Describe the management of acute anterior wall myocardial infarction.

I. Pre-Hospital Management

The initial phase focuses on early recognition of symptoms and rapid activation of the emergency medical system. Key steps include:

• Symptom Recognition: Patients typically present with chest pain (often described as crushing, squeezing, or tightness), radiating to the left arm, jaw, or back. Other symptoms include shortness of breath, nausea, vomiting, and diaphoresis.
• Immediate Actions: Administer oxygen, establish intravenous access, and obtain a 12-lead ECG.
• Nitroglycerin: Sublingual nitroglycerin can be administered if systolic blood pressure is >90 mmHg, unless contraindicated (e.g., recent phosphodiesterase-5 inhibitor use).
• Aspirin: Administer 300mg of aspirin (chewed) unless contraindicated.
• EMS Activation: Rapid transport to a hospital capable of performing primary percutaneous coronary intervention (PCI) is paramount.

II. Hospital Management – Acute Phase

Upon arrival at the hospital, the following steps are crucial:

A. Diagnosis & Risk Stratification

• Confirmation of Diagnosis: Review the pre-hospital ECG and obtain serial ECGs and cardiac biomarkers (troponin I or T, CK-MB).
• Risk Stratification: Utilize scoring systems like the TIMI risk score or GRACE score to assess the patient’s risk of adverse events.

B. Reperfusion Therapy

The primary goal is to restore blood flow to the ischemic myocardium as quickly as possible. Two main strategies are employed:

• Primary Percutaneous Coronary Intervention (PCI): This is the preferred strategy if available within 90-120 minutes of first medical contact. It involves catheter-based intervention to open the blocked LAD artery and restore blood flow.
• Fibrinolytic Therapy: If PCI is not readily available within the recommended timeframe, fibrinolytic therapy (e.g., alteplase, tenecteplase, reteplase) should be administered within 30 minutes of arrival. Contraindications to fibrinolysis must be carefully assessed.

C. Adjunctive Pharmacotherapy

• Antiplatelet Therapy: Continue aspirin and add a P2Y12 inhibitor (e.g., clopidogrel, ticagrelor, prasugrel) based on the reperfusion strategy chosen.
• Anticoagulation: Administer anticoagulants (e.g., heparin, enoxaparin, bivalirudin) as per established protocols.
• Beta-Blockers: Initiate beta-blockers (if not contraindicated) to reduce myocardial oxygen demand and prevent arrhythmias.
• ACE Inhibitors/ARBs: Initiate ACE inhibitors or ARBs, especially in patients with heart failure or left ventricular dysfunction.
• Statins: High-intensity statin therapy should be initiated regardless of baseline cholesterol levels.

D. Monitoring & Management of Complications

• Continuous ECG Monitoring: Monitor for arrhythmias (ventricular tachycardia, ventricular fibrillation, bradycardia).
• Hemodynamic Monitoring: Monitor blood pressure, heart rate, and oxygen saturation.
• Management of Complications: Be prepared to manage complications such as heart failure, cardiogenic shock, arrhythmias, and mechanical complications (e.g., ventricular septal rupture).

III. Post-Acute Phase & Secondary Prevention

Following the acute phase, long-term management focuses on secondary prevention to reduce the risk of recurrent events:

• Cardiac Rehabilitation: Enroll patients in a comprehensive cardiac rehabilitation program.
• Lifestyle Modifications: Encourage smoking cessation, healthy diet, regular exercise, and weight management.
• Medication Adherence: Ensure adherence to prescribed medications (aspirin, P2Y12 inhibitor, beta-blocker, ACE inhibitor/ARB, statin).
• Risk Factor Control: Optimize control of hypertension, diabetes, and hyperlipidemia.
• Regular Follow-up: Schedule regular follow-up appointments with a cardiologist.