Complications Of Acute Coronary Syndromes

Many complications can occur and increase morbidity and mortality. They can be categorized broadly as

(See also Procedure for acute coronary syndromes.) Many complications can occur and increase morbidity and mortality. They can be broadly categorized as electrical dysfunction (conduction disturbance, arrhythmias) Mechanical dysfunction (heart failure, myocardial rupture or aneurysm, papillary) Thrombotic complications (recurrent coronary ischemia, mural thrombosis) Inflammatory complications (pericarditis, Dressler syndrome) Electrical malfunctions occur in> 90% of patients with myocardial infarction (heart rhythm disorders). The electrical malfunctions that often result in the first 72 h to death, include tachycardia (independent of focus) with such high frequencies, that the cardiac output is reduced and the blood pressure can be lowered, an AV block II. Grade type 2 ( Mobitz) or III. Degree atrioventricular (AV) block, ventricular tachycardia (VT) and ventricular fibrillation (VF). Asystole is rare. It occurs only as a terminal manifestation of a progressive left ventricular failure and a shock. In patients with cardiac arrhythmia blood gas and electrolyte controls are necessary to detect signs of hypoxia or electrolyte imbalance, which may be responsible for the arrhythmia or contributes. Sinus node dysfunction of the sinus node dysfunction can occur when the supply of the sinus node artery is affected by acute coronary syndrome. You are more likely if already a malfunction was (common in the elderly). Sinus bradycardia sinus bradycardia The most common dysfunction of the sinus node. You will not be treated as a rule, if hypotension or a heart rate of <50 beats / min present. means a lower heart rate, if it is not too low, a decreased cardiac output and possibly a smaller infarct size. Bradycardia with hypotension (can reduce myocardial perfusion) is treated with atropine sulfate 0.5-1 mg i.v. treated. The dose can be repeated in case of insufficient response after a few minutes. Several small doses are best because high doses can cause tachycardia. Occasionally need a temporary transvenous pacemaker werden.Sinustachykardie introduced Sustained sinus tachycardia is a concern in the rule, since it is often a sign of left ventricular failure and low cardiac output. This arrhythmia may be responsive to a beta-blocker to (p.o. or i.v., depending on the urgency) if no heart failure or any other identifiable cause exists. Supraventricular arrhythmia, supraventricular arrhythmias (supraventricular arrhythmias, atrial fibrillation and less commonly, atrial flutter) occurred in approximately 10% of patients with myocardial infarction and may indicate a left ventricular insufficiency or a heart attack in his right atrium. Paroxysmal supraventricular tachycardias are unusual and are found usually in patients who already have such episodes in the past. Atrial premature beats are usually benign. However, they are increasing in frequency, is a clarification of the cause, v. a. of heart failure, is necessary. Frequent atrial premature beats may respond to a beta-blocker. An atrial fibrillation occurring within the first 24 h atrial fibrillation is usually transient (atrial fibrillation). Risk factors include a life aged> 70 years, heart failure, a history of myocardial infarction, large anterior myocardial infarction, atrial infarction, pericarditis, hypokalemia, hypomagnesemia, chronic lung disease and hypoxia. Atrial fibrillation A fibrinolytic therapy reduces the frequency. A recurrent paroxysmal atrial fibrillation is a sign of poor prognosis and increases the risk of systemic embolism. Because of the risk of systemic embolism, heparin is conventionally used in atrial fibrillation. Beta blockers iv the ventricular rate rapidly (eg. as atenolol slow 2.5-5.0 mg over 2 minutes to a total dose of 10 mg in 10-15 minutes, metoprolol 2-5 mg every 2-5 minutes up to a total dose of 15 mg in 10-15 minutes). Heart rate and blood pressure should be closely monitored. The treatment is set when the ventricular rate dropped satisfactory or the systolic blood pressure has dropped <100 mmHg. Digoxin i.v., which is not as effective as beta-blockers, used cautiously and only in patients with atrial fibrillation and left ventricular systolic dysfunction. (N. D. Talk .: This procedure is very controversial in Germany and is therefore not recommended!) Normally, it takes at least 2 hours to digoxin effectively slows down the heartbeat, and it may worsen with recent acute coronary syndrome in rare cases ischemia in patients , For patients with no discernible systolic left ventricular dysfunction or delayed excitation line (indicated by wide QRS complexes) can be a therapy with verapamil i.v. or diltiazem iv be considered. Diltiazem may as an i.v. Infusion for longer-term control of heart rate are given. If, under the atrial fibrillation to a deterioration of the circulatory situation (and z. B. thus to a left ventricular insufficiency, hypotension and chest pain) may be carried out electrical cardioversion. Occurs then again on atrial fibrillation, administration of amiodarone should i.v. werden.Vorhofflattern contemplated in atrial flutter (atrial flutter) the rate is controlled, as in atrial fibrillation. Heparin is necessary because the risk of thromboembolism is similar to atrial fibrillation. Low-power direct current (DC) cardioversion terminated atrial flutter usually atrial flutter. (Note: presentation of a right bundle branch block) conduction disturbances Morbitz type I block (Wenckebach type, with a progressive increase in the PR interval with letztendlichem Systolenausfall) occurs relatively common in a diaphragmatic infarction (heart block II. degree type 1) on, however, is self-limiting, as a rule, and rarely goes into a higher grade block. AV block II. Grade type 1, the PR interval is longer and longer with every stroke until the atrial pulse is no longer forwarded and the QRS complex precipitates (Wenckebach phenomenon). The AV conduction takes place on the next swing again and the sequence is repeated. An AV-block II. Grade type 2 (Type Mobitz with precipitating beats) and a complete heart block with wide QRS complexes (atrial pulses do not reach the ventricles) normally a sign of a massive anterior infarction, but both are rare. The occurrence of a complete block atriventrikulären III. The degree depends on where the infarct is located (AV-block III. Grade). A complete AV block occurs in 5-10% of patients with an inferior infarction and is usually transient. A complete block can be found at <5% with uncomplicated anterior infarction, but in up to 26% of patients with right bundle branch block and linksposteriorem hemiblock. Even a temporary complete atrioventricular block with an anterior myocardial infarction is an indication for the use of a permanent pacemaker because the risk of sudden death is significantly without stimulation. AV-block III. Degree AV block A II. Grade Type 1 does not require treatment usually. In a real block II. Degree Type 2 is precipitated with shock or an AV block with slow, wide QRS complexes a temporary transvenous stimulation (pacing), the treatment of choice. Until the introduction of temporary transvenous pacemaker can first be stimulated externally. Although isoproterenol may temporarily restore the rhythm and heart rate as an infusion, it is not used because it increases the oxygen demand and the risk of rhythm disorders. (Editor's note: Not available in Germany!) Atropine 0.5 iv mg every 3-5 minutes up to a total dose of 2.5 mg can be useful with narrow QRS complexes and low ventricular rate in an atrioventricular block, but it is not recommended for a new atrioventricular block with wide complexes. Ventricular arrhythmias, ventricular arrhythmias are common and can consist of hypoxia, electrolyte shifts (hypokalemia, hypomagnesemia may be), or a sympathetic hyperactivity in ischemic cells adjacent to the electrically non-active tissue infarction results. This applies the cause of the arrhythmia and determine the extent possible to treat them. The potassium level in serum should be maintained at above 4.0 mmol / l. iv administration of potassium chloride is recommended. In general, 10 mmol / h are infused, this dose can be in severe hypokalemia (serum potassium <2.5 mmol / l) can be increased to 20-40 mmol / h, which must then be infused through a central venous catheter. The frequent post-myocardial infarction ventricular premature beats require no special treatment. Treatment with beta-blockers iv in the early Myokardinfarktphase, which is then continued with oral beta-blockers, the incidence of ventricular arrhythmia is reduced (ventricular fibrillation included) and mortality in patients without heart failure or hypotension. Prophylaxis with other drugs (eg. As lidocaine) increases the risk of mortality and is therefore not recommended. After the acute infarction phase increase complex ventricular arrhythmias or non sustained ventricular tachycardia, the mortality rate, v. a. when they occur in combination with significant left ventricular systolic dysfunction. An implantable cardioverter defibrillator (ICD) should be considered and is indicated when the left ventricular ejection fraction is <35%. Programmed electrical stimulation can be helpful to find out the most effective antiarrhythmic drug for the patient or to determine the need for an ICD. Prior to treatment with an antiarrhythmic or ICD therapy coronary angiography, or other tests are performed to determine recurrent myocardial ischaemia, which make possible a percutaneous coronary intervention or coronary arteries bypass surgery required. Ventricular tachycardia The non-sustained ventricular tachycardia (VT <30 seconds), and even the continuing slow VT (accelerated idioventricular rhythm) without hemodynamic instability erforden no therapy during the first 24 to 48 hours usually (ventricular tachycardia with a wide QRS complex.). The polymorphic ventricular tachycardia, the continued (?30 s) monomorphic ventricular tachycardia or ventricular tachycardia with any symptoms of instability (z. B. heart failure, hypotension, chest pain) is terminated by a synchronized cardioversion. Ventricular tachycardia without hemodynamic adverse effects can i.v. with lidocaine, procainamide or amiodarone are treated. (Editor's note: Under no circumstances lidocaine) Some clinicians treat a complex ventricular arrhythmia with magnesium sulfate 2 g iv over 5 minutes, regardless of whether a low level of magnesium is present or not. Ventricular tachycardia can occur months after a heart attack. A later occurring ventricular tachycardia is more likely in patients with transmural infarction. It is then often lasting. Ventricular tachycardia with a wide QRS complex. The QRS duration is 160 ms. Lead II is an independent P-wave shows. (Arrows). There is a type of location shift of the middle frontal axis to the left. A ventricular fibrillation occurs in 5-12% of patients within the first 24 h, h usually within the first 6 after a myocardial infarction. Late occurring ventricular fibrillation is usually a sign of a persistent or recurrent ischemia and has in a simultaneous hemodynamic deterioration a poor prognosis. In ventricular fibrillation immediately unsynchronized cardioversion must be performed. Ventricular © Springer Science + Business Media var model = {thumbnailUrl: '/-/media/manual/professional/images/381_v_fib_slide_20_springer_high_de.jpg?la=de&thn=0&mw=350' imageUrl: '/ - / media / manual / professional / ? images / 381_v_fib_slide_20_springer_high_de.jpg lang = en & thn = 0 ', title:' fibrillation ', description:' u003Ca id = "v38395786 " class = ""anchor "" u003e u003c / a u003e u003cdiv class = ""para "" u003e u003cp u003eDiese rhythm strip showing the ultrafast base waves

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