Recurrent myocardial infarction. Second myocardial infarction consequences. cardiac asthma. Pulmonary edema

Fedorov Leonid Grigorievich

The reasons

The main influence on the development of the problem is exerted by atherosclerosis of the vessels. If fatty deposits appear on the walls, then their lumen narrows, and blood circulation is disturbed. If an atherosclerotic plaque breaks away from the wall of the artery, it will block or completely block the lumen. At the same time, the myocardium suffers from insufficient blood flow, which is accompanied by the death of its cells and necrosis of certain areas of the heart muscle.

This problem can also cause a second attack, since atherosclerosis will not go anywhere, and plaques continue to be on the walls of blood vessels. And if the old artery becomes clogged again, then the cells next to the old scar will die off, thereby increasing the area of ​​the lesion.

The development of a repeated attack can occur under the influence of:

• gender. Men suffer more from pathologies of the cardiovascular system. This is due to the fact that female sex hormones protect against such disorders, but until a certain age. With the onset of menopause, the latter also become vulnerable to such diseases;
• age-related changes in the body. After age 50, the risk of heart attack increases;
• genetic predisposition;
• obesity;
• diabetes mellitus. Violation of metabolic processes negatively affects the state of the aorta, coronary arteries and small vessels;
• arterial hypertension. High pressure leads to a deterioration in the contractility of the heart, thickening of the walls of the myocardium, an increase in oxygen demand;
• high levels of cholesterol in the blood, which is deposited on the walls and forms plaques;
• improper nutrition. It helps to increase the level of cholesterol in the blood;
• a sedentary lifestyle, due to which body weight increases and the endurance of the whole organism decreases;
• chronic stress. They lead to an increase blood pressure, permanent and other disorders in the work of the heart;
• alcohol abuse and smoking. This leads to damage to the vessels from the inside.

A second heart attack may occur if the patient:

• does not follow the recommendations of the doctor and leads the same way of life with the use of alcoholic beverages and smoking;
• often nervous, experiencing stress;
• exposes the body to physical stress;
• suffered a hypertensive crisis;
• undergoing a course of treatment that does not have a positive effect on the body.

Types of pathology

The second time the patient may experience a recurrent or repeated heart attack. These attacks have one difference.

Recurrent myocardial infarction is an attack that develops for several months after the previous one, it happens in the acute period.

A second heart attack may occur later than two months later. The focus may be in the same place as the first, or have a different localization. Distinguish extensive and heart attack.

Such cases are not uncommon, which is associated with non-compliance by patients with doctor's prescriptions in the acute period. Relapses are observed in 40% of patients. The risk of a recurrent attack is highest in the first days after a heart attack.

It is desirable for people belonging to the risk group to be registered with a cardiologist for a year.

How many heart attacks can you endure?

There is no exact answer to the question of how many heart attacks a person can endure. It all depends on the size and depth of lesions, the number of coronary vessels involved in the pathological process. often one is enough, since large volumes of the heart muscle are damaged, which completely changes the work of the heart. In the case of a better situation, a person can endure two or three of them.

A severe course of a heart attack is usually observed in people at a young age. In older patients, collateral circulation is gradually established, in which blood bypasses the affected area.

After an attack, the likelihood of a relapse is high. You can protect yourself with acetylsalicylic acid, angiotensin-converting enzyme inhibitors and beta-blockers.

It is also important to monitor blood pressure so that it does not exceed acceptable limits.

There are cases when a person dies after the first attack. Three heart attacks or more can be transferred by those who have a small area of ​​​​damage. This will only reduce the performance of the heart muscle, but will not harm the contractile abilities of the heart. But even in this case, it is important to remember that each repeated attack increases the risk of death, as the amount of necrotic tissue increases.

Characteristic symptoms

Recurrent myocardial infarction has the same symptoms as the previous attack. Its main is severe pain in the region of the heart or sternum. Such sensations usually appear as a result of stress, physical exertion, or even at rest. The duration of the pain syndrome is from 15 minutes to several hours. The pain radiates to the arm, shoulder blade, neck, jaw. The use of Nitroglycerin does not help alleviate well-being or gives only a short-term effect. Because of the pain, sweating increases, the person turns pale, feels severe weakness.

The clinical picture with a second attack will be more pronounced. The main symptoms are accompanied by manifestations of complications. If pulmonary edema occurs, then suffocation occurs and the skin becomes bluish. With and cardiogenic shock, arterial blood pressure drops sharply.

A heart attack is an extreme variant of the course of coronary heart disease. It happens when there is an acute lack of blood supply to the heart muscle, resulting in cell death in a certain area. Unfortunately, some people, even after successful treatment, may experience a second myocardial infarction, which is associated with great danger, especially in the early recovery period.

It is interesting! Statistics say that this can happen in 20-25% of patients who have had a heart attack.

Unfortunately, it is impossible to know for sure whether a recurrence of a heart attack will occur in a particular patient or not. However, there are special scales that allow you to assess the risk and likelihood of such an event.

Repeated and recurrent heart attacks greatly reduce myocardial contractility, which provokes the rapid progression of heart failure, so patients suffering from coronary disease heart, you need to be more attentive to your own health and follow all the recommendations of doctors. This will reduce the likelihood of serious complications.

Etiology

The main reason for the development of this pathology is atherosclerosis, leading first to chronic coronary heart disease, and then to its acute manifestation - a heart attack. In a certain part of patients, it can develop even against the background of complete well-being, however, this is less common. There is no clear cause, which would be considered the main risk factor for the development of atherosclerosis, it is considered a multifactorial disease.

According to recent studies, the main role is played by dysregulation of vascular tone and endothelial dysfunction in combination with an excess of atherogenic lipids and lipoproteins. As a result, excess fat penetrates into the vascular walls and forms first lipid spots, and then atherosclerotic plaques. They can significantly narrow the lumen of the vessel, interfering with blood flow, which will lead to ischemia of the myocardium or other peripheral organs.

The following risk factors have been identified that affect the likelihood of developing atherosclerotic lesions. These include:

1. Age.
2. Obesity or metabolic syndrome.
3. arterial hypertension.
4. Diabetes mellitus or impaired glucose tolerance.
5. congenital predisposition.
6. Elevated levels of cholesterol and low-density lipoproteins in the blood.
7. Sedentary lifestyle, hypodynamia.
8. Chronic stress disorders, neurosis.
9. Drinking alcohol, smoking.

Note! Even without taking medication, you can reduce the risk of developing a heart attack. It is enough just to give up bad habits, switch to a proper, balanced diet and lead a healthy lifestyle.

Pathogenesis

Due to the fact that the integrity of the endothelium is violated at the site of plaque formation, this provokes a gradual increase in a blood clot on it. At the same time, there are unstable plaques that easily fall apart, which leads to the separation of a blood clot and plaque pieces and their entry into the bloodstream. There they travel with the bloodstream until they occlude a smaller vessel, causing its complete obstruction.

At the same time, a thrombus can form again at the site of the plaque, which can subsequently lead to a recurrence of a heart attack. Due to the lack of oxygen, the cells of the heart muscle quickly die or are “stunned”. As a result, myocardial contractility drops sharply, acute heart failure, hypotension and shock develop. Frequent consequences are ventricular arrhythmias, which increase mortality.

Classification

Despite the fact that the heart attack is always based on insufficient coronary blood flow and cell death, there are different variants this disease. Depending on which part of the heart is affected, the following types of heart attacks are considered:

• Front.
• Rear.
• Lower.
• Side.
• Mixed version, for example, anterolateral, posteroinferior or circular.

It is interesting! Also distinguish between left and right ventricular infarction and an isolated lesion of the apex of the heart or interventricular septum.

A heart attack is called recurrent, which is caused by a repeated entry of a blood clot into the same coronary artery, which leads to a second lesion of an already ischemic area within the first week from the moment of the first heart attack. Repeated is called a heart attack associated with an embolism of another coronary artery, while the second focus appears no earlier than a month after the first attack. Therefore, it is very important not to lose extracts from the medical history - if necessary, this will help doctors make a correct diagnosis.

Clinical picture

In the case of acute coronary syndrome, patients complain of a very characteristic intense pain in the sternum and to the left of it, which often radiates to the region of the scapula and left arm. Anginal pain, as a rule, is described by people as burning, baking, less often - as a feeling of strong pressure on a section of the chest wall. However, there are cases when complaints of abdominal pain, nausea and vomiting prevail. This happens with posterior inferior localizations of heart attacks. These symptoms are due to activation of the phrenic nerves.

It is important! Unlike angina attacks, pain in a heart attack can last much longer and does not disappear after taking nitrates.

In addition to direct pain, signs of heart failure may appear already in the early stages - patients complain of sudden or increased shortness of breath, coughing. On examination, swelling of the legs and abdomen, a pale or even cyanotic complexion can be detected. Often a heart attack is complicated by arrhythmias. Ventricular arrhythmias almost always lead to hypotension, acute heart failure and shock in patients, so it is extremely important to provide patients with a heart attack with qualified medical care as soon as possible.

First aid and further treatment

If a person complains of chest pain and other signs that suggest a heart attack, it is necessary to give him a Nitroglycerin tablet, let him lie down and call an ambulance.

Remember! The sooner doctors can provide qualified assistance, the better. Time is one of the main criteria for successful treatment in case of a heart attack.

Doctors at the first stage should take an electrocardiogram of the patient. It is advisable to familiarize yourself with the previous ECG tapes, if the patient has them. In any case, the patient should be hospitalized in a cardiological hospital. There are techniques that allow in the early stages to restore the patency of the affected coronary artery and resume blood flow, thus minimizing damage to the heart muscle.

For this purpose, special drugs can be used that dissolve blood clots, or a minimally invasive surgical intervention - angiography, followed by stenting of the affected artery. However, both of these methods come with certain risks. In addition, they are most effective only in the first hours after the onset of symptoms. Therefore, it is very important not to waste precious time and not wait until the pain goes away “by itself”.

Recurrent myocardial infarction is a rather serious condition that is associated with high risks for the patient. This is due to the fact that after several heart attacks, the mass of the working myocardium is significantly reduced, it is replaced by scar tissue, the contractility of the heart decreases in a person, which leads to aggravation of heart failure, a significant decrease in the quality of life and a worse prognosis.

Also, one should not forget about the risk of developing acute heart failure or life-threatening ventricular arrhythmias in the acute stage. The cause of the second infarction, as a rule, is atherosclerosis and further destabilization of the plaque with the ingress of thrombotic masses into the coronary arteries. To avoid this, after the first case, patients are prescribed a special treatment regimen designed to slow down the processes of atherogenesis and thrombosis.

Therefore, for a second and subsequent heart attack, it is necessary to review the treatment regimen and make sure that the patient understands the prescriptions made and follows them. If necessary, you need to once again explain to the patient the seriousness of this pathology and convince him that he should take medication and monitor his health.

Recurrent myocardial infarction called the repetition of an acute infarction during the entire acute period of the previous infarction, i.e., a relapse occurs in the period from 3 days to 2 months from the onset of the first infarction. In most cases, such a recurrence is localized in the area of ​​​​the first infarction or along its periphery, as if increasing its size. Sometimes it has localization and at a distance from the first heart attack. A repeated myocardial infarction is an acute infarction that has developed against the background of postinfarction cardiosclerosis, i.e. later than 2 months after the onset of the first heart attack.

It can develop both in the same wall hearts. as the first one, and in the other wall, including in the area diametrically opposite to the location of the first infarct in their relation to the "electric center" of the heart. Depending on the relative position of infarctions and their size, the electrocardiographic picture and the difficulties of diagnosis both in the acute period of a repeated infarction and in the period of its scarring significantly depend.

Recurrent myocardial infarction develops during an acute infarction, i.e. from 3 days to 2 months from the onset of the first heart attack. In the acute period of relapse or re-infarction, changes in all teeth and segments of the ECG can be observed. The QRS complex is deformed due to a change in the direction of the previously deviated pathological EMF vector, depending on the relative position of the primary and recurrent infarcts.

When repeated heart attack. developed on the side of the left ventricle opposite to the first infarction, the initial QRS vector deviates in the direction opposite to its original direction determined by the first infarction. As a result, the Q wave, reflecting the first infarction, decreases or disappears depending on the size of the re-infarction. The same ratios of sizes of opposite infarcts determine the appearance or absence of a pathological Q wave in the leads corresponding to the localization of a repeated infarction (or in the leads opposite to it, an increase in the reciprocal R wave).

If a second heart attack greater than the first, then the old Q wave disappears, a new pathological Q appears in the leads corresponding to a re-infarction, or R increases in the leads opposite to a re-infarction. In this case, one heart attack is diagnosed. And with equal sizes of heart attacks in the cicatricial stage, there may be no signs of both heart attacks. However, even in such cases, in the most acute period of re-infarction, an increase in the RS-T segment or its reciprocal downward displacement in leads from the opposite side will be recorded.

Recurrent myocardial infarction often localized on the same side of the heart as the primary one, as if increasing it. In such cases, a pathological Q wave appears or an R wave decreases in leads located next to leads where the ECG was previously changed and the RS-T segment is shifted upward. rise of RS - T, then inversion of T will come to light. At a unilateral arrangement of both heart attacks on an ECG in a cicatricial stage the picture of one extensive heart attack is observed.

In cases of location heart attack primary and repeated in different walls (but not diametrically opposed to each other) on the ECG there may be changes in the QRS complex, the RS-T segment and the T wave, characteristic of both heart attacks.

terminal part of the ventricle complex. as a rule, changes significantly in the acute stage of recurrent infarction. However, these changes in the RS-T segment and T-wave may be short-lived, especially RS-T shifts. Therefore, daily ECG dynamics is necessary.

With repeated heart attacks, changes in the R wave are often observed, indicating an overload of the left atrium.

For ECG diagnostics re-infarction, determining its size and diagnosing an old scar, it is of great importance to compare the latest ECGs with old ECGs.

Recurrent myocardial infarction

A repeated MI is said to occur if it develops several months (usually at least 2) or years after a previous infarction, i.e., after the complete completion of the scarring of the previous focus. Most often it occurs within the 1st year.

There is a trend towards an increase in the number of patients with recurrent infarction, which is explained by the improvement in early diagnosis and treatment of myocardial infarction, as well as an increase in the number of patients with chronic coronary artery disease. More often, repeated MI develops in men. Among the patients, elderly people predominate. The development of repeated MI contributes to hypertension, especially hypertensive crises.

The clinical picture of recurrent MI is influenced by a number of factors: the duration of the interinfarction period, the size of the newly emerging infarction, the initial state of the heart muscle [Popov VG 1971, etc.]. Repeated MI is more severe, with frequent development of acute and then chronic heart failure. Asthmatic variant of a heart attack, an atypical course of the disease, a tendency to various arrhythmias are not uncommon. Mortality in recurrent myocardial infarction, as well as in a protracted course of myocardial infarction, is significantly higher than in the primary one.

Electrocardiographic diagnosis of recurrent MI is difficult in many cases. ECG changes can be very diverse. They depend on the localization of cicatricial and fresh focal changes in the myocardium, their magnitude, the period elapsed from the previous infarction to the last, the number of infarcts.

The so-called pseudonormalization of the ECG may be observed, for example, the appearance of a positive T wave instead of a negative one or an increase in the previously reduced S-T interval to the isoelectric line. Therefore, to identify repeated focal changes and clarify their localization, it is important to compare the ECG with the previous ones and dynamic monitoring of the ECG.

If, based on the ECG, it is difficult to conclude that there are repeated fresh focal changes in the myocardium, the clinic of the disease, the dynamics of changes in blood composition, temperature, enzymes should be especially carefully analyzed, myocardial scintigraphy with pyrophosphate should be performed. In such cases, it is possible to confirm or reject the diagnosis of recurrent MI only with a sufficiently long (at least 5–7 days) observation.

"Myocardial infarction", M.Ya. Ruda

Protracted and recurrent course of myocardial infarction

Complications of myocardial infarction

Complications of myocardial infarction can be early, occurring in the acute period of the disease, and late, forming in the subacute period.

Cardiogenic shock

is one of the most severe early complications of acute myocardial infarction.

Pathogenesis

In the pathogenesis of cardiogenic shock, several links are distinguished: a decrease in the pumping function of the myocardium, a decrease in vascular tone, and in the presence of arrhythmia (especially with ventricular paroxysmal tachycardia), an additional decrease in cardiac output.

The severity of cardiogenic shock correlates with the area of ​​the focus of necrosis in infarction, i.e., depends on the decrease in the mass of the functioning myocardium of the left ventricle. In patients with repeated myocardial infarction against the background of already existing postinfarction scars, cardiogenic shock can also occur with a small-focal form of infarction.

As a result of the listed pathogenetic changes, severe disturbances in the microcirculation of organs and tissues occur with the formation of erythrocyte stasis, an increase in the permeability of capillary walls and the development of metabolic acidosis.

In the development of cardiogenic shock, the initial state of the patient is also important, as in persons suffering from hypertension. cardiogenic shock can develop with a moderate decrease in blood pressure (up to 130/80 mm Hg).

The severity of cardiogenic shock depends on:

1) its duration;

2) reactions to pressor amines;

3) the severity of oliguria;

4) severity of acidosis;

5) indicators of arterial and pulse pressure. The most severe is the so-called areactive shock. resistant to antishock therapy.

Clinic

Cadiogenic shock is manifested by a sharp decrease in arterial (especially pulse) pressure, which is accompanied by symptoms of shock. pallor, sometimes cyanosis of the skin, cold, sticky sweat. At the same time, facial features are pointed, the pulse is thready, systolic blood pressure is below 70 mm Hg. Art. disturbance of consciousness in varying degrees, oliguria up to anuria are noted.

cardiac asthma. Pulmonary edema

The development of these complications is associated with the weakness of the contractile function of the left ventricular myocardium with massive necrotic myocardial damage and a sharp increase in diastolic pressure in the left ventricle. Left ventricular failure occurs during a painful attack or immediately after it ends.

Pathogenesis

In the pathogenesis of left ventricular failure, not only a decrease in the pumping function of the heart is important. but also a reflex spasm of the pulmonary vessels (Kataev's reflex), an increase in the permeability of the capillary wall as a result of hypoxia and activation of the sympathoadrenal system. As a result, the pressure in the pulmonary veins and capillaries rises sharply, the liquid part of the blood exits from their lumen, first into the lung tissue (interstitial edema), and then into the alveoli (alveolar edema).

Clinic

Cardiac asthma is clinically manifested as an asthma attack, which is accompanied by pallor of the skin, acrocyanosis and the appearance of cold sweat.

The patient is agitated, feels fear of death, takes a forced position - orthopnea.

Auscultatory in the lungs (at first only in the lower sections, and then over the entire surface) are determined moist rales, often combined with dry wheezing caused by concomitant bronchospasm. With the progression of edema, moist rales increase, breathing becomes bubbling, foamy sputum appears, often with an admixture of blood.

Radiologically, the picture of a “stagnant lung” is determined with a cloud-like basal thickening of the lung pattern, gradually clearing towards the periphery.

Rhythm and conduction disorders

Rhythm and conduction disturbances occur in the vast majority of patients with myocardial infarction.

In connection with the formation of a focus of necrosis, the threshold of myocardial excitability decreases, foci of pathological impulses appear, conditions are created for the “re-entry” mechanism, and intracardiac conduction slows down. Rhythm and conduction disturbances in myocardial infarction are often transient. The occurrence of arrhythmia significantly changes hemodynamics.

Rhythm disturbances accompanied by tachycardia with a significant decrease in stroke and minute output (tachysystolic form of atrial fibrillation, paroxysmal ventricular tachycardia) are unfavorable prognostically. They can cause further development of arrhythmogenic shock or acute heart failure. Some arrhythmias may precede or provoke other more severe and unfavorable prognostic arrhythmias. Complete atrioventricular blockade can be accompanied by Morgagni-Adams-Stokes attacks in the form of a short-term loss of consciousness with convulsions and cause the development of heart failure.

Heartbreak

Rupture of the heart is a rare complication of myocardial infarction. but leads to almost 100% lethality. It often occurs on the 5-6th day from the onset of a heart attack, but it can also occur in the first days of the disease. Myocardial rupture is clinically manifested by severe pain, which is not relieved by taking analgesics. With a rupture of the myocardial wall, a picture of cardiogenic shock and cardiac arrest quickly develop. caused by cardiac tamponade.

With an extensive gap, death occurs instantly, with a small gap - within a few minutes or even hours.

With a small ("covered") gap, a false aneurysm may form. which prolongs the life of patients by several months.

Rupture of the interventricular septum is manifested by auscultatory rough systolic murmur in the lower third of the sternum and the rapid development of total circulatory failure.

Abdominal syndrome

Abdominal syndrome develops in the acute period of myocardial infarction and can occur in various clinical forms: formation of acute erosions and ulcers of the mucous membrane gastrointestinal tract, development of paresis of the stomach, intestines, atony of the bladder.

The formation of ulcers and erosions is associated with mucosal hypoxia against the background of hemodynamic disorders, thrombosis of small vessels, and the action of medications (aspirin).

The formation of ulcers is accompanied by pain, unstable stools, and sometimes bleeding (vomiting coffee grounds, melena).

Intestinal paresis manifests itself as bloating, arching pains, delayed stool and gas, and may be the result of repeated administration of morphine and atropine, as well as atony of the bladder.

Epistenocardiac pericarditis

Aseptic inflammatory process, which is manifested by a limited and short-term pericardial friction rub.

Irritation of subepicardial arrhythmogenic zones can cause supraventricular arrhythmias.

In some patients, pericardial effusion may organize with the formation of adhesions.

heart aneurysm

This is a limited protrusion of the wall of the myocardium, usually the left ventricle. More often an aneurysm is formed in the acute, less often in the subacute period of myocardial infarction. Its formation is associated with the pressure exerted by the blood on the damaged area of ​​the heart muscle.

More often an aneurysm is formed in the area of ​​the anterior wall of the myocardium, less often - the apex, posterior wall or interventricular septum.

On palpation of the patient, precordial pulsation is determined in the region of the III-IV ribs to the left of the sternum. The left border of the heart is shifted to the left to the midaxillary line. Auskultativno determined deafness of heart tones, systolic, rarely diastolic murmur.

On the ECG for a long time, a monophasic curve typical of the acute period of a heart attack persists. The diagnosis is confirmed by echocardiography data.

An aneurysm can be a source of thromboembolism, rupture at early stages formations. Often, patients with aneurysms develop rhythm and conduction disturbances.

Thromboendocarditis

This is an aseptic inflammation that develops in thrombotic masses on the surface of the endocardium in the infarct zone.

More often, thromboendocarditis complicates the course of macrofocal and transmural infarctions, especially with the formation of postinfarction aneurysm of the heart.

Subfebrile body temperature, weakness, tachycardia, excessive sweating are noted. In some patients, thromboendocarditis does not manifest itself.

Echocardiography and ventriculography reveal intracardiac thrombus.

Thromboembolic complications

Thromboembolic complications occur in myocardial infarction due to impaired hemodynamics and rheological properties of blood.

Thromboembolism occurs when pieces of parietal blood clots are torn off at the site of necrosis or loose blood clots in the veins of the lower extremities and small pelvis. The branches of the pulmonary artery are predominantly affected.

The clinical picture is different and depends on the diameter of the vessel. With thromboembolism of a large-caliber vessel, as a rule, rapid death occurs, sometimes after an attack of the sharpest retrosternal pain and suffocation. Thromboembolism of small vessels is manifested by the clinic of infarct pneumonia.

Mental disorders

Mental disorders can occur at any stage of the disease. They are associated with hypoxia, thrombosis or thromboembolism of small vessels of the brain, more often occur in the elderly.

In the first days of the disease, a depressive or anxiety-depressive syndrome is more often recorded, alternating with periods of euphoria.

Brief psychotic states and even delirium may occur.

True reactive states occur within the first 2 weeks. At a later date, asthenic syndrome may form. hypochondria.

In the absence of adequate treatment of these disorders, the patient may have asthenia, sleep disturbance, severe neurotic reactions and phobias for a long time.

Post-infarction syndrome

Postinfarction syndrome (Dressler's syndrome) develops at 2-6 weeks of myocardial infarction.

The development of postinfarction syndrome is associated with the formation of tissue autoantigens in the necrotic area of ​​the myocardium, for which autoantibodies are produced in the body.

The clinical picture of Dressler's syndrome includes a triad of signs: pericarditis. pleurisy and pneumonia (three "P" syndrome).

The components of the triad can be observed in the patient in the form of monolesion or combined.

In addition, with postinfarction syndrome, synovitis, periarthritis, nephritis, and vasculitis may develop.

This complication is accompanied by an increase in body temperature, an acceleration of ESR and leukocytosis with a shift of the formula to the left, as well as eosinophilia.

The defeat of the serous membranes is fibrinous, serous or hemorrhagic in nature and is often characterized by a persistent relapsing course. Glucocorticoids are effective in treatment.

Recurrent and recurrent myocardial infarction

With severe atherosclerosis of the coronary arteries. a tendency to stenosis or active thrombosis, the patient may suffer several myocardial infarctions. If a new heart attack occurs during the period when the formation of the scar has not yet ended (within 2-2.5 months after an acute attack), they speak of a recurrent heart attack, if at a later date - a recurrent myocardial infarction.

Recurrent infarction is usually manifested by a typical pain attack, inflammatory-resorptive syndrome (low-grade fever, leukocytosis, accelerated ESR, increased activity of marker enzymes in the blood) and characteristic ECG changes are observed.

Recurrent myocardial infarction is often accompanied by the development of heart failure. rhythm and conduction disturbances, cardiogenic shock.

Recurrent myocardial infarction occurs more often in the elderly. In this case, the pain syndrome may be expressed slightly or absent.

Sometimes a repeated heart attack proceeds as an attack of cardiac asthma or an episode of acute arrhythmia. After it, circulatory failure often develops.

The diagnosis of recurrent infarction is complicated by the presence of postinfarction changes on the ECG from previous infarcts.

The lethality at a repeated heart attack is much higher, than at primary.

Treatment of complications

Treatment of disorders of excitability and automatism

(such as atrial and ventricular extrasystole, paroxysmal tachycardia, atrial fibrillation) is carried out by antiarrhythmics of group IA (quinidine, novocainamide 10% 5 ml intramuscularly every 6 hours), group 1B (lidocaine and diphenine), calcium channel blockers, less often β-blockers adrenergic receptors. All these groups of drugs lengthen the phase of repolarization and, to a lesser extent, depolarization, suppress the automatism of ectopic foci of excitation, but also have a number of side effects if they are not used rationally.

In this case, arrhythmogenic side effects(torsade de pointes arrhythmias, ventricular tachycardia, ventricular fibrillation, blockade), lupus-like syndrome, hypotension, syncope. dizziness, bitter taste in the mouth, diarrhea, loss of appetite, nausea. vomit. gastralgia, hepatitis. anemia. thrombocytopenia, allergic reactions.

Treatment of supraventricular extrasystoles and paroxysms, as well as paroxysms of atrial fibrillation

it is necessary to start with novocainamide, isoptin 0.04 g 3-4 times a day, cordarone 5% 6-9 g intravenously and cardiac glycosides. With the ineffectiveness of such therapy, β-blockers can be used (obzidan in tablets of 0.04 g 3-4 times a day). If they do not bring the expected effect, they resort to electrical impulse therapy (EIT).

With ventricular paroxysms and frequent ventricular extrasystoles

first of all, lidocaine 1% 10 ml intravenously is prescribed, if there is no effect, novocainamide or obzidan 0.1% 5 ml is prescribed, and if arrhythmia persists, electropulse therapy.

After the restoration of sinus rhythm, long-term (within weeks or months) antiarrhythmic treatment with maintenance doses is carried out.

Bundle of His bundle block and incomplete atrioventricular block I degree

in myocardial infarction, they are often transient and do not require special treatment if they do not cause a deterioration in the patient's condition.

Treatment of cardiogenic shock

primarily aimed at the relief of pain. At the same time, it is necessary to increase blood pressure and propulsive ability of the myocardium.

For this purpose, dopamine (dopmin) 4% 5 ml intravenously is prescribed, which enhances and accelerates myocardial contractions, increases cardiac output and blood pressure, without causing a sharp increase in peripheral resistance. Dopamine is administered intravenously slowly. In the absence of dopamine, norepinephrine or mezaton are used, which are also administered slowly intravenously in combination with droperidol to prevent spasm of peripheral vessels.

Effectively combined administration of dopamine and intravenous nitroglycerin solution, which gives a combination of a stimulating cardiotropic effect and a decrease in pre- and afterload on the myocardium.

To increase blood pressure, glucocorticoids (prednisolone 20-30 mg), low molecular weight dextrans are used.

When cardiogenic shock is combined with cardiac arrhythmias, antiarrhythmic therapy is carried out according to the accepted schemes in combination with vasopressive agents. Limitation of thrombus formation (both coronary and peripheral) is achieved by the use of heparin.

To combat acidosis, alkaline solutions are injected intravenously (sodium lactate, sodium bicarbonate 5% 200 ml intravenously).

Treatment of cardiogenic shock should be long-term and not end at the time of stabilization of blood pressure and improvement in the patient's well-being, since its relapses are an unfavorable prognostic sign.

cardiac asthma. Pulmonary edema

The treatment of these complications is aimed at reducing pressure in the left ventricle and the pulmonary circulation in the diastolic phase by increasing the contractile function of the myocardium, reducing blood flow to the heart from the vena cava and reducing the total peripheral vascular resistance. For this purpose, peripheral vasodilators, primarily nitrates, are widely used.

Nitrates dilate small-caliber venous vessels, reducing blood flow to the right atrium, and also reduce the tone of arterioles, reducing total peripheral resistance.

Patients with high arterial hypertension are prescribed apressin. Perhaps a very slow drip of cardiac glycosides in combination with a polarizing mixture, which reduces the risk of developing arrhythmias.

The pressure in the vessels of the lungs decreases after intravenous administration of aminophylline. The preload on the heart is quickly and effectively reduced by ganglionic blockers (arfonad, pentamine), but they should be used only at normal systolic pressure.

The appearance of symptoms of pulmonary edema requires the appointment of defoamers (antifomsilane - 10% alcohol solution), the introduction of atropine, calcium chloride and fast-acting diuretics (lasix) 40-80 mg intravenously.

If necessary, prescribe sedatives (seduxen).

Thromboembolic complications

treated with anticoagulants and fibrinolytics.

Heparin is administered in a daily dose of 40,000-60,000 IU, streptase - 1,000,000 IU. These drugs are prescribed in combination with vasodilators (papaverine). Reopoliglyukin is also used. Treatment is carried out under regular monitoring of blood clotting time.

Dressler's Postinfarction Syndrome

it is treated pathogenetically with the appointment of small and medium doses of steroid hormones (prednisolone 30-60 mg per day). In addition, according to indications, symptomatic agents are prescribed: analgesics, antihistamines.

Chronic cardiovascular insufficiency

treated with the appointment of cardiac glycosides and diuretics, including saluretics.

Furosemide (lasix) is most effective, and in the absence of sufficient diuresis, hypothiazide, ethacrynic acid (uregit) are prescribed.

The appointment of thiazide drugs causes significant kaliuresis, so the simultaneous use of potassium preparations or aldosterone antagonists with a potassium-sparing effect (veroshpiron, triamterene) is necessary. In the early stages, adenosine-converting enzyme inhibitors (captopril, enalapril) are effective.

With insufficient effect, peripheral vasodilators are added. It is mandatory to prescribe means of metabolic action (folic acid, riboxin, retabolil).

All patients with myocardial infarction should undergo a full course of rehabilitation therapy, which includes:

1) drug treatment;

2) physical rehabilitation;

3) mental rehabilitation;

4) social rehabilitation.

The goals of rehabilitation treatment are the maximum possible restoration of the somatic and psychological state patient and encourage him to return to socially useful work. Rehabilitation is carried out at the inpatient stage of treatment (placement in the intensive care unit, cardiology department and rehabilitation department), at the stage of sanatorium treatment and in the clinic.

Sanatorium-and-spa treatment is one of the stages of rehabilitation of patients, the favorable aspects of which are:

1) the correct mode for this patient with a further consistent expansion of physical activity under medical supervision;

2) beneficial effect of natural factors of the sanatorium-resort zone;

3) creation optimal conditions for a good psychological mood of patients.

Patients are referred for sanatorium-and-spa treatment 4-6 months after acute myocardial infarction in the absence of frequent angina attacks and signs of congestive heart failure.

The main principle of rehabilitation therapy after myocardial infarction is a gradual increase in the intensity of physical activity against the background of adequate and effective drug therapy. This requires constant medical supervision and monitoring of the dynamics of clinical data and stress tests.

The question of the working capacity of a patient with a myocardial infarction. resolved depending on the results of rehabilitation treatment, in most patients - 3-4 months after the onset of the disease.

The following points are of decisive importance:

1) the area and depth of the infarction, the presence or absence of severe complications in the acute period of the disease;

2) the presence or absence of cardiovascular insufficiency;

3) the severity of postinfarction angina syndrome;

4) the state of the reserves of the cardiovascular system, revealed in the process of rehabilitation treatment;

5) the psychological attitude of the patient to return to work (or lack of this attitude).

All patients with myocardial infarction. should be under dispensary observation in order to maintain the optimal physical and psychological state of the patient, prevent possible complications of the disease, address issues of his employment and ability to work.

The drug therapy that patients with myocardial infarction receive during the rehabilitation period is prescribed individually, taking into account the degree of chronic coronary insufficiency. the presence or absence of arrhythmias and cardiac insufficiency. With a favorable course of the disease, maintenance therapy includes β-adrenergic blockers and small doses of aspirin.

Although recurrent and recurrent myocardial infarction in general serve as evidence of the resumption of necrotic processes in the muscle tissues of the heart, there are differences between them. So recurrent is a process that began less than two months after myocardial infarction. The second one develops after more than two months.

The classification of myocardial infarction is quite extensive. It is distinguished by its shape, localization zone, flow, rate of development, and so on. So recurrent processes can begin regardless of the already ongoing pathological process. But acute MI is a rapidly developing pathology (both primary and secondary). Without proper treatment, follow-up and prevention, it is impossible to determine how beneficial the consequences will be. After all, MI is a very dangerous disease, bordering on a mortal risk to the life of the patient.

The danger of MI is also in the fact that, in addition to serious consequences, none of the patients is immune from the second, third or more inflammations. That only exacerbates the condition of the patient's cardiovascular system. Statistical data speaks of at least 25-29% of repetitions. Moreover, it is impossible to say who is more insured - a patient observing a protective regimen or leading a habitual lifestyle.

How to distinguish a relapse from a repeat by ECG

Hardware diagnostics of a repetitive process is complicated by the fact that necrosis is renewed more often at the site of a previous MI. Therefore, the electrocardiogram may not show characteristic signs of pathology.

Sometimes the localization zone is located as close as possible to the old scar, at a distance or in the region of another wall. And in these cases, the EC-gram will already indicate fresh infarct changes.

In case of recurrence, the pathological process in each new focus begins anew. It proceeds independently, regardless of the primary manifestation of MI (that is, when the initial infarction has not yet fully healed). On the EK-gram, it is noticeable in 70% of cases.

Characteristic signs of relapse

Recurrent MI is insidious and can be confused with a protracted course. But an experienced doctor in the process of diagnosis will be able to expose the "deceiver". With a prolonged course, the zone of localization of the primary manifestation increases, the most acute and acute periods drag on and on. And in new foci, the inflammatory process begins anew. Therefore, the impression of "marking time" is created.

Primary infarction is considered here as large-focal or extensive, and is an acute violation of the coronary circulation. Its course is long, divided into four periods:

1. The most acute (0.5-2 hours) - a decrease in the blood supply to the site, the appearance of signs of tissue death;
2. Acute (2-10 days or more) - the formation of a necrotic area, muscle softening;
3. Subacute (up to 4 weeks) - First stage scarring;
4. Post-infarction (3-5 months) - full-fledged scar formation, myocardial adaptation to new working conditions.

Stenosing atherosclerosis of the coronary arteries is the most likely cause of recurrence

As a result of numerous observations, conclusions were drawn about the most probable reasons relapses. The main condition for this form of MI is severe stenosing atherosclerosis of the coronary arteries with damage to the collateral vessels. There is not only a “shutdown” of the coronary artery due to thrombosis, but also its ability to adequately expand is impaired. Functional burdening of the myocardium leads to the formation of new necrosis.

At the same time, one should not exclude the fact that the recurrent process can begin not only on the periphery, but also in the infarct zone. This is due to the discrepancy between the need for blood supply and the state of coronary blood flow. As a result, the percentage of recurrent course ranges from 4% to 30%.

The following is observed:

• reduction in the mass of the contractile myocardium;
• an increase in the frequency of chronic circulatory failure;
• exacerbation of cardiac arrhythmias;
• an increase in the duration of inpatient treatment (due to recurring infarction processes, an acute period of the course is observed for a long time);
• the risk of death increases, including inpatients (up to 35% of cases).

Options clinical picture relapse:

• arrhythmic;
• gastralgic;
• asthmatic;
• asymptomatic;
• anginal.

This causes some difficulties in laboratory and hardware diagnostics. So, for example, if the attacks of pain during the initial heart attack were weak, and the patient was not hospitalized. Then later, with the next attacks and hospitalization, the primary heart attack on the ECG will be invisible, while recurrent inflammation is better seen. The patient is diagnosed with myocardial infarction without recurrence, and the initial symptoms are defined as a manifestation of angina pectoris. This can further affect the entire treatment process.

Another relapse can be "hidden" under the pretext of complications of MI, for example, arrhythmia. Recurrent processes of necrosis negatively affect the state of the patient's body. There may be:

• swelling of the respiratory system;
• cardiogenic shock;
• extensive necrotic lesion.

Characteristic signs of a repeated heart attack

As mentioned, recurrent myocardial infarction develops 2 or more months after the first case. At risk are elderly men who have had this disease. The repeated course is severe, asthmatic and arrhythmic variants are often detected. Symptoms are already less pronounced, since pain sensitivity is reduced in the previously affected areas of MI.

The most common cause of any myocardial infarction is atherosclerosis, which is plaque buildup on the walls of the coronary arteries. The gradual decrease in the lumen, the subsidence of thrombotic formations leads to complete occlusion. In the tissue, the supply of oxygen and useful substances contained in the blood is stopped, which, in fact, begins the death of cells.

With repeated MI, atherosclerotic plaques do not go anywhere, sooner or later occlusion cannot be avoided. If the same blood vessel is involved in the process, then necrosis is formed in the area of ​​​​the scar of the first infarction, but if other vessels are involved, then repeated MI affects other walls of the heart.

Influencing factors:

• gender of the patient: men are more likely than women to develop heart disease;
• age: for men, there is a risk at any age, for women - after the onset of menopause; average indicators range from 45-50 years and older, by the age of 70 the percentage of men and women levels off;
• genetic predisposition;
• overweight;
• chronic endocrine diseases;
• high blood cholesterol;
• high blood pressure;
• wrong way of life: food, mode, bad habits;
• psychoemotional disorders, stress;
• inadequate prevention of atherosclerotic disease or its absence;
• non-compliance with the medical prescription of a sparing regimen after a heart attack: nutrition, exercise, smoking, alcohol.

Recurrent heart attack is characterized by pressing or sharp pains in the region of the heart.

A repeated heart attack can develop in the same way as the first case, have the same course and symptoms. It is characterized by prolonged pain in the region of the heart, radiating to the left arm, forearm, interscapular space, neck, lower jaw. Their character is sharp or pressing. Pain is not relieved by nitroglycerin, or is partially relieved, for a short time. General weakness is felt, blanching of the skin, hyperhidrosis is observed.

The nature of the pain may this time be somewhat different from the previous manifestation of the pathology. A heart attack usually has consequences, which leaves a negative imprint on each new outbreak.

Repeated myocardial necrosis can occur without pain in the heart, but with signs of an arrhythmic, abdominal or asthmatic variant:

• shortness of breath;
• breathing problems, pulmonary edema;
• cyanosis;
• loss of consciousness;
• a sharp drop in blood pressure.

How to avoid repetition

Prevention of myocardial infarction will help prevent diseases of the cardiovascular system. General strengthening medical prophylaxis of the body (not only directed action treatment) is also applicable.

In addition, you need to reconsider your lifestyle and try to eliminate all possible factors of influence.

Patients suffering from diabetes mellitus are at risk, so regular cardiological monitoring is essential.

For prevention and rehabilitation, doctors recommend the constant use of beta-blockers, antiplatelet agents and statins.

Prevention and rehabilitation after a heart attack are necessary to prevent post-infarction angina and recurrent necrosis. Medical advice includes:

1. Permanent, continuous, lifelong intake of beta-blockers, antiplatelet agents and statins.
2. Lifestyle correction: regimen, nutrition, rejection of bad habits, moderate physical activity.
3. Prevention or treatment of psycho-emotional state.
4. Bed rest (during the acute period and with recurrent MI).
5. LFK on purpose.
6. Regular non-exhausting walks in the fresh air.
7. Sanatorium-resort rest and treatment.
8. Temporary disability: long-term sick leave or transition to light forms of work. Note that for repeated MI, a conditional period of 90-120 days is set. But in the case of reconstructive surgery of blood vessels, the sick leave is provided for a year.
9. Those who have had a heart attack are not recommended to return to work after they are such professions: a pilot, a pilot, a driver of any type of transport, a dispatcher, a postman, a courier, a crane operator, a high-altitude fitter, and so on. Daily employment and night shifts are also contraindicated.

Myocardial infarction has recently become much younger. This disease does not occur suddenly, it is preceded by many adverse factors, including vascular disease. An acute heart attack requires an emergency response, because in the absence of the first six hours of adequate treatment, the patient may simply die. Therefore, it is important for people at risk to regularly attend scheduled examinations by a cardiologist. Yes, and the rest too. After all, this heart is the main engine of the human body!