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Clinical Profile of Arrhythmias in Golden Hour of Myocardial Infarction

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Clinical Profile of Arrhythmias in Golden Hour of Myocardial Infarction CLINICAL PROFILE OF ARRHYTHMIAS IN GOLDEN HOUR OF MYOCARDIAL INFARCTION Dissertation Submitted to THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY In partial fulfillment of the regulations for the award of the degree of MD GENERAL MEDICINE BRANCH- 1 TIRUNELVELI MEDICAL COLLEGE THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY CHENNAI INDIA APRIL 2 013 1 2 3 CERTIFICATE This is to certify that this dissertation entitled “Clinical profile of Arrythmias in Golden Hour of Myocardial Infarction” is the bonafide original work of DR.C.ANANTHI in partial fulfillment of the requirement for MD (BRANCH1) GENERAL MEDICINE examination of the TAMILNADU DR.M.G.R MEDICAL UNIVERSITY to be held in April 2013. PROF . DR. GEETHA RANI. MD PROFESSOR AND HEAD DEPARTMENT OF MEDICINE TIRUNELVELI MEDICAL COLLEGE HOSPITAL TIRUNELVELI. DR.M.MANOHARAN. MS DEAN TIRUNELVELI MEDICAL COLLEGE HOSPITAL TIRUNELVELI 4 DECLARATION DR.C.ANANTHI, solemnly declare that this dissertation “CLINICAL PROFILE OF ARRHYTHMIAS IN GOLDEN HOUR OF MYOCARDIAL INFARCTION” is a bonafide record of work done in DEPARTMENT OF MEDICINE, GOVERNMENT TIRUNELVELI MEDICAL COLLEGE & HOSPITAL, TIRUNELVELI under the guidance of PROF.DR.GEETHARANI MD., GOVERNMENT TIRUNELVELI MEDICAL COLLEGE HOSPITAL, TIRUNELVELI. This dissertation is submitted to THE TAMILNADU DR.M.G.R.MEDICAL UNIVERSITY , CHENNAI in partial fulfillment of the university regulations for the award of MD DEGREE GENERAL MEDICINE (BRRANCH 1) to be held in APRIL 2013 PLACE : TIRUNELVELI DATE: 5 ACKNOWLEDGEMENT I would like to thank DR. M.MANOHARAN, MS., DEAN Government Tirunelveli Medical College Hospital for permitting me to utilize the hospital facilities for this dissertation. I also extend my sincere thanks to PROF.DR.R.GEETHARANI, MD., Professor& Head Of Medicine for her constant support during the study. I express my sincere thanks to DR.RAVICHANDRAN EDWIN, MD.DM., Professor of cardiology and DR.BALACHANDRAN, MD.DM., Additional Professor of Cardiology for permitting me to utilise the facilities in the Intensive Coronary Care Unit for the purpose of this study and guiding me with enthusiasm throughout the study period. I thank the Asst.Professors of my unit DR.RATHNAKUMAR, MD., DR.MOHAMMED RAFI, MD., & DR.JAWAHAR, MD., for their valid comments and suggestions. Finally I thank the patients for their extreme patience and co- operation. 6 CONTENTS S.NO TITLE PAGE NO 1 INTRODUCTION 1 2 AIM OF THE STUDY 5 3 REVIEW OF LITERATURE 6 4 MATERIALS & METHODS 38 5 RESULTS & OBSERVATION 49 6 DISCUSSION 69 7 CONCLUSION 75 8 PROFORMA 77 9 ANNEXURES 80 10 BIBLIOGRAPHY 85 11 MASTER CHART 92 7 ABBREVIATIONS SA Node – Sino atrial node AV Node-Atrio Ventricular Node ICCU- Intensive Coronary Care Unit AV Block- Atrioventricular Block LAHB - Left Anterior Hemiblock LPHB – Left Posterior Hemiblock LBBB – Left Bundle BranchBlock RBBB –Right Bundle Branch Block LAD – Left Anterior Descending Artery LCX – Left Circumflex Artery S 1 – 1 Septal branch D 1 – 1 Diagonal branch SHT – Systemic Hypertension DM – Diabetes Mellitus 8 INTRODUCTION Acute myocardial infarction is the commonest cause of death and disability and it poses great economic burden than any other ailments. In AMI the main cause for mortality is arrhythmias, which are due to a autonomic nervous system imbalance, electrolyte imbalance and ischemia which causes conduction blockade in the infarcted zone. Even though there are vast advances in the mode of diagnosis and management of Infarction related arrhythmias over the past 25 years it continues to be a major cause of mortality in industrialized world and is emerging as a great health hazard in developing countries.The development of acute myocardial infarction is a fatal event in about one third of the patients, and among this,half of the deaths occurs due to ventricular tachyarrhythmias that occurs within one hour of the event. So to reduce the incidence of mortality careful monitoring of cardiac rhythm and accurate management of arrhythmias in the golden hour of infarction is essential. Several phases in the management of patients lead to decline in mortality from Acute myocardial infarction.”CLINICAL 9 OBSERVATION PHASE “ – Focussed on detailed recording of physical & laboratory findings, treatment consists of strict bed rest and sedation. “CORONARY CARE UNIT PHASE “ – Focussed on detailed analysis and vigorous management of arrhythmias. “HIGH TECHNOLOGY PHASE” - Which is done by the introduction of interventions like pulmonary artery floatation catheter for bedside monitoring of haemodynamics and more precise management of heart failure. Lawn and his colleagues, by their proactive works found that prevention of ventricular arrhythmias related death in AMI could be achieved only through intensive coronary care. During the past 25 years the mortality has been reduced from 30% to about 15% due to the vast advancement in the Intensive coronary care and timely diagnosis and prompt management of serious life threatening arrhythmias. 10 This is achieved in the Intensive coronary care units by the continuous monitoring of cardiac rhythm of each patient and hemodynamic monitoring in selected patients. Defibrillators, Respirators, Pacemakers, Pacingcatheter s and also trained staffs who can recognize arrhythmias and administer antiarrhythmics and perform cardiac resuscitation if necessary. .Arrhythmias affect the prognosis of the patient after AMI by causing hemodynamic instability and also by directly affecting the myocardial contractility. The common type of arrhythmias in anterior wall myocardial infarction is tachyarrhythmias while in inferior wall myocardial infarction bradyarrhythmias are common. Timely restoration of flow in the epicardial infarct related artery combined with improvement of the downstream zone of the infracted myocardium ultimately results in a limitation of infarct size.Because the recognition and treatment of arrhythmias in the first hour not only reduces the in- hospital mortality , but also the long term survival is also excellent in those patients who survive after primary ventricular fibrillation ( VF that occurs in early hours and is not associated with any 11 predisposing factors like CHF, shock, bundle branch block or ventricular aneurysm) Various studies have analysed the effect of different types of arrhythmias in a individually but data from India is insuficient. In this study we are going to analyse the incidence and prognosis of various types of arrhythmias in the “Golden hour of myocardial infarction”. The “Golden hour of myocardial infarction” is the first 60 minutes . “Total ischaemic time” is within 120 minutes. The first 60 minutes of myocardial infarction is important because during an attack of acute myocardial infarction while the central zone of the infarct contains the necrotic tissue that is irreversibly lost , the fate of surrounding ischaemic myocardium ( ischaemic penumbra ) may be improved by timely restoration of coronary perfusion , reduction of myocardial O2 demands , prevention of the accumulation of noxious metabolites , and blunting the impact of mediators of reperfusion injury ( eg. Calcium overload and oxygen derived free radicals ) 12 AIM OF THE STUDY The aim of the study is to analyse: 1. The incidence of different types of arrhythmias in 100 patients with acute MI admitted to intensive coronary care unit of Tirunelveli Medical College Hospital. 2. Correlation of each type of arrhythmia with respect to location and extension of acute myocardial infarction. 3. To assess the risk factors like age, sex , personal habits in relation to the various types of arrhythmias. 4. To assess the prognostic factors in various types of arrhythmias and their outcome. 5. To interpret effect of arrhythmias on the mortality and morbidity in patients in the golden hour acute myocardial infarction. 13 REVIEW OF LITERATURE HISTORICAL ASPECTS The field of electrophysiology was ushered in the Twentieth century- As the Ducth physician Einthoven introduced Electrocardiography. In 1960- Development of intracavitary recording, particularly, His bundle electrogram with programmed stimulation of heart , marked the beginning of contemporary clinical electrophysiology. In 1990s-Interventional cardiac electro physiology came in to existence after the adoption of radiofrequency technology to ablate cardiac tissue.1 Anatomy and Physiology of the conduction system: 14 The sinoatrial node (SANode) is the pacemaker of the heart where the normal cardiac impulses are generated, which is located at the juction of the right atrium and superior vena cava.2 This impulse is slowly transmitted through the nodal tissue to the anatomically complex atria, where it is more rapidly conducted to the atrioventricular node (AVN) inscribing the `p’ wave of the ECG. There is a perceptible delay in conduction through the anatomically&functionally heterogenous AVN. The time needed for activation of the atria and the AVN delay is represented as the PR interval of the ECG. The impulses travel through the right & left Bundle of His and through the purkinje fibres and ventricles are activated inscribing a QRS complex .4Recovery electrical excitability results in repolarisation occurring first on the epicardial surface then proceeding to the endocardium which inscribes a T wave normally. 15 BLOOD SUPPLY OF HEART & CONDUCTION SYSTEM The arterial blood supply of the heart is derived from two coronary arteries – Right coronary & Left coronary arteries . Left coronary artery arises from left sinus of valsalva and it divides in to left anterior descending and
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