Myocardial infarction is second leading
disease of cardiovascular system after the hypertension that result from the
stressful and competitive environment of present age.
It has been reported that more than one
million patients have been hospitalized every year in U.S.A.(American Heart
Association. 2002). Myocardial infarction usually results from the imbalance
between oxygen supply and its demand (Richard, 2007).Increase load on the heart
leads to the increase demand of oxygen and nutrition by means of blood. If this
supply of oxygen or nutrition by means of blood to the heart is reduced due to
obstruction in coronary artery (clot formation or thrombus) results in ischemia
of cells and this is start of myocardial infarction. Myocardial infarction is
usually diagnosed in two categories with the help of ECG,(A) Non ST elevated
Myocardial Infarction (NSTE MI),and ST elevated Myocardial
infarction(STEMI).Most of the case are diagnosed as non ST segment elevated on
their electrocardiograph paper in the start of disease.
( Braunwald E,2000).Early diagnosis and
improved acute treatment plan in ST segment elevated patients can lead to the
improved management of complications, available pharmacological and mechanical
therapies has significantly reduced the cardiac morbidity and mortality(Ryan
TJ,1999; Grines CL,1993; Zijlstra F,1993; Suryapranata H,1998; Stone
G,2002).Treatment plan is usually followed according to the guideline provided
by American Heart Association(AHA/ACC).This association has separate treatment
protocol for the ST elevated and non ST elevated patients of myocardial
infarction. According to these guidelines, every patient with MI must be
provided ventilation and some pharmacological agents like lower doses of
asprin,fibrinolytic agents, beta blockers and nitroglycerine( in the start of
therapy ).Other than pharmacological treatment plan,AHA also suggested some
mechanical procedure to minimize the mortality rate due to MI.
Our present short communication will
elaborate the comparison between treatment protocol adopted by the cardiologist
and treatment guidelines offered by international community for the better
treatment of myocardial infarction.Furthermore, this study of particular case
will highlight the rational use of drugs in acute interior wall myocardial
An old man of 55 years of age was brought in the casualty
ward of federal government hospital with left sided chest pain radiating from
chest and penetrating to the left arm and jaws. Patient was shedding his cold sweat
and was in the state of apprehension. Available Health care provider started
early investigation parallel with the treatment. It was suspected from the
evident signs and symptoms that this is an acute case of myocardial infarction
.Blood and urine samples were collected and sent to the laboratory for expert
opinion and convert their suspect
case into exact case of myocardial
infarction. In the mean while, patient was given intravenous infusion of
injection streptokinase 1.5 M I.U. (A thrombolytic agent) in one hour, tablet
lowplat (Clopidogrel) platelet aggregation inhibitor, another drug of same
class tablet Loprin (Aspirin),one tablet in a day, tab Limitrol 10 mg at the
time of need. This was emergency treatment protocol given to the patient. After
few hours injection Lasix (Diuretic) has been given and then patient was
treated with injection Norpine (Catecholamine) then with injection Dopamine at
the infusion rate of 8-12 drops per minut.In the mean time tablet digoxin 0.25
mg was recommended in twice a day dose.
It was surprising to observe that treatment given after the primary cause was
ionotropic and chronotrpic in its action while in myocardial infarction we have
to reduce these activities. All laboratory finding showed normal results of
lipid profile, cardiac enzymes, renal and liver function tests with one
insignificant exception that AST (aspartate transaminase) with value of 46 u/L
versus normal value which is 35 u/L.ECG finding showed ST segment elevation
which lead to the evidence of acute
interior wall myocardial infarction. This patient has no family history of drug
and disease like hypertension and diabetes, risk factor like obesity is
negative and smoking is positive and was busy in daily routine activities. Beta
blockers are not recommended which are used to reduced the workload of heart
and diuretic and digoxin have been recommended which find their no role on
The Case study under discussion reported
that patient has no family history of hypertension and diabetes. No risk factor
like obesity, hypertension and diabetes present except for smoking. Smoking
seems to be dominant factor for this illness. Death reported with acute attacks
of angina pectoris is minimum as compared to myocardial infarction because
these attacks are transient (fifteen seconds to fifteen minutes).(Richard,
2007). It is well established fact that
clear relationship exist between the mortality and time delay in the treatment
from onset of the symptoms in patients with ST EMI treated with
thrombolytic(Fibrinolityc Therapy Trialists’ (FTT) Collaborative Group,1994)(
Zijlstra F, 2002)(Newby LK,1996). STEMI is becoming to be a significant public
health issue in industrialized countries and is going to be an
emerging problem in developing countries.(Rogers WJ,2000).According to
guidelines provided by AHA for the ST elevated myocardial infarction, at the
time of onset of signs and symptoms, one tablet of nitroglycerine sublingually,
after every 5 minutes up to 3 doses before calling casualty observations, can
greatly reduce the intensity of the pain.( US Department of Health and Human
Services,2001)( Eisenberg MJ,1996).Injection streptokinase was given in
infusion rate of 10-12 drops per minute support the importance of fibrinolytic
agents at the emergency time. Early use of fibrinolytic agent not only reduce
the ischemic type chest discomfort but also will reduce the mortality due to
attacks.(GISSI,1986)( Armstrong PW,2003).Enteric coated Aspirin was recommended at the dose of 75 mg once in a
day which justify its use as per guide lines of AHA but dose of the drug need
to be adjusted. In a dose of 162 mg or more, aspirin produces a rapid clinical
antithrombotic effect caused by immediate and near-total inhibition of
thromboxane A2 production.Asprin found to be effective in suspected case
of STE MI and dose should be between 175-325 mg in
acute cases and 75 mg continued dose for indefinite time.( Antithrombotic
Trialists’ Collaboration,2002) Although some trials have used
enteric-coated aspirin for initial dosing, more rapid buccal absorption
occurs with non–enteric-coated formulations.( Sagar KA,1999). According to American Heart Association
(AHA),It is reasonable to administer beta-blockers promptly to STEMI
patients without contraindications, especially if a tachyarrhythmia or
hypertension is present. Overwhelming results have been observed in the NSTE MI
patients without contraindications to their use. In this case, beta blockers have not been
prescribed which leads to the question mark and failure to understand the
protocols of the disease.Frusemide diuretics have been recommended in both
infusion and oral dosage form which find its no use except for pulmonary
congestion while sign and symptoms reported no such type of
complications.Iontropic agents like norepinephrine and dopamine have been
recommended which might increase oxygen demand of the heart, can worst the
situation. According to AHA/ACC,only condition in which ionotropic agents
justify their use is bradycardia or CHF.This pathological condition actually
potentiated by the aggressive dose of diuretic(Frusemide) which resulted in the
decrease in blood pressure. In order to overcome this prescription error,
ionotropic agents and cardiac glycoside have been recommended. Cardiac
glycosides and Loop diuretic(Frusemide) greatly reduce the potassium level of
the body further leading to the weakening of heart muscle and bradycardia. In
the whole tenure of hospitalization, patient blood pressure could not exceed
from 100/40 mmof Hg which further threatened the risk of kidney failure.
Glycoprotein II a/III b inhibitors are prescribed together for the long time
management of the disease which contradict with the guidelines of AHA for ST
elevated myocardial infarction patient that only smaller doses of Aspirin 75mg
is sufficient to mitigate the future attacks.Clopidogrel and Aspirin both can
further cause bleeding disorder or can produce results which are
therapeutically not required.AHA further suggest that if pathological
conditions of the patient is not improving then mechanical therapies like
CABG(coronary artery bypass grafting) should be performed.
the context of above mentioned discussion, it can be concluded that it is
important to follow the AHA guide lines for the treatment of myocardial
infarction which not only mitigate the symptoms of that life threatening
clinical condition but also prevent secondary complications. In case of angina,
typical antianginal drugs should be prescribed at priority like beta blockers,
nitrates and calcium channel blockers. Diuretics and digoxin may find their use
in some particular conditions but should not be used as typical agents for
the guidelines of American Heart Association for myocardial infarction which
are as under,
should be given before pre hospitalization after 5 minutes interval up to 3
should be prescribed at maximum dose of 175-325 mg in start and then 75 mg dose
for indefinite time period.
blockers should be recommended to reduce the work load of heart which
ultimately reduces the oxygen demand.
channel blockers can be recommended in some particular situations like
hypertension and coronary vasodilatation.
IIb/IIIa inhibitor shown to be effective not only in emergency situation but
also reduces the frequency of future episodes.
ventilation and regular walk can alleviate the severity of disease.
procedures are part of therapy and must be considered when it is inevitable.
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