Ischmic Heart Disease Myocardial Infarction Current clinical

Ischmic Heart Disease Myocardial Infarction

Current clinical practice guidelines of the ACC/AHA Curr Opin Cardiol 2008; 23: 613– 619

Acute Coronary Syndrome v Electrocardiographic changes are often nonspecific in more than 50% of patients with chest pain. v Cardiac biomarkers take hours from symptoms onset to exceed the normal range.

Role of Echocardiography in AMI Anatomical, functional and hemodynamic information 1. Diagnosis and exclusion of AMI in patients with chest pain and non-diagnostic ECG findings 2. Estimation of the amount of myocardium at risk and final infarct size after reperfusion therapy

Role of Echocardiography in AMI 3. Evaluation of unstable hemodynamics 4. Detection of infarct complications 5. Evaluation of myocardial viability 6. Risk stratification

Wall motion abnormality in AMI v Compensatory hyperkinesis v RWMA at other area : Multi vessel involvement v Wall Motion Score Index

Acute Myocardial Infarction-LAD

Acute Myocardial Infarction-LAD

Acute Myocardial Infarction-LAD

Acute Myocardial Infarction-LCX

Acute Myocardial Infarction-LCX

Acute Myocardial Infarction-LCX

Acute Myocardial Infarction-RCA

Acute Myocardial Infarction-RCA

Complications of Acute Myocardial Infarction • Mechanical Complications Ventricular septal rupture Papillary muscle rupture and MR Free wall rupture Incidence (%) 1 -2 1 -6 Time to occur 3 -5 days after onset of MI 3 -6 days after onset of MI Physical examination Murmur 90% Murmur 50% Neck vein enlargement, Old age, hypertension, Posteromedial PM rupture electromechanical dissociation anterior wall Mi, lack by inferior wall MI Old age, hypertension, female, At risk of collateral circulation first attack of MI, large Q wave infarct Defect in ventricular Echocardiography Frail or prolapsing leaflet septum regurgitant jet to left atrium left to right shunt Just like pericardial effusion intrapericardial thrombus • Pericardial effusion, LV thrombus, Aneurysm, RV involvement

Ventricular Septal Rupture Hypotension, Systolic murmur Ventricular septal defect with left to right shunt by echo

Acute Myocardial Infarction Posteroinferior myocardial infarction Contrast echo study Free wall rupture and pseudoaneurysm was observed. Contrast echo for pericardial leakage was done.

Acute Myocardial Infarction Anterior wall myocardial infarction Large LV apical thrombus

Right Ventricular Infarction

Right Ventricular Infarction

Dobutamine stress echo Subtotal stenosis of proximal LAD Baseline Low Dose Dobutamine Echo

Stenting and f/up Echo LAD stenting in 10 months later

Patients with Chest Pain System Syndrome Cardiac Stable and unstable angina Gastrointestinal Esophageal reflux Acute myocardial infarction Peptic ulcer Pericarditis Gallbladder disease Aortic stenosis Vascular Aortic dissection Pulmonary embolism Pancreatitis Musculoskeletal Cervical disc disease Pulmonary hypertension Pulmonary Costochondritis Trauma or strain Pleuritis and/or pneumonia Tracheobronchitis Infectious Herpes zoster Pneumothorax Psychological Panic disorder

Acute Pulmonary Embolism D-shaped LV Thrombi Estimation of PA pressure

Hypertrophic Cardiomyopathy No identified disease to cause hypertrophy T-inversion on ECG Severe ventricular hypertrophy No RWMA

Acute Pericarditis Chest pain, elevated cardiac enzymes, and ST elevation on ECG Pericardial effusion No RWMA High e’ velocity Respiratory variation of mitral inflow

Aortic Dissection

Tako-tsubo Cardiomyopathy Apical Ballooning Syndrome v First described in Japan v The ballooning configuration of the LV is similar to a tako-tsubo (Japanese octopus trap)

Modified Mayo Clinic Criteria of stress induced cardiomyopathy (1) transient hypokinesis, akinesis, or dyskinesis in the LV mid segments with or without apical involvement; RWMA that extend beyond a single epicardial vascular distribution; and frequently, but not always, a stressful trigger (2) the absence of obstructive coronary disease or angiographic evidence of acute plaque rupture

Modified Mayo Clinic Criteria of stress induced cardiomyopathy (3) new ECG abnormalities (ST-segment elevation and/or T-wave inversion) or modest elevation in cardiac troponin (4) the absence of pheochromocytoma and myocarditis ***Patients were assigned this diagnosis when they satisfied all these criteria.

Stress induced cardiomyopathy

CAG with F/U echocardiogram Follow up Echocardiogrpahy