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inadequate response occurs Morphine sulfate (4 mg intravenously followed by increments of 2 mg) is valuable in acute pulmonary edema Diuretics are usually effective; however, because most patients with acute infarction are not volume overloaded, the hemodynamic response may be limited and may be associated with hypotension Vasodilators will reduce PCWP and improve cardiac output by a combination of venodilation (increasing venous capacitance) and arteriolar dilation (reducing afterload and LV wall stress) In mild heart failure, sublingual isosorbide dinitrate (25 10 mg every 2 hours) or nitroglycerin ointment (625 25 mg every 4 hours) may be adequate to lower PCWP In more severe failure, especially if cardiac output is reduced, sodium nitroprusside is the preferred agent It should be initiated only with arterial pressure monitoring; the initial dosage should be low (025 mcg/kg/min) to avoid excessive hypotension, but the dosage can be increased by increments of 05 mcg/kg/min every 5 10 minutes up to 5 10 mcg/kg/min until the desired hemodynamic response is obtained Excessive hypotension (mean BP < 65 75 mm Hg) or tachycardia (> 10/min increase) should be avoided Intravenous nitroglycerin (starting at 10 mcg/min) also may be effective but may lower PCWP with less hypotension Oral or transdermal vasodilator therapy with nitrates or ACE inhibitors is often necessary after the initial 24 48 hours (see below) Inotropic agents should be avoided if possible, because they often increase heart rate and myocardial oxygen requirements and worsen clinical outcomes Dobutamine has the best hemodynamic profile, increasing cardiac output and modestly lowering PCWP, usually without excessive tachycardia, hypotension, or arrhythmias The initial dosage is 25 mcg/kg/ min, and it may be increased by similar increments up to 15 20 mcg/kg/min at intervals of 5 10 minutes Dopamine is more useful in the presence of hypotension (see below), since it produces peripheral vasoconstriction, but it has a less beneficial effect on PCWP Amrinone is a positive inotrope and vasodilator that produces hemodynamic effects similar to those of dobutamine but with a greater decrease in PCWP However, its longer duration of action makes it less useful in unstable situations Milrinone is a more potent and newer congener of amrinone with fewer side effects It should be commenced in a loading dose of 50 mcg/kg over 10 minutes, followed by an infusion of 0375 075 mcg/kg/min Digoxin has not been helpful in acute infarction except to control the ventricular response in atrial fibrillation, but it may be beneficial if chronic heart failure persists 2 Hypotension and shock Patients with hypotension (systolic BP < 100 mm Hg, individualized depending on prior BP) and signs of diminished perfusion (low urinary output, confusion, cold extremities) that does not respond to fluid resuscitation should be considered for hemodynamic monitoring with a PA catheter Up to 20% will have findings indicative of intravascular hypovolemia (due to diaphoresis, vomiting, decreased venous tone, medications such as diuretics, nitrates, morphine, -blockers, calcium channel blockers, and thrombolytic agents and lack of oral intake) These should be treated with successive.

RV infarction is present in one-third of patients with inferior wall infarction but is clinically significant in less than 50% of these It presents as hypotension with relatively preserved LV function and should be considered whenever patients with inferior infarction exhibit low BP, raised venous pressure, and clear lungs Hypotension is often exacerbated by medications that decrease intravascular volume or produce venodilation, such as diuretics, nitrates, and narcotics RA pressure and jugular venous pulsations are

The schedule line category determination is carried out automatically by the system on the basis of the following: The item category of the sales order line item plus the MRP type found on the material master, MRP 1 screen, of the material master record (See Figure 3-19)

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high, while PCWP is normal or low and the lungs are clear The diagnosis is suggested by ST-segment elevation in rightsided anterior chest leads, particularly RV4 The diagnosis can be confirmed by echocardiography or hemodynamic measurements Treatment consists of fluid loading to improve LV filling, and inotropic agents if necessary

The pericardium is involved in approximately 50% of infarctions, but pericarditis is often not clinically significant Twenty percent of patients with Q wave infarctions will have an audible friction rub if examined repetitively Pericardial pain occurs in approximately the same proportion after 2 7 days and is recognized by its variation with respiration and position (improved by sitting) Often, no treatment is required, but aspirin (650 mg every 4 6 hours) will usually relieve the pain Indomethacin and corticosteroids can cause impaired infarct healing and predispose to myocardial rupture, and therefore should generally be avoided in the early post-myocardial infarction period Likewise, anticoagulation should be used cautiously, since hemorrhagic pericarditis may result One week to 12 weeks after infarction, Dressler s syndrome (post-myocardial infarction syndrome) occurs in less than 5% of patients This is an autoimmune phenomenon and presents as pericarditis with associated fever, leukocytosis and, occasionally, pericardial or pleural effusion It may recur over months Treatment is the same as for other forms of pericarditis A short course of nonsteroidal agents or corticosteroids may help relieve symptoms

Partial or complete rupture of a papillary muscle or of the interventricular septum occurs in less than 1% of acute myocardial infarctions and carries a poor prognosis These complications occur in both anterior and inferior infarctions, usually 3 7 days after the acute event They are detected by the appearance of a new systolic murmur and clinical deterioration, often with pulmonary edema The two lesions are distinguished by the location of the murmur (apical versus parasternal) and by Doppler echocardiography Hemodynamic monitoring is essential for appropriate management and demonstrates an increase in oxygen saturation between the RA and PA in VSD and, often, a large v wave with mitral regurgitation Treatment by nitroprusside and, preferably, IABC reduces the regurgitation or shunt, but surgical correction is mandatory In patients remaining hemodynamically unstable or requiring continuous parenteral pharmacologic treatment or counterpulsation, early surgery is recommended, though mortality rates are high (15% to nearly 100%, depending on residual ventricular function and clinical status) Patients who are stabilized medically can have delayed surgery with lower risks (10 25%), although this may be due to the death of sicker patients, some of whom may have been saved by earlier surgery

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