更新202-P197-myocardial infarction.docVIP

202-1976 Myocardial Infarction Ischemic myocardial necrosis usually resulting from abrupt reduction in coronary blood flow to a segment of myocardium. Symptoms and Signs About 2/3 of patients experience prodromal ?[proudrouml] symptoms days to weeks before the event, including unstable or crescendo angina, shortness of breath, or fatigue. The first symptom of acute MI usually is deep, substernal, visceral pain described as aching or pressure, often with radiation to the back, jaw, or left arm. The pain is similar to the discomfort of angina pectoris but is usually more severe, long-lasting, and relieved little, or only temporarily, by rest or nitroglycerin. However, discomfort may be very mild, and perhaps 20% of acute MIs are silent or unrecognized as illness by the patient. Women may have atypical chest discomfort. Older patients may complain of dyspnea more than ischemic-type chest pain. In severe episodes, the patient becomes apprehensive and may sense impending doom. Nausea and vomiting may occur, especially in inferior MI. Symptoms of LV failure, pulmonary edema, shock, or significant arrhythmia may dominate. On examination, the patient is usually in severe pain, restless, and apprehensive, with pale, cool, diaphoretic [,da??f?ret?k] skin. Peripheral or central cyanosis may be apparent. The pulse may be thready, and the BP is variable, although many patients initially manifest some degree of hypertension unless cardiogenic shock is developing. Heart sounds are usually somewhat distant; the presence of a fourth heart sound is almost universal. A soft systolic blowing apical murmur (a reflection of papillary muscle dysfunction) may occur. At initial evaluation, a friction rub or more striking murmurs suggest preexisting heart disease or another diagnosis. Detection of a friction rub within a few hours after onset of MI symptoms is distinctly unusual and might suggest acute pericarditis rather than MI. Friction rubs, usually evanescent, are common on days 2 and