CURRENT MANAGEMENT OF ACUTE MYOCARDIAL-INFARCTION

Acute myocardial infarction is a devastating cardiac clinical event, w hich is the result of progressive coronary arteriosclerosis. Coronary heart disease is a major health concern that accounts for a significan t number of hospitalizations, health care expenditures, and deaths. Re cent advancements in the nature and pathophysiology of progressive cor onary disease and infarction have allowed us to curb the natural cours e of the disease, shorten hospital stays, and improve patient outcomes . Focused history taking and physical examination, with the assistance of the appropriate laboratory studies and an electrocardiogram, facil itate the rapid identification of a patient with myocardial infarction . Overall clinical results will be improved by minimizing the time fro m diagnosis to therapy. Several initial measures are readily available to the physician at the time of the patient's arrival in the hospital emergency room. Consideration regarding relief of pain, anticoagulati on and contraindications for thrombolytic therapy should accompany the initial evaluation. For patients in whom the diagnosis is in doubt, a djunctive confirmatory testing and imaging studies should be urgently sought. Elderly patients have a higher mortality rate from infarction, so an aggressive approach in this group of patients is warranted. Adm inistration of thrombolytic therapy or primary angioplasty will be mos t efficacious in a majority of patients. The evolution of adjunctive m edications will further improve efficacy and avoid reinfarction. Prope r dosage and timing of adjunctive medications, along with dosage titra tion based on hemodynamic response, will facilitate the best possible results. Rapid restoration of flow down a suddenly occluded epicardial coronary vessel is the primary end point in therapy. With this in min d, there has been an increasing trend toward mechanical restoration of flow by means of primary angioplasty in centers where this technologi c capability is available. Close attention to the patient's hemodynami c status along with rapid identification and therapy of periinfarction arrhythmias will help to avoid clinical complications. When periphera l perfusion is compromised, hemodynamic monitoring, inotropic medicati ons, and mechanical assistance may become necessary. Subsequent severe pump failure is usually the result of a devastating mechanical compli cation. Patients with mechanical complications have a high associated event-related mortality rate. Urgent identification of the nature of t he complication with the use of invasive and noninvasive imaging studi es, mechanical and inotropic assistance, and emergency surgical correc tion may be lifesaving.Careful patient follow-up and medical therapy a imed at maintaining left ventricular geometry, reducing ischemia and r elated events, and attempting to retard the progression of arterioscle rosis with anti-ischemic agents and lipid-lowering therapy, as well as estrogen replacement in female patients, can reduce the incidence of subsequent events and prolong life. New insights into the interactions of macromolecules, medications, rand hormones with the coronary endot helium and atherosclerotic plaque are helping to shape the evolution o f appropriate therapy for myocardial infarction and coronary heart dis ease in general.