase :1.5 million units in 500ml of 5% Dextrose/100ml of 0.9% Saline IV over 30-60 mins. (Cost=Rs. 2500-3500/=)

Anistreplase(APSAC) 30U in 5ml sterile water/saline by slow IV bolus over 2-5 mins.

tPA(Alteplase) : 15mg bolus; 0.75 mg/kg over 30 mins (max 50 mg); 0.5 mg/kg over 30 mins(max.35mg). Total dose </=100mg. (Cost =Rs 1.37.500/=)

The t-PA regimen quoted is called FRONT LOADING regimen(GUSTO TRIAL). Higher early patency rate.