Management of the complicated myocardial infarct General

• Oxygen to maintain SaO2>98%

• Appropriate and prompt monitoring and investigations as indicated, e.g. echocardiogram, pulmonary artery catheter, angiography, ECG

• Early thrombolysis should still be given. rt-PA followed by heparin should be given in preference to streptokinase if invasive procedures and/or surgery are contemplated.

• Arterial or central venous cannulation should not be delayed if clinically indicated. These procedures should be performed by an experienced operator to minimise the risk of bleeding. The subclavian route should be avoided.

• Angioplasty or revascularisation surgery is beneficial if performed early. The cardiologist should be informed promptly if a patient is admitted in pump failure, continuing pain, or valvular dysfunction.

Specific

• Cardiopulmonary arrest—cardiopulmonary resuscitation

• Continuing chest pain:

• If ischaemic — IV nitrate and heparin infusions, aspirin, clopidogrel, calcium antagonist and p-blocker (unless contraindicated); consider urgent angiography.

• If pericarditic—consider non-steroidal anti-inflammatory agent

• Management of heart failure — also consider IABP

• Tachyarrhythmia — antiarrhythmics, synchronised DC cardioversion

• Bradycardias — chronotrope, consider temporary pacing

• Valve dysfunction —heart failure management; consider surgery

• Pericardial tamponade —pericardial aspiration

• Ventricular septal defect—heart failure management, consider surgery

• Thrombolysis complications

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