Myocardial infarction with pulmonary edema

Myocardial infarction with pulmonary edema - cell death of the cardiac muscle segment as a result of their necrosis, which develops due to a sharp disruption of intracellular metabolism with a critical decrease or complete cessation of blood circulation through the coronary arteries (ischemia), which is accompanied by accumulation in the alveoli and lung tissues released from the vessels blood plasma. That is, acute heart failure in patients is complicated by a decrease in respiratory function of the lungs.

An acute infarction has a code for ICD 10 (the latest version of the International Classification of Diseases) - 121; his current complications assigned the code I23. Acute edema of the lung with left ventricular failure (cardiac asthma) is encoded 150.1.

[1], [2], [3], [4], [5]

Causes of myocardial infarction with pulmonary edema

In clinical cardiology, the pathogenesis of myocardial infarction with pulmonary edema (cardiogenic pulmonary edema) is associated not only with sudden occlusion or narrowing of the coronary artery lumen due to progressive atherosclerosis, but also with increased pressure in the left ventricle of the heart in the presence of diastolic dysfunction.

The heart pumps the blood in cycles by alternating rhythmic contractions and relaxation of the cardiac muscle (myocardium) of the "pumping chambers" - the ventricles. During relaxation (diastole), the ventricle should be filled with blood again, so that during the next contraction (systole), throw it into the bloodstream.

With an infarct, as well as with coronary heart disease, high blood pressure (arterial) pressure, aortic stenosis, hypertrophic cardiomyopathy, the ventricles become "hard", that is, they can not completely relax during diastole. This is due to pathological changes, and in the case of myocardial infarction - partial focal necrosis of muscle cell cells, which, due to ischemia, lose glycogen, magnesium, potassium, phosphorus and simultaneously accumulate lipids, sodium, calcium and water.

Cardiogenic pulmonary edema as a result of acute decompensated heart failure is expressed in stagnation of blood in a small circle of blood circulation and pulmonary capillaries, strengthening of hydrostatic pressure in them, as well as in the penetration and accumulation in the tissue and interstitial space of the lungs of the blood plasma squeezed out of blood vessels. This is a potentially fatal cause of acute respiratory failure in general and myocardial infarction in particular.

[6], [7], [8], [9]

Symptoms of myocardial infarction with pulmonary edema

The first signs of a myocardial infarction with pulmonary edema noted by physicians are manifested in the form:

• severe pain behind the sternum, in the heart and in the pit of the stomach;
• violation of heart rate to paroxysmal ventricular tachycardia (180-200 or more cuts per minute);
• increasing general weakness;
• increased blood pressure;
• difficulty breathing (feeling lack of air) in a lying position;
• inspiratory dyspnea (with inhalation of air);
• dry, and then wet wheezing in the lungs;
• coughing with sputum;
• the appearance of cold sweat;
• blueing of the mucous membranes and skin (cyanosis).

A few hours or a day later, the patient's body temperature rises (not above + 38 ° C).

When extravasation of blood cells and subsequent edema affects all lung tissue, which often occurs in left ventricular acute heart failure and myocardial infarction, dyspnea rapidly increases and the violation of alveolar gas exchange develops into choking.

Then, from the interstitial tissues, the transudate can penetrate directly into the alveolar and bronchial cavities. In this case, adhesion of the alveoli occurs, and the patients have strong wet wheezing in the lungs; when exhaled from the mouth appears pink foamy sputum, which is able to block the work of the bronchi and cause hypoxia with a fatal outcome. And the more foam forms, the more this threat is.

Effects

If help has come in a timely manner and has been correctly received, you can avoid the sudden death that occurs due to atrial fibrillation of the ventricles of the heart or asphyxia. And often the consequences of myocardial infarction with pulmonary edema are manifested by the return of severe retrosternal pains, acute heart failure and interruptions in the work of the heart with tachycardia.

As a result of this type of myocardial infarction, the following can develop:

• cardiogenic shock with a fall in blood pressure, a threadlike pulse and subsequent cardiac arrest;
• postinfarction cardiosclerosis - replacement of dead tissue of myocardium with cicatricial;
• acute fibrinous pericarditis - inflammation of the fibrous-serous membrane of the heart, which can progress to exudative pericarditis (leakage of vnekaneva fluid in the pericardial cavity) and eventually lead to cardiac tamponade - the accumulation of excessive fluid volume inside the pericardium;
• partial violation or complete cessation of conduction of intracardiac electrical impulses (atrioventricular block of 2-3 degrees);
• bulging of the damaged area of the wall of the left ventricle (postinfarction aneurysm) - occurs after several months in approximately 15% of cases;
• pulmonary thromboembolism or pulmonary infarction - obstruction of one of the arteries of the lungs, resulting in normal blood supply to the lung tissue and necrosis (in the case of minor lesions, the dead tissue is replaced with scar tissue over time);
• embolic cerebral infarction (cardioembolic stroke).

The prognosis of myocardial infarction with pulmonary edema, given its lethal effects in 25-30% of cases, can not be considered favorable. Death occurs as a result of various localization of external and internal ruptures of the heart muscle tissue that occur in large areas of myocardial necrosis, very high blood pressure, untimely (or ineffective) medical care, and in older age patients.

[10], [11], [12], [13], [14], [15],

Diagnostics

In most cases, the primary diagnosis of myocardial infarction with pulmonary edema is performed by emergency physicians based on a sufficiently pronounced clinical picture of the disease (the symptoms are described above).

Instrumental or instrumental diagnosis of myocardial infarction with pulmonary edema is carried out by listening to the rhythm of the heart with a stethoscope and taking ECG readings - an electrocardiogram.

After admission of the patient to the hospital (often this department of cardiac resuscitation), echocardiography (ultrasound of the heart and lungs) or lung fluoroscopy can be performed.

Analyzes with myocardial infarction with pulmonary edema can determine the scale of the necrotic focus in the myocardium and include a biochemical blood test, according to which the doctors determine the level of leukocytes, platelets, fibrinogen in the blood, ESR and pH. The content of specific proteins is determined: albumin, A2-, Y- and G-globulins, myoglobin and troponins. The level of serum enzyme content of creatine phosphokinase-MB (MB-CKK) and transmnase: aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) is also determined.

Differential diagnosis of myocardial infarction with pulmonary edema should be carried out taking into account the similarity of some symptoms with severe internal bleeding, pulmonary embolism, aortic dissection, pneumothorax, acute pericarditis, acute pancreatitis, perforation of the stomach or duodenal ulcer.

[16], [17], [18], [19]

Treatment of myocardial infarction with pulmonary edema

It should be taken into account that the treatment of myocardial infarction with pulmonary edema is urgent, combining intensive therapy for life indications (indicatio vitalis) with the simultaneous use of pharmacological drugs that improve the functioning of the heart muscle and circulatory and respiratory systems.

Everyone should know that before the arrival of emergency medical care at the first sign of a heart attack a person should not be laid, but to arrange a semi-sitting, and to expand the coronary vessels under the tongue put 1-2 tablets of nitroglycerin, doing this every 10-15 minutes. Also it is necessary to take inside (necessarily chew!) Not less than 150-160 mg Aspirin (acetylsalicylic acid).

With intravenous (jet) administration of Nitroglycerin (1% solution, up to 20 mcg per minute), and doctors are beginning to help. Nitrogicerin acts not only as a vasodilator, but also helps reduce the return of venous blood in the heart and the needs of the heart muscle in oxygen, and also increases its contractions. To stop the pain syndrome, an antipsychotic, antiarrhythmic and adrenolytic effects are injected intravenously. Dehydrobenzperidol (Droperidol, Inapsin) in combination with a powerful analgesic Fentanyl (or their ready-made mixture - Talamonal). Used to relieve pain Morphine and Promedol act on respiration depressingly.

The management of pulmonary edema with myocardial infarction (after intravenous administration of Nitroglycerin and narcotic painkillers) is continued by submerging oxygen (using a mask, nasal cannula, or by intubation) in the patient's airway. To suppress the formation of foam during pulmonary edema, oxygen is fed through gauze moistened with medical alcohol (60-70%), with the same purpose, the liquid preparation Antifosilan is used. And intravenous injection of diuretics - Furosemide (Lasix), Bumetanide, Piretamide or Urehit - allows to reduce the volume of circulating fluid in the body, but they are used only at high blood pressure.

If there is an obvious threat or early development of cardiogenic shock, emergency therapy includes injections: Dopamine or Dobutamine (stimulates myocardial contraction, supporting coronary and general blood circulation), and also Metoprolol, Isoproterenol, Enalapril, Amrinone - to maintain rhythm and conduction of the heart.

In resuscitative cardiology, such drugs are used for myocardial infarction with pulmonary edema:

• Anticoagulants (Heparin, Neodikumarin, Sinkumar) and thrombolytics (Streptokinase, Anistreplase, Alteplase, Urokinase) - to reduce blood clotting, dissolve thrombus and resume blood flow through the coronary vessels.
• Ganglia-blockers (Nitroglycerin, Sodium nitroprusside, Pentamine, Benzohexonium) - to reduce the load on the small circle of blood circulation.
• Antiarrhythmic drugs (reduce the heart rate) - Propafenone, Mexilil, Procainamide, as well as an anesthetic Lidocaine.

Beta-blockers (Metoprolol, Propranadol, Amiodarone, Atenolol, Solatol) - also have antiarrhythmic effect.

• Glucocorticosteroids (Prednisolone, Hydrocortisone) - for stabilization of cell and lysosomal alveolar-capillary membranes.
• ACE (angiotensin-converting enzyme inhibitors) - Enalapril, Captopril, Lizinopril, Ramipril - improve the flow of blood into the myocardium and reduce the cardiac load.
• Antiaggregants (Aspirin, Warfarin) - to reduce platelet aggregation and thrombogenesis.

In the absence of the effect of the aforementioned medications, defibrillation is carried out - cardiopulmonary resuscitation with the help of electropulse action on the heart.

Operative treatment

To date, surgical treatment of myocardial infarction with pulmonary edema and left ventricular failure is the opening of a clogged blood vessel with the aid of an intra-aortic balloon counterpulse (balloon coronary angioplasty).

Through the femoral (or radial) artery, a special catheter equipped with a balloon made of polyurethane is inserted into the aorta, into the zone of atherosclerotic narrowing of the lumen. With the help of a pump (adjusted by the computer according to ECG indications) helium is injected into the balloon (in the diastolic phase of the contractile heart cycle), the balloon swells, and the diastolic pressure rises in the aorta. This increases the coronary blood flow, the heart continues to work, but with much less stress.

When the balloon is blown off, diastolic and systolic pressure, as well as resistance to blood flow, decrease. As a result, the load on the left ventricle and the damaged myocardium is significantly reduced, as is its need for oxygen.

To remove the balloon once again, the lumen of the vessel does not become narrower again, the stent is installed on the damaged site of the vascular wall - a metal mesh "prosthesis" that from the inside holds the vessel, not allowing it to narrow.

Coronary artery bypass grafting (not later than 6-10 hours from the time of myocardial infarction, until irreversible changes in the myocardium) is performed instead of a new vessel blocked by a blood clot and restoration of coronary blood flow. In this operation, bypassing the damaged vessel, an autoimmunity is implanted - a segment of the saphenous vein from the patient's leg. Another approach is mammaro-coronary bypass, in which the internal thoracic artery (on the left side) is used as a shunt. As cardiac surgeons note, with complete occlusion of the vessel, stent placement is impossible and then only shunting is performed.

The decision to conduct urgent surgical intervention is made on the basis of the clinical picture of myocardial infarction, ECG data and radiographic examination of heart pulsation (electrocampography), and also taking into account the biochemical blood test for serum enzymes. But the cardiologists consider the results of the radiographic contrast examination of the heart (coronary angiography) to be the decisive factor, which makes it possible to assess the state of all intracardiac vessels.

As a method of choice, aortocoronary shunting can not be performed with obliterating coronary endarteritis (atherosclerosis of several coronary arteries), diabetes mellitus, acute inflammatory and oncological diseases.

Alternative treatment

What can be an alternative treatment for myocardial infarction with pulmonary edema?

When a person is in intensive care, often on the verge of life and death, no herbal treatment of myocardial infarction with pulmonary edema is simply impossible ...

Over time, in the post-infarction period - but only on the advice of a doctor - this is permissible. As a rule, in herbal medicine for cardiological problems, decoctions of the herb of the motherwort, hearth nettle, stinging nettle, sweet potato, fruits and flowers of the hawthorn prickly, the roots of elecampane high are used. Alternative healers are advised to drink carrot juice, eat nuts with honey,

As practice shows, homeopathy with myocardial infarction with pulmonary edema is not applied.

Although as an auxiliary method it can be used - again, on the recommendation of an experienced physician - during traditional medical treatment of cardiac arrhythmias, for example, arrhythmia.

[20], [21], [22], [23]

Prevention

If you ask any cardiologist what is the prophylaxis of myocardial infarction with pulmonary edema, the specialist's answer will consist of a few simple points:

• regular exercise,
• normalization of body weight (i.e., revision of the nutritional system and the assortment of food products used),
• refusal from smoking and drinking alcohol,
• timely detection and treatment of atherosclerosis, arterial hypertension, angina pectoris, renal failure, and other diseases.

For example, elderly Americans, in order to avoid a heart attack, drink aspirin, and overseas doctors say that this reduces the risk of a heart attack by almost a quarter.

They also believe that the main factor of cardiovascular risk is a positive family history of myocardial infarction (including accompanied by pulmonary edema). Although to determine the genes responsible for the hereditary component of the infarction, to date, failed. And many researchers focused on finding new approaches to the prevention and therapy of myocardial infarction with pulmonary edema on the basis of available genetic information.