Now, management continues. All patients
with AMI should undergo intensive
treatment for modifiable risk factors. What were they again?
Aspirin, ACE, beta-blockers, secondary prevention. So
you want to continue taking baby aspirin,
ACE inhibitors always a good thing, beta-blockers
all these are then for secondary prevention.
Treatment of hyperlipidemia, statins. I had
another drug in there for you that is very
relevant. That's your, once again proprotein convertase
subtilisin kexin 9 inhibitor, and those of
some of your monoclonal antibodies, we have
referred to that earlier known as alirocumab
or your evolocumab, locumab is their suffix
you pay attention to please. diabetic control,
smoking, and diet and exercise. If you are
able to do this and if you are able to educate
your patient properly where you are exercising
prevention is not the best medicine.
Mechanical complications that we are worried
about. Weakened infarcted cardiac tissue.
the timeline that we walked through with myocardial
infarction and at some point with that scar
formation, it might become weak and may result
in a ventricle aneurysm or rupture. Oh my
goodness we have either septal or wall rupture
may result in papillary muscle might have
a new type of murmur that has been introduced.
A mitral valve regurg or if you had a septal
rupture, it kind behaves like a VSD. What
kind of murmurs are these please? Close your
eyes. You got theses. Systolic murmurs that
are being introduced newly. If it is a wall
rupture, you're worried about death from what? Sudden
accumulation of blood within your pericardial
cavity and say that you have tachycardia and
have hypertension, you have what is known
as kussmaul sign mean to say positive JVD
and you have muffled heart sounds. Worried about
pericardial tamponade, don't you? What is your
next step in management? My goodness gracious
get in there, do a pericardiocentesis and get
that fluid out. Mechanical complications require
emergency type of surgical issues. Papillary
muscle rupture can present with acute hypotension,
acute pulmonary edema. Understand that everything
is being backed up. Here is our mitral valve.
Are you with me? And you have regurg back into where?
Left atrium. Back into where? Pulmonary veins.
Pulmonary edema acutely, new systolic murmur.
Chronically what kind of issues are you worried
about? Conduction system big time and if that
is the case my goodness gracious you plant
a pacemaker, arrhythmias due to scar formation.
That's what we'd talk about over and over again and
major complication that you are worried about
resulting in sudden death is the fact that
you are messing up the conduction chronically.
Mechanical failure, your left systole or should
I say your left ventricle is dying. So, therefore,
the systolic function on the left side is
also not working. And so therefore, now I
want you to pay attention to this statement,
there is a lot of clinical importance for
this particular stanza. When I walk you through
this, if your heart dies on the left side
and that is which you focus upon here, please.
If the heart dies on the left side, it cannot
pump forward. What is the active process of
your heart phase? Systolic. What kind of dysfunction
would you call this if the left ventricle
is not functioning properly? A systole dysfunction,
stop there. If I can pump my blood forward
into the aorta, where is all my blood? In the
left ventricle. It is stuck in the left ventricle.
How are you going to measure this? On the
left side, a central venous pressure or you
are going to use a PCWP, a pulmonary capillary wedge
pressure. You are correctly telling me PCWP,
pulmonary capillary wedge pressure. Where
is my blood? In the left ventricle. Why? It
is not moving forward. Are you seeing this?
Close your eyes and conceptualize, the only
way that you get all the questions right.
There is my blood lying in my left ventricle,
increased preload and your PCWP is increased, correct?
Yes. Now the mitral valve wants to open, the
blood wants to rush into the left ventricle.
But the problem is there is blood still remaining
there residually from the previous systolic
dysfunction. So could that systolic dysfunction
then give rise to a diastolic dysfunction? Yes, it can.
What does that mean to you? Pay attention here. What
kind of heart sounds are you going to find
here? If it is a systolic dysfunction, what
does that mean? The blood is not moving forward.
So, therefore, my left ventricle could be
rather large and it could result in what kind
of heart sound? An S3. We talked about that
earlier, an S3 gallop, what is happening?
It is the fact that because of the systolic
dysfunction, you have a large left ventricle,
as soon as a mitral valve opens, it create
an S3, stop there. Well what if the blood starts accumulating
in your left ventricle? Right.
So now that's a diastolic dysfunction because
you cannot properly fill up the left ventricle
and that blood now that is rushing from your left
atrium, are you seeing this? That blood that
is rushing from the left atrium through the
mitral valve, into the left ventrical,
hitting the blood in your left
ventricle, is going to create a what? A fourth
heart sound. What does a fourth heart sound
mean to you? You have heard of this as
being hitting a stiff left ventricle. But
with all that blood in there, it might as
well be stiff. If you haven’t understood
that, please make sure that you go back and
review what I just told you with that particular
statement. Do you understand how much clinical
relevance there is with each one of these statements?
Some more than others, especially when it comes
to pathology. Continue. Insufficient or significant
damage myocardium, it cannot do what? It cannot
maintain the proper heart function.