Mi ka management batao pura
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Myocardial Infarction (MI) ka management ek medical topic hai - pehle medical library skill padhta hoon.
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Fuster's Heart aur Washington Manual mein comprehensive content hai. Teen files parallel mein padhta hoon:
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Myocardial Infarction (MI) - Pura Management
Overview (STEMI vs NSTEMI)
MI do types ka hota hai:
- STEMI - ST-segment elevation MI (complete coronary occlusion)
- NSTEMI - Non-ST-elevation MI (partial occlusion, enzyme raise hoti hai)
STEP 1 - Immediate / Upstream Therapy (Sabse Pehle)
Jab bhi MI suspect ho, turant ye drugs deni chahiye:
| Drug | Dose | Note |
|---|---|---|
| Aspirin (ASA) | 162-325 mg chew karke | Sabko dena hai, contraindication na ho to |
| P2Y12 inhibitor (clopidogrel/ticagrelor/prasugrel) | Loading dose | Ticagrelor: 180 mg load, fir 90 mg BD |
| Anticoagulant (UFH/LMWH) | UFH: 60 units/kg IV bolus + 12 units/kg/h | Thrombolysis ya PCI dono ke saath |
| Nitroglycerin | 0.4 mg sublingual, har 5 min mein 3 baar | Hypotension ho to mat do |
| Oxygen | Sirf agar hypoxic ho (SpO2 <90%) | Routine oxygen band kar di gayi hai |
| Beta-blocker (Metoprolol) | 25 mg PO | HF, shock, advanced AV block, bronchospasm mein AVOID |
| Morphine | Pain ke liye | Caution - ongoing ischemia symptoms mask kar sakta hai |
STEP 2 - Reperfusion Strategy (STEMI Ke Liye Sabse Zaroori)
Reperfusion = STEMI ka cornerstone treatment hai. Baaki sab secondary hai.
Option A - Primary PCI (Preferred)
- Door-to-balloon time < 90 minutes mein available ho to PCI hi karo
- PCI > thrombolysis kyunki:
- Better vessel patency (TIMI 3 flow)
- Kam reinfarction
- Hemorrhagic stroke ka risk bahut kam
- Improved survival
- Symptom onset se 12 hours ke andar sabse effective
Option B - Thrombolysis (Jab PCI 90-120 min mein available na ho)
Drugs:
- Alteplase (rt-PA): 15 mg IV bolus, fir 0.75 mg/kg 30 min, fir 0.5 mg/kg 60 min
- Reteplase: Do 10-unit IV boluses, 30 min apart
- Tenecteplase (TNK): 0.5 mg/kg single IV bolus
Thrombolysis ke baad:
- Chest pain relief + >50% ST reduction at 90 min = successful reperfusion
- Reperfusion arrhythmia (accelerated idioventricular rhythm) bhi sign hai
- Sab patients ko 24 hours mein coronary angiography ke liye refer karo
Thrombolysis Contraindications (Absolute):
- Intracranial hemorrhage history
- Ischemic stroke 3 months ke andar
- Aortic dissection
- Active bleeding
- Severe uncontrolled HTN (SBP >180 / DBP >110)
- Acute pericarditis
STEP 3 - Antiplatelet & Anticoagulation Detail
Antiplatelet (DAPT - Dual Antiplatelet Therapy):
- ASA lifelong 81 mg/day (PCI ke baad)
- P2Y12 inhibitor sath dena hai:
- Ticagrelor 90 mg BD (clopidogrel se better, mortality benefit)
- Prasugrel (PCI ke liye)
- Clopidogrel (sirf thrombolysis ke sath use karo)
Anticoagulants:
| Drug | Dose | Note |
|---|---|---|
| UFH | 60 units/kg bolus + 12 units/kg/h | PCI aur thrombolysis dono mein |
| Enoxaparin (LMWH) | 30 mg IV bolus, fir 1 mg/kg SC BD | >75 years: bolus nahi, 0.75 mg/kg SC |
| Bivalirudin | 0.75 mg/kg bolus + 1.75 mg/kg/h | Sirf PCI mein validated |
| Fondaparinux | 2.5 mg IV, fir 2.5 mg SC daily | Thrombolysis mein preferred, PCI mein catheter thrombosis risk |
STEP 4 - Peri-Infarct / CCU Management
- CCU mein admit karo - minimum 24 hours telemetry monitoring
- Daily assessment: chest pain, HF symptoms, ECG
- Echocardiogram (ECHO) baseline lena zaroori:
- EF check karo
- Wall motion abnormality
- Valvular lesions
- Ventricular thrombus
- Pacing: AV block aane par - inferior wall MI mein transient hota hai, anterior wall MI mein unstable ho sakta hai (temp pacemaker laga sakte hain)
STEP 5 - Secondary Prevention (Long-Term, Discharge Ke Baad)
Ye medicines survival improve karti hain:
| Drug | Purpose |
|---|---|
| Aspirin 81 mg lifelong | Antiplatelet |
| P2Y12 inhibitor (1 year tak DAPT) | Post-stenting |
| Beta-blocker (Metoprolol/Carvedilol) | Mortality benefit, LV remodeling rokta hai |
| ACE inhibitor / ARB | Post-MI, especially LV dysfunction mein |
| High-intensity Statin | LDL <70 mg/dL target |
| GPIIb/IIIa inhibitor | Sirf PCI + stenting mein |
NSTEMI / Unstable Angina (UA) Management
NSTEMI mein thrombolysis NAHI dete - ST depression mein contraindicated hai.
- DAPT + anticoagulant dena hai
- Risk stratification karo (TIMI score / HEART score)
- Early invasive strategy (coronary angiography within 24-48 hours)
Complications Jo Monitor Karni Hain
- Arrhythmias (afib, VT, VF) - sabse common early complication
- Cardiogenic shock - intra-aortic balloon pump / vasopressors
- Mechanical complications - papillary muscle rupture (severe MR), VSD, free wall rupture (emergency CABG)
- Ventricular aneurysm
- Dressler's syndrome (post-MI pericarditis)
Yaad Rakhne Ka Formula (Mnemonic) - "MONA + DAPT + Reperfusion"
| Letter | Meaning |
|---|---|
| M | Morphine (pain ke liye) |
| O | Oxygen (sirf hypoxia mein) |
| N | Nitrates |
| A | Aspirin |
| DAPT | Dual Antiplatelet Therapy |
| Reperfusion | PCI first choice, thrombolysis second |
Sources: Washington Manual of Medical Therapeutics, p.152-160 | Symptom to Diagnosis, 4th Ed., p.175 | Fuster & Hurst's The Heart, 15th Ed.
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