java barcode reader example F Myocardial Rupture in Objective-C

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F Myocardial Rupture
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Complete rupture of the LV free wall occurs in less than 1% of patients and usually results in immediate death It occurs 2 7 days postinfarction, usually involves the anterior wall, and is more frequent in older women Incomplete or gradual rupture may be sealed off by the pericardium, creating a pseudoaneurysm This may be recognized by echocardiography, radionuclide angiography, or LV angiography, often as an incidental finding It demonstrates a narrow-neck connection to the LV Early surgical repair is indicated, since delayed rupture is common
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An LV aneurysm, a sharply delineated area of scar that bulges paradoxically during systole, develops in 10 20% of patients surviving an acute infarction This usually follows anterior Q wave infarctions Aneurysms are recognized by persistent STsegment elevation (beyond 4 8 weeks), and a wide neck from the LV can be demonstrated by echocardiography, scintigraphy, or contrast angiography They rarely rupture but may be associated with arterial emboli, ventricular arrhythmias, and CHF Surgical resection may be performed for these indications if other measures fail The best results (mortality rates of 10 20%) are obtained when the residual myocardium contracts well and when significant coronary lesions supplying adjacent regions are bypassed
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After the first 24 hours, the focus of patient management is to prevent recurrent ischemia, improve infarct healing and prevent remodeling, and prevent recurrent vascular events
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purely for secondary prevention Antiarrhythmic therapy other than with -blockers has not been shown to be effective except in patients with symptomatic arrhythmias Amiodarone has been studied in several trials of postinfarct patients with either LV dysfunction or frequent ventricular ectopy Although survival was not improved, amiodarone was not harmful unlike other agents in this setting Therefore, it is the agent of choice for individuals with symptomatic postinfarction supraventricular arrhythmias While implantable defibrillators improve survival for patients with postinfarction LV dysfunction and heart failure, the DINAMIT trial found no benefit to implantable defibrillators implanted in the 40 days following acute myocardial infarction Cardiac rehabilitation programs and exercise training can be of considerable psychological benefit and appear to improve prognosis
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Patients with hemodynamic compromise, who are at high risk for death, need careful monitoring and management of volume status
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Just as for non ST-segment elevation acute coronary syndrome, risk stratification is important for management of ST-segment elevation acute myocardial infarction GRACE and TIMI risk scores can be helpful tools Patients with recurrent ischemia (spontaneous or provoked), hemodynamic instability, impaired LV function, heart failure, or serious ventricular arrhythmias should undergo cardiac catheterization (Table 10 5) ACE inhibitor (or ARB) therapy is indicated in patients with clinical heart failure or LV EF < 40% For patients not undergoing cardiac catheterization, submaximal exercise (or pharmacologic stress testing for patients unable to exercise) before discharge or a maximal test after 3 6 weeks (the latter being more sensitive for ischemia) helps patients and physicians plan the return to normal activity Imaging in conjunction with stress testing adds additional sensitivity for ischemia and provides localizing information Both exercise and pharmacologic stress imaging have successfully predicted subsequent outcome One of these tests should be used prior to discharge in patients who have received thrombolytic therapy as a means of selecting appropriate candidates for coronary angiography
C ACE Inhibitors and ARBs in Patients with LV Dysfunction
Patients who sustain substantial myocardial damage often experience subsequent progressive LV dilation and dysfunction, leading to clinical heart failure and reduced longterm survival In patients with EFs less than 40%, longterm ACE inhibitor (or ARB) therapy prevents LV dilation and the onset of heart failure and prolongs survival The HOPE trial, as well as an overview of trials of ACEinhibitors for secondary prevention, also demonstrated a reduction of approximately 20% in mortality rates and the occurrence of nonfatal myocardial infarction and stroke with ramipril treatment of patients with vascular disease and without confirmed LV systolic dysfunction Therefore, ACE inhibitor therapy should be strongly considered in this broader group of patients and especially in diabetics and patients with even mild systolic hypertension, in whom the greatest benefit was observed
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