Repeated myocardial infarction - Causes, symptoms and treatment. MF.

Causes of repeated heart attacks
Symptoms of
First aid and diagnosis
Treatment of
Complications and prognosis of

The risk of myocardial infarction is not only that it causes serious consequences, but also that it can occur in the same patient for two andmore times, leading each time to new problems with the cardiovascular system. According to statistics, repeated infarction develops in 25 - 29% of all cases.

Predicting whether a repeated infarction or not in a particular patient is impossible. Some patients observe a strict protective regime after the first heart attack, and still this pathology again overtakes them, despite all the precautions. And some, on the contrary, continue to lead the old way of life, with the same load, do not always take medicine, but they do not have a second heart attack. The same can be said about the consequences of repeated infarctions - in some patients small foci of necrosis occur in the cardiac muscle remotely from the first postinfarction cicatrix, and this can not have a negative effect on cardiac activity as a whole. In this case, the patient can live dozens of years after the second or even third infarction, and for some patients the second heart attack can be fatal.

Distinguish recurrent and repeated myocardial infarction. Recurrent is a heart attack, developed during the first two months after the previous, that is, in an acute period. Repeated is the development of a heart attack two months or more after the previous one.

A repeated infarction is fine-focal and large-focal( extensive), and may be in the same place as the former, or be of a different localization.

Reasons for repeated infarction

The most common cause of any myocardial infarction is arteriosclerosis of the vessels and the deposition of atherosclerotic plaques on the walls of the coronary arteries. This leads to the closure of the lumen of the vessel, and as the plaque builds up and the blood clots settle on it, a complete blockage of the lumen-occlusion occurs. Myocardium stops receiving blood, cells do not get oxygen and die. Necrosis of the heart tissue develops. In case of repeated infarction, the reason lies in the fact that atherosclerosis does not disappear anywhere, plaques continue to exist in the walls of the coronary arteries and can cause their occlusion. In this case, cell death occurs at the periphery of the old cicatrix if the same artery is damaged again as in the first infarction or on the other wall of the heart if a blockage of another artery occurs.

Atherosclerosis and myocardial infarction develop in individuals with the following risk factors:

- Male gender. Men are prone to heart disease more than women, due to the "protective" effect of female sex hormones. But this ratio is applicable up to a certain age, since after menopause women are equally vulnerable to coronary artery disease and heart attack, as well as men. After 70 years, the incidence among them is the same.
- Age is more than 45 - 50 years. As the body ages, its adaptive capacity decreases.
- Genetic predisposition. The presence of heart disease among close relatives.
- Obesity - waist circumference more than 102 cm for men and more than 88 cm for women, or body mass index greater than 25. Calculated by the formula: BMI = height in meters /( body weight in kg) 2
- Diabetes affects the aorta negatively, coronary arteries and small vessels.
- Arterial hypertension worsens heart contractility, causes thickening of its walls, which leads to an increased need for oxygen, and coronary arteries can not meet this need.
- High cholesterol in the blood is the main cause of plaque deposition.
- Improper diet leads to increased cholesterol.
- The sedentary lifestyle contributes to excess weight, the total detenity of the body and heart.
- Chronic stresses contribute to psychogenic increase in blood pressure, constant tachycardia and other heart problems.
- Tobacco smoking and alcohol abuse damage all the vessels from the inside.

Infringement-provoking factors:

- violation of the doctor's recommendations and the maintenance of the former wrong lifestyle( smoking, alcohol abuse)
- lack of compliance( adherence to treatment)
- frequent emotional disturbances
- extreme physical activity
- hypertensive crisis

Symptoms of repeated myocardial infarction

In most cases, repeated infarction manifests itself with the same signs as the previous one. The main complaint is an intense pain syndrome in the chest, in the heart or sternum area that occurs after stress, stress or at rest, a protracted pattern( 15-20 minutes to several hours).Pain can give in the arm, interscapular space, in the jaw and neck, do not disappear when taking nitroglycerin, or the effect of it is short-lived. Pain is accompanied by general weakness, pallor, sweating.

Complaints can be more pronounced than with a previous heart attack, and combine with manifestations of complications, for example, pronounced suffocation and cyanotic skin coloration with pulmonary edema, loss of consciousness, a sharp decrease in pressure and a general severe condition with heart failure and cardiogenic shock.

Sometimes, a repeated infarction can occur in a painless form, and the patient only notes a general malaise and weakness. There are also arrhythmic, asthmatic and abdominal variants.

For the arrhythmic form of a repeated infarction is characterized by complaints of a feeling of rapid heartbeat, interruptions and fading in the heart. Such symptoms are ventricular extrasystole, atrial fibrillation, blockade of the bundle's legs and other rhythm disturbances in the infarction.

The asthmatic version of may not be accompanied by pains in the heart, but manifested by shortness of breath, a feeling of lack of air, a suffocating cough with pink foamy expectoration. These symptoms correspond to pulmonary edema, which is an unfavorable form of the infarction.

The abdominal form of is characterized by complaints of abdominal pain, and is often mistaken for stomach and intestinal problems due to concomitant nausea and vomiting, so the patient consults a doctor later, which also significantly reduces the likelihood of a favorable outcome with repeated myocardial infarction.

Emergency care for suspected myocardial infarction

If symptoms appear, the following should be done:

- put the patient in an elevated position, release the chest and neck from the squeezing clothes, open the window for oxygen access;
- call the ambulance;
- take nitroglycerin under the tongue of one tablet at intervals of 5 - 10 minutes twice;
- chew the aspirin tablet( aspirin Cardio, cardiomagnet, tromboass, etc.);
- when breathing is stopped and there is no pulse, start artificial respiration and indirect heart massage before the doctor arrives.

Diagnosis of recurrent myocardial infarction

It is very important to compare ECG films recorded earlier and for the time being in order to diagnose a repeated infarction. Therefore, for each patient who underwent myocardial infarction, it is always advisable to have with him the ECG tapes made at the last visit to the doctor. But it is not always possible to suspect a second infarction, especially if a new zone of necrosis was formed in the affected area of ​​the same artery as the previous time, or if signs of necrosis on the ECG are masked by atrial fibrillation or a complete blockage of the left bundle of the bundle. Therefore, in diagnostically unclear cases, it is necessary to focus, first of all, on clinical manifestations, and if the doctor considers it necessary to hospitalize in the department with suspicion of a second heart attack, it is better, of course, to be examined in the hospital.
ECG - signs of myocardial infarction:

- signs of myocardium damage( necrosis) of a certain heart wall( deep wide Q tooth in the corresponding leads with ST segment elevation or negative T wave);
- signs of a post-infarction scar may be reduced or completely eliminated. For example, with anterior recurrent infarction, signs of a scar on the back wall disappear, fixed on the previous cardiogram, and vice versa - the so-called "improvement" of the ECG caused by a second infarction;
- in the absence of reliable signs of recurrent myocardial infarction, an indirect sign should be considered even a short-term rise of the ST segment, as a sign of an acute stage of the process.

In addition to ECG, echocardiography has a significant diagnostic value, since it allows to identify zones of hypo- and akinesia, that is, areas of impaired myocardial contractility, and to assess heart function as a whole, such as ejection fraction, stroke volume, blood flow and pressure level in the heart chambers, the aorta and the pulmonary artery.

From laboratory diagnosis of , the presence of a heart attack can be reliably determined by blood tests on the level of creatine phosphokinase( CK and CFC-MB), troponins, lactate dehydrogenase( LDH), ALAT and ASAT.

The CKK rate is 10 - 110 IU or CFC - MB not more than 4 - 6% of the total CK.It should be remembered that the activity of CK-MB increases after 3 to 4 hours from the onset of pain in the heart and returns to an almost normal level after 48 hours.

The norm of troponin in the blood - troponin I 0.07 nmol / l, troponin T 0.2 - 0.5 nmol / l. Troponin I is defined in the blood up to 7 days, troponin T - up to 14 days.

The norm of LDG is up to 250 U / l. It grows during 2 - 3 days from the onset of a heart attack, it returns to the initial level on the 10th - 14th day.

The ASA norm is up to 41 U / l( more specific for heart damage, and ALT for liver damage).It grows in a day, decreases by 7 days after a heart attack.

For differential diagnosis of myocardial and liver damage, the Rytis coefficient is used - the ratio of ASAT to ALAT.If it is more than 1.33, the probability of a heart attack is higher, if less than 1.33 - liver diseases.

MB-CK and troponin test have the greatest cardiospecificity. In addition to these methods, general blood and urine tests, a biochemical blood test, an internal ultrasound scan, a chest X-ray and other methods determined by the doctor are prescribed.

Treatment of repeated infarction

If the patient is delivered to the clinic no later than 12 hours after the onset of a painful attack( or ECG changes in painless form), the greatest efficacy in treatment is noted with thrombolysis and emergency balloon angioplasty.

Thrombolysis is the use of drugs that can "dissolve" a thrombus in the lumen of the coronary artery and restore blood flow to the deceased portion of the myocardium. Streptokinase, urokinase, alteplase are used.

Indications - acute, including repeated myocardial infarction with abnormal Q teeth and ST segment elevation, no later than 12 - 24 hours.

Contraindications - bleeding of any location in the last six months( in the stomach, intestines, bladder, uterine, etc.), strokes in the acute and subacute period, exfoliating aneurysm of the aorta, intracranial tumors, blood clotting disorders, severe surgery or trauma in the last 1.5 months.

Balloon angioplasty is an endovascular( intravascular) injection and installation of a balloon inflated under pressure and restoring the lumen of the vessel. The technique is carried out under the control of the X-ray television.

It is applied either immediately within 12-24 hours from the onset of a heart attack( emergency angioplasty), or 5-7 days after thrombolysis( delayed angioplasty), or routinely with successful elimination of thrombolysis occlusion.

Indications - persisting for one and a half to two hours after thrombolysis of pain and signs of myocardial damage by ECG( thrombolysis is not effective).

Contraindications - are determined individually, because even in the severe condition of the patient, for example, with the development of cardiogenic shock, it is preferable to conduct emergency angiography and angioplasty.

Drug therapy for recurrent myocardial infarction

Begins during the transportation of the patient by an ambulance team. The following drugs are used in combination:
- beta-adrenoblockers - metoprolol, carvedilol;
- antiplatelet agents and anticoagulants - aspirin, clopidogrel, heparin, plavix;
- nitroglycerin and its long-acting analogues - nitroglycerin intravenously, pectrol, nitrosorbide or monocinve in tablets;
- ACE inhibitors - enalapril, perindopril;
- statins, lowering the level of cholesterol in the blood - atorvastatin, rosuvastatin.

Lifestyle with recurrent myocardial infarction

To prevent postinfarction angina and recurrent myocardial infarction, follow the doctor's recommendations:

- permanent, continuous, lifelong reception of beta adrenoblockers, antiplatelet agents and statins
- lifestyle modification - rejection of bad habits, proper nutrition, exclusion of significant physical exertion and stresses
- during the acute period of infarction( 2 - 3 days) strict bed rest( up to7 - 10 days), then therapeutic exercise, appointed by a doctor. After discharge from the hospital, daily physical activity is necessary, but without excessive loads, for example, slow walks on short distances
- in the recovery period after a heart attack, spa treatment is indicated( indications and contraindications are determined by the doctor while in hospital)
- question aboutrestoration of work capacity or disability is decided by the clinical and expert commission at the place of residence and depends on the degree of circulatory disturbance. Temporary disability( sick leave) with a second heart attack is possible for no more than 90 to 120 days, and for reconstructive operations on coronary vessels - up to 12 months. Return to work, even with a good condition of the cardiovascular system, is contraindicated for such working people as workers in socially important occupations( drivers, pilots, railway dispatcher, air traffic controller, etc.), working night or daily shifts, at the height( crane operator), persons, whose work is associated with long walking( postman, courier), etc.

Complications of the disease

Repeated myocardial infarction is often complicated by the development of acute heart failure, pulmonary edema, cardiogenic shock, rhythm disturbancesma heart, rupture of aneurysm of the left ventricle, thromboembolism of the pulmonary artery. Prevention of complications is the timely access to medical care for pain in the heart, the constant intake of prescribed medications, as well as regular visits to the doctor with the registration of the cardiogram.

Forecast

The prognosis of small-focal re-infarction is favorable. For a large-focal, or extensive, infarct, the prognosis is not so optimistic, because complications occur in this form more often, and the lethality in the first 10-14 days is 15-20%.Mortality in men over 60 years of repeated infarction is 14% and in women over 70 years - 19%.

Doctor therapist Sazykina O.Yu.