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Donetsk National Medical University after M.Gorky

Technique Guidelines


the students’ individual preparation for

Practice activities

SUBJECT: Ischaemic heart disease: Myocardial Infarction

INTENDED AUDIENCE: 5-year students

of International Medical Faculty

Donetsk – 2009


PhD, prof. ass. Sklyanna O.V.

PhD, prof. ass. Kalinkina N.V.


Parhomenko Т.А., prof. ass. of department of internal medicine №2

Basiy R.V., prof. ass. of department of humen anatomy, head of methodical room of Donetsk national medical university

  1. Importance of the subject:

Ischaemic heart disease (IHD) today is one of the most widespread and disablementing diseases in the world. It affects men more frequently than women. Encouraging cardiovascular health is not only about preventing IHD: health entails the ability to exercise, and enjoying vigorous activity (withing reason!) is one of the best ways of achieving health. Acute coronary syndromes (ACS) includes unstable angina and envolving Myocardial Infarction (MI), which share a common underlying pathology – plague rupture, thrombosis, and inflammation. Usually divided into ACS with ST-segment elevation or new onset LBBB – what most of us mean by acute MI; and ACS without ST-segment elevation – the ECG may show ST-depression, T-wave inversion, non-spesific changes, or be normal (includes non-Q wave or subendocardial MI). The degree of irreversible myocyte death varies, and significant necrosis can occur without ST-elevation. Cardiac troponins (T and I) are the most sensitive and spesific markers of myocardial necrosis, and have become the test of choice in patients with ACS.

^ Risk factors. Non-modifiable: age, family history of IHD (in first degree relative < 55 yrs), mens. Modifiable: smoking, hypertension, hyperlipidaemia, obesity, sedentary lifestyle. Controversial risk factors include: stress, type A personality, LVH, increasing of apoprotein A, increasing of fibrinogen, hyperinsulinaemia, high level of homocysteine, cocaine use. Incidence: 5/1000 per annum (UK) for ST-segment elevation.

Mortality: 50% of deaths occur within 2h of onset of symptom.

^ If the importance of the subject has been understood, proceed to studying the learning objectives.

II. Learning Objectives

Key objective: to develop skills in making a differential diagnosis of MI, and planning a patient management, diagnostics and treatment of complications of MI.

^ Specific Goals

To develop skills in:

Prior-to- Practice Level of Knowledge and Skills

Possessing a knowledge of and skills in:

  1. Picking out of a patient’s complaints, anamnesis and physical neurological examination the most important symptoms typical of MIe.

Collecting complaints, anamnesis and performing a physical examination of a patient (Covered by the course of Faculty Therapy)

2. Making up an individual diagnostic chart and interpreting the obtained findings in MI. Determining the localization, stage and type of MI according to classification.

Determining a volume of necessary methods of study: general clinic and biochemical (Covered by the courses of Propedeutic Therapy); X-ray (Covered by the course of Radiology); electrophysiological (Covered by the course of Physiology).

3. Making a differential diagnosis of MI and its complications.

To identify sydromes of cardio-vascular diseases (Covered by the courses of Propedeutic Therapy)

4.Determining a tactic of treating a patient and tactic of giving emergency medical service

Applying medications of pathogenetic and symptomatic therapy (Explained in the Pharmacology Course).

The information necessary for reviewing and revising the basic knowledge and skills can be found in the following references:

  1. Oxford Handbook of Clinical Medicine. Murray Longmore, Ian B.Wilkinson, Supray Rajagopalan. New York, 2004.

  2. Klabunde R.E. Cardiovascular Physiology Concepts. Lippincott, 2004. 256 pp.

  3. Internal diseases. An introductory course. Edited by V.Vasilenko and A.Grebenev. Moscow, 2006.

Pre-Practice Knowledge and Skills Test Questions

Q1. A 48-year-old patient, was delivered to the cardiological department with symptoms of anterolateral Myocardial Infarction with ST-segment elevation. Оcclusion of which artery is possible in this case?

А. Anterior intraventricular branch;

B. Circumflex branch;

C. Right coronary artery;

D. Posterior intraventricular branch;

E. Circumflex branch and Posterior intraventricular branch

Q 2. A 47-year-old patient complaints of acute chest pain, nausea, dyspnoea. Level of CK-MB is high. Which of the following is the most probable diagnosis?

А. Stable angina;

B. Hypertension;

C. Dilated cardiomyopathy;

D. Miocardial Infarction;

E. Variant angina.

Q 3. Technetium perfusion scan of 47-year-old patient has shown local accumulation of Technetium in myocard. Which of the following is the most probable diagnosis?

А. Miocardial Infarction;

B. Variant angina;

C. Hypertension

D. Heart amiloidosis ;

E. Pericarditis.

Q 4. The blood count of the patient with a cardio-vascular disease shows changes, which are typical of MI. The blood count shows the following:

А. Increasing of ESR, leucocytosis with neutricytosis, increasing of CK-MB level;

B. Increasing of ESR, leucocytosis with lymphocytosis increasing of CK-MB level

C. Increasing of ESR, high level of LDH, neutropenia, lymphopenia;

D. high level of glucosa in the blood, increasing of ESR, lymphocytosis;

E. Decreasing of ESR, low level of LDH, leucocytosis with neutricytosis.

Q 5. At ECG testing of 39-year-old patient were present ST depression, inverted T waves. These changes were held out for 4 weeks. were accompanied by central chest pain.

Which of the following is the most probable diagnosis?

А. MI without ST-segment elevation;

B. Stable angina;

C. Cervical osteochondrosis;

D. Variant angina;

E. Hypertension.

Q 6. A laboratiry tests of a 49-year-old patient, suffering from central chest pain, have shown changes in level of cardiac enzymes. Level of what enzyme was abnormal?


B. Lypasa;

C. Amylasa;

D. Gialuronidasa;

E. Esterasa.

Q 7. At ECG tests of 56-year-old patient were observed changes typical for acute posterior MI. Where were ECG changes?

А. II, III, aVF, V1-V2;

B. I, aVL,V2-V6;

C. I, aVL,V1-V2;

D. I, III, aVL;

E. I, II, V3-V4.

Q 8. A 67-year-old patient suffers from bafflel-apical MI without ST-segment elevation. What ECG-changes can confirm this diagnosis?

А. ST-segment depression, T-wave inversion in I, II, aVL,V1-V4;

B. ST-segment elevation, T-wave inversion in II, III, aVL,V5-V6;

C. Pathological Q-waves in I, II, aVL,V1-V4;

D. Pathological Q-waves in II, III, aVL,V5-V6;

E. ST-segment elevation in II, III, aVF.

Q 9. A 67-year-old patient, suffering from IHD, Stable angina, a central chest tightness had developed after receiving some drugs. MI was diagnosed. It is known that this drug can cause “robbing phenomenon”. Which of the following was taken by the patient?

А. Dipiridamol;

B. Panangin;

C. Nitroglycerin;

D. Nebilet;

E. Trimetazidin.


Key Answer 2

Correct answer is D – Myocardial Infarction.

High level of CK-MB during the first 24-36 hours after the beginning of central chest pain is the consiquence of acute MI.

Key Answer 3.

Correct answer is А – Myocardial Infarction. Local accumulation of Technetium in myocard is pathognomical mark of MI, its diffusional accumulation can be observed at unstable angina, amyloidosis, pericarditis or after electric cardioversion.

IV. Subject Material

Theory Topics on the Subject:

  1. Clinical features, anamnesis and examination of the patient affected with Myocardial Infarction

  2. Differential diagnostics of MI.

  3. Clinical classification of MI.

  4. Emergency conditions at MI.

  5. Management of the patients affected by MI and urgent treatment of them.

The information necessary for mastering the theory issues may be found in the following references:

  1. Lectures on Hospital Therapy.

  2. Usuf S.Y., Cairns J., Camm J., Fallen E.L. Gersh B. Evidence Based Cardiology. BMJ Publishing Group, 2002. 1024 pp.

  3. Montgomery H., Holdright D. 100 Questions in Cardiology. BMJ Publishing Group, 2001. 222 pp.

  4. Break-down chart on the subject “Myocardial Infarction” (Appendix 1).

  5. Differential diagnostical algorithm on the syndrome «Pain in precardial area» (Appendix 3).

  6. Management of cardiogenic shock (Appendix 4).

Then, proceed to solving some test questions and checking test question 5 with the key answer.

Q 1. The patient B. 53 years old entered to the cardiological department with complaints of pain in precardial area. The pain was compressing, conducted with adventure, lasted during 4 hours, hasn’t cut by sublingual nitroglycerin intake (in whole 15 tablets during 3 hours). The day before he had psychological stress at work. The patient suffers from Hypertension 12 years.

On examination there were pale skin, cyanosis of lips. Mixed dyspnea at rest. The breathing is vesicular, there were no rales. Heart borders are at LML, there were no cardiac murmurs, Pulse was 110/min, BP 160/80. Heart sounds were muffled. The blood count showed the following: erythrocytes 4,1×1012, Hb was 141 g/l, color index was 1.0, leucocytes were 10×109 , 5% eosinophils, 14% band neutrophils, 60% segmented neutrophils, 12% lymphocytes, 9% monocyte, 35% blasts, and ESR was 17 mm/h, MB-KK had high level.

Which of the following is the most probable diagnosis?

А. Stable angina FК IV;

B. Prinzmetal’s angina;

C. Myocardial Infarction;

D. Hypertension, hypertensic crisis;

E. Myocarditis.

Q 2. The patient B. 80 years old, admitted to the intensive care unit of cardiological department with suspicion of Myocardial Infarction. ECG showed pathological Q in II, III, avF.

What localization of MI there was?

А. inferior wall of;

B. septoanterial wall of L V ;

C. lateral wall of LV;

D. right ventricle;

E. posterior wall of L V.

Q 3. The patient B. 54 years old suffers from anterior-septal MI (the second day) suddenly has fallen, lost conscience. Pulse and BP haven’t been observed at that time.

What actions must the urgent doctor make?

А. Cardiopulmonary resuscitation,

B. Nitroglycerin, atropine intravenous,

C. Bundles on the extremities, Nitroglycerini intravenous;

D. ECG-test, intravenous Isadrini ;

E intramuscular solution of Phentanili and Droperidoli.

Q 4. Inferior non-Q-MI has developed in the patient B. 77 years old suffered from IHD, unstable angina.

What ECG changes were there?

A. ST-segment depression, T invertion in II, III, aVF;

B. ST-segment depression, T invertion in II, III, V1-V5;

C. formation of pathological Q, ST-segment elevation in II, III, aVF;

D. formation of pathological Q, ST-segment depression in II, III, aVF;

E. ST-segment depression, T invertion нверсия in I, II, aVL.

Q 5. The patient suffers from Q –MI (4 hours from onset) was delivered to the intensive care unit. What medicine should be used in treatment of this patient?

А. Digoxin;

B. Aspercam;

C. Alteplasa;

D. Nifedipin;

E. Papaverin.

Key Answer 5.

The correct answer is C – Alteplasa. In pathogenesis of MI lies formation of thromb in the coronary artery, its occlusion and terminations of coronary blood flow. Alteplasa relates to the group of thrombolytic drugs. At intravenous or intracoronarial introduction causes thrombolysis. This procedure is effective in the first 12 hours after the development of MI.

^ Summary of procedures for the practice on the subject “Myocardial Infarction”:

At the beginning of the practice prior-to-practice level of knowledge and skills is assessed. Each student gets a patient for curation, examines patients in the ward, and takes part in additional methods of examination.

After fulfilling the tasks, students and the teacher perform the analysis of each student’s independent work where all the students take part.

At the end of the class final testing on the subject and summing up the results of the lesson are performed.

Appendix 1

break-down chart on the SUBJECT:

break-down chart on the SUBJECT

^ Myocardial Infarction”

Myocardial Infarction Infarction

Main symptoms and syndromes


Pain irradiation

Left paddle, left hand,, left arm, left jaw, right arm, epigastrium etc.

Pain localization

Central chest epigastrium

Pain characteristics

constricting, compressive


Pain intensity


Pain continuance

More than 30 min

Effect of Nitriglycerin intake

No effect after 3 times intake

Pain syndrome

Investigations and diagnosis



^ ECG (pathological Q formation, ST-segment elevation or depression, Т invertion).

(area of gypocynesis and acinesis)

Scintigraphy (local accumulation of Technetium)

Blood count (leucocytosis, ESR increasing).

Biochemical blood count: (МВ-KK, АLТ, АSТ, LDG).

TroponinT, Тtroponin I.

Monoclonal AB to myosine


differential diagnostics algorithm on the subject :

Unstable angina, myocarditis, dissecting aortic aneurism, pneumothoraxс, pulmonary embolism, acute cholecystitis, stroke

Clinical classification of MI

Clinical types


painful, asthmaticus, abdomenal, arrhythmycal, cerebral

Q-MI – with ST-segment elevation

withoutQ MI - with out ST-segment elevation





Appendix 2

Tactic of treatment




QIM > 12 hours from onset

QIM < 12 hours from onset


IV or systemic

  • Nitrates,

  • β-blockers,

  • antiaggregants,

  • geparin,

  • ACE-inhibitors

  • statins


  • percutaneous transluminal coronary angioplasty

  • CABG

differential diagnostical algorithm on the syndrome
Appendix 3
Pain in precardial area»

List of Nosological Units:

  1. ^
    Аоrtic stenosis

  2. Vertebral osteochondrosis

  3. Myositis
  4. Hypertrophic cardiomyopathy
5.Myocardial Infarction
6. Angina.

Pain in precardial area

pain at palpation of vertebras signs of osteochondrosis at X-Ray

Aortic stenosis at Echo-KG





pat Q / marcers of myocardial damage (МВ-КК, тroponin T and I)


advice of neurologist

painful palpation of muscles, local hyperthermia, effect of using NSAID

advice of cardiosurgeon





Asymmetrical septal hyperthrophy

advice of cardiosurgeon




ST-segment depression or elevation at heart attack more than 1мВ at ECG





Appendix 4
anagement of cardiogenic shock


Titrate to maintain adequate arterial saturation


iamorphine 2,5-5 mg IV for pain and anxiety

Investigations and close monitoring

Correct arrhythmias, U and E abnormality or acid-base imbalance

Optimize filling pressure

if available measure pulmonary capillary wedge pressure (PCWP)

If PCWP <15mm Hg fluid load If PCWP >15mm Hg

Give a plasma expander Inotropic support

100 ml every 15 min IV eg dobutamine 2,5-10μg/kg/min

Aim for PCWP of 15-20 mmHg IV aim for a systolic BP>80mm


Concider renal dose dopamine 2-5μg/kg/min IV

Concider intra-aortic balloon pump if you expect the underlying condition to improve, or you need time awaiting surgery

Appendix 5
lgorithm of ST-segment elevation or depression

ST-segment elevation



↑MB-KK, Troponin

ST-segment elevation (>2 мм) in I, II, AVL

ST-segment depression (>2 мм) in 2 or more leads

Acute inferior МI

Acute anterior МI


ST-segment elevation (>1 мм) in (II, III, aVF)

↑KK, troponins



without Q-MI

unstable angina


Appendix 6
соnditions and complications of myocardial infarction

  • Arrhythmias;

  • Acute heart failure (severe pulmonary oedema, cardiogenic shock);

  • Cardiac tamponade;

  • Acute aneurysm of heart;

  • Epistenocarditic pericarditis;

  • Thrombendocarditis;

  • Systemic embolisms;

  • Gastroenterological troubles (paresis of stomach, ulceration);

  • Troubles with urination (miction delay);

  • Dressler’s syndrome;

  • Mitral regurgitation;

  • Mental insanity (different degree knocking, hallucinations, neurotic reactions, phobias, reactive depressions).

Appendix 7

Groups of drugs, which are used for treatment of myocardial infarction

I. Drugs with established effects in acute stage:

  • Thrombolytics

  • Aspirin

  • Heparin

  • Nitrates iv

  • β-blockers iv

  • Clopidogrel

II. Drugs potentially dangerous in acute stage:

  • Nifedipine

  • Lidocain

III. Drugs effective on long-run applications:

  • Aspirin

  • Anticoagulants (phenilin) – if aspirin hasn’t used and in case of thrombos of LV

  • β- blockers

  • ACE-inhibitors

  • Clopidogrel

  • Diltiazem or Verapamil at without Q-MI (if there isn’t heart failure)

IV. Drugs potentially dangerous at long using:

  • Calcium antagonists at compensated Heart failure

  • Antiarrhythmics of І class (at preventive treatment)

At the end of the practice class, you shall take a final test, and with this aim in mind, pay attention to the following example tests.

Final Test Questions

Q 1. The patient 87 years old, affected by Q-MI 4 years ago, has hypertension now.

What medicine is undesirable to be prescribed to to this patient?

А. Propranolol;

B. Gipotiazide;

C. Lisinipril;

D. Nifedipine;

E. Diltiazem;

Q 2. The patient F. 50 years old complains of intensive central chest pain, without any effect of 3-times nitroglicerin intake.

What the most informative method of diagnostics in addition to ECG-test can be used in this situation?

А. Complete blood count;

B. X-Ray of chest;

C. Troponin level;

D. Complete urine count;

E. Echo-CG.

Q3. The patient C. 53 years old affected by IHD, Stable angina after alcohol abusing experienced the intensive central chest pain with irradiation to the left arm, without any effect of nitroglicerin. He was delievered to the cardiological department. ECG-test: findings specific for Q acute inferiorlateral MI.

What ECG – changes were there?

А. ST-segment elevation, negative T, pathological Q in II, III, aVF, V4-V6 ;

B. ST-segment elevation, negative T, pathological Q in I, II, aVL, V4-V3;

C. ST-segment depression in II, III, aVF;

D. negative Т, pathological Q, ST>1мм в V3R-V4R;

E. pathological Q in II, III, aVF, V4-V6 .

Q 4. The patient C. 53 years old was delievered to the cardiological department with typical clinics of acute MI. ECG-test: conduction disorder, which makes difficult diagnostics of MI .

What interruption of impulse conduction was it?

А. First degree Atrioventricular block ;

B. Right bundle branch block;

C. Sinoatrial block;

D. Left bundle branch block;

E. Left posterior hemiblock .

Q 5. The patient C. 43 years old, affected by Q-MI 2 month ago, receives some drugs. One of these drugs can prevent development of reccurent MI.

What drug was prescribed to the patient?

А. Lidocain;

B. Novocainamid;

C. Asparcam;

D. Riboxin;

E. Aspirin.


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