ACUTE MYOCARDIA INFARCTION ISCHEMIA MI Draz MY
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Transcript of ACUTE MYOCARDIA INFARCTION ISCHEMIA MI Draz MY
الرحيم الرحمن اللله بسم
ACUTE CORONARY SYNDROME SIMPLE NOTES
Draz MY , Egypt 2008
Mb. Bch (Tanta), D. Sc (Al azhar) .,M. Sc (Cairo) ,M. Sc (Ain shams).
Surgeon ,Internist, Emergency [email protected]
AtherosclerosisAtherosclerosis
One of the most common diseases in U.S.AOne of the most common diseases in U.S.A..
50%50% of U.S. Deaths are attributed to MIof U.S. Deaths are attributed to MI
Atherosclerosis is the Principal cause of Atherosclerosis is the Principal cause of Death in Western World (Braunwald)Death in Western World (Braunwald)
Atherosclerosis begins in childhood and Atherosclerosis begins in childhood and advances throughout lifeadvances throughout life
RISK FACTORS AND PATHOGENESIS OF ATHEROMATOUS LESIONS OF ARTERIES.
CORONARY HEART DISEASE : CLINICAL CORONARY HEART DISEASE : CLINICAL MANIFESTATIONS AND PROBLEMSMANIFESTATIONS AND PROBLEMS
STABLE ANGINASTABLE ANGINAFIXED CORONARY FIXED CORONARY ATHEROMATOUS LESIONATHEROMATOUS LESION
UNSTABLE UNSTABLE ANGINA ANGINA
DYNAMIC CORONARY DYNAMIC CORONARY OBSTRUCTIONOBSTRUCTION
MIMIMYONECROSIS DUE TO ACUTE MYONECROSIS DUE TO ACUTE ISCH.ISCH.
HEART FAILUREHEART FAILUREMYOCARDIAL DYSFUNCTIONDUE MYOCARDIAL DYSFUNCTIONDUE TO INFARCTION OR ISCH.TO INFARCTION OR ISCH.
ARRYTHMIAARRYTHMIAALTERED CONDUCTION DUE TO ALTERED CONDUCTION DUE TO ISCH.OR INFARCTIONISCH.OR INFARCTION
SUDDEN DEATHSUDDEN DEATHV.TACH.,ASYSTOLE,MASSIVE MIV.TACH.,ASYSTOLE,MASSIVE MI
Myocardial IschemiaMyocardial Ischemia
•Spectrum of presentation•silent ischemia•exertion-induced angina•unstable angina•acute myocardial infarction
ACC/AHA 2002 GUIDLINESACC/AHA 2002 GUIDLINES
ACC/AHA 2002 GUIDLINESACC/AHA 2002 GUIDLINES
ACC/AHA 2002 GUIDLINESACC/AHA 2002 GUIDLINES
UNSTABLE ANGINA
Acute Coronary SyndromeAcute Coronary Syndrome
Ischemic DiscomfortUnstable Symptoms
No ST-segmentelevation
ST-segmentelevation
Unstable Non-Q Q-Waveangina AMI AMI
ECG
AcuteReperfusion
HistoryPhysical Exam
THROMBOSIS IN MYOCARDIAL THROMBOSIS IN MYOCARDIAL INFARCTION SCORE FOR UNSTABLE INFARCTION SCORE FOR UNSTABLE
AND NSTSMIAND NSTSMI
Unstable AnginaUnstable Anginaprecipitating factorsprecipitating factors
Inappropriate tachycardiaInappropriate tachycardia
anemia, fever, hypoxia, tachyarrhythmias, anemia, fever, hypoxia, tachyarrhythmias, thyrotoxicosisthyrotoxicosis
High afterloadHigh afterload
aortic valve stenosis, LVHaortic valve stenosis, LVH
High preloadHigh preload
high cardiac output, chamber dilatationhigh cardiac output, chamber dilatation
Inotropic stateInotropic state
sympathomimetic drugs, cocaine intoxicationsympathomimetic drugs, cocaine intoxication
Acute Coronary SyndromeAcute Coronary Syndrome
**Process of resolutionProcess of resolutionspontaneous thrombolysisspontaneous thrombolysis
vasoconstriction resolutionvasoconstriction resolution
presence of collateral circulationpresence of collateral circulation
**Delayed or absence of resolution may Delayed or absence of resolution may lead to non-Q-wave or Q-wave lead to non-Q-wave or Q-wave myocardial infarctionmyocardial infarction
Unstable AnginaUnstable AnginaTherapeutic GoalsTherapeutic Goals
**Therapeutic GoalsTherapeutic Goals
Reduce myocardial ischemiaReduce myocardial ischemia
Control of symptomsControl of symptoms
Prevention of MI and deathPrevention of MI and death
**Medical ManagementMedical Management
Anti-ischemic therapyAnti-ischemic therapy
Anti-thrombotic therapyAnti-thrombotic therapy
Unstable AnginaUnstable AnginaMedical TherapyMedical Therapy
Anti-ischemic therapyAnti-ischemic therapynitrates, beta blockers, calcium antagonistsnitrates, beta blockers, calcium antagonists
Anti-thrombotic therapyAnti-thrombotic therapyAnti-platelet therapyAnti-platelet therapy
aspirin, ticlopidine, clopidogrel, aspirin, ticlopidine, clopidogrel, GP IIb/IIIa inhibitorsGP IIb/IIIa inhibitors
Anti-coagulant therapyAnti-coagulant therapy
heparin, low molecular weight heparin heparin, low molecular weight heparin (LMWH), warfarin, hirudin, hirulog(LMWH), warfarin, hirudin, hirulog
Unstable AnginaUnstable AnginaAnti-ischemic TherapyAnti-ischemic Therapy
restrict activitiesrestrict activities
morphinemorphine
oxygenoxygen
nitroglycerinenitroglycerinepain relief, prevent silent ischemia, control pain relief, prevent silent ischemia, control hypertension, improve ventricular dysfunctionhypertension, improve ventricular dysfunction
nitrate free period recommended after the first nitrate free period recommended after the first 24-48 hours24-48 hours
Unstable AnginaUnstable AnginaAnti-ischemic TherapyAnti-ischemic Therapy
beta-blockersbeta-blockerslowering angina thresholdlowering angina threshold
prevent ischemia and death after MIprevent ischemia and death after MI
particularly useful during high sympathetic toneparticularly useful during high sympathetic tone
calcium antagonistscalcium antagonistsparticularly the rate-limiting agentsparticularly the rate-limiting agents
nifedipine is not recommended without nifedipine is not recommended without concomitant ß-blockadeconcomitant ß-blockade
Unstable AnginaUnstable AnginaAnti-platelet TherapyAnti-platelet Therapy
•ThienopyridinesThienopyridines–ticlopidine ticlopidine (Ticlid; Hoffmann-La Roche)(Ticlid; Hoffmann-La Roche)
–clopidogrel clopidogrel (Plavix; Bristol-Myers (Plavix; Bristol-Myers Squibb)Squibb)
•block platelet aggregation induced by block platelet aggregation induced by ADP and the transformation of GP ADP and the transformation of GP IIb/IIIa into its high affinity stateIIb/IIIa into its high affinity state
Unstable AnginaUnstable AnginaAnti-platelet TherapyAnti-platelet Therapy
ClopidogrelClopidogrelCAPRIE CAPRIE (Clopidogrel versus Aspirin in Patients at Risk (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events)of Ischemic Events)
19,00019,000 patients randomly assigned to clopidogrel (75 patients randomly assigned to clopidogrel (75 mg/d) or to aspirin (325 mg/d)mg/d) or to aspirin (325 mg/d)
there was an there was an 8.7%8.7% reduction in the combined reduction in the combined incidence of stroke, MI, or death (P=.043)incidence of stroke, MI, or death (P=.043)
patients with MI did better with aspirinpatients with MI did better with aspirin
patients with PVD or stroke did better with patients with PVD or stroke did better with clopidogrelclopidogrel
Lancet 1996;348:1329-1339Circulation 1998;97:1107
Unstable AnginaUnstable AnginaAnti-platelet TherapyAnti-platelet Therapy
GP IIb/IIIa inhibitorsGP IIb/IIIa inhibitorsabciximab (monoclonal antibody)abciximab (monoclonal antibody)
eptifibatide (peptidic inhibitor)eptifibatide (peptidic inhibitor)
lamifiban and tirofiban (non-peptides)lamifiban and tirofiban (non-peptides)
direct occupancy of the GP IIb/IIIa receptor by a direct occupancy of the GP IIb/IIIa receptor by a monoclonal antibody or by synthetic monoclonal antibody or by synthetic compounds mimicking the RGDcompounds mimicking the RGD sequence for sequence for fibrinogen binding prevents platelet fibrinogen binding prevents platelet aggregationaggregation
Unstable AnginaUnstable AnginaAnti-platelet TherapyAnti-platelet Therapy
Tirofiban Tirofiban (Aggrastat; Merk & Co.)(Aggrastat; Merk & Co.)PRISMPRISM (Platelet Receptor Inhibition for (Platelet Receptor Inhibition for Ischemic Syndrome Management)Ischemic Syndrome Management)
3,2003,200 patients with unstable angina were patients with unstable angina were treated with either heparin or tirofibantreated with either heparin or tirofiban
At 48 hours, there was significant risk At 48 hours, there was significant risk reduction (5.9% to 3.6%) in the rate of reduction (5.9% to 3.6%) in the rate of death, MI, or refractory ischemia. The death, MI, or refractory ischemia. The benefit was lost at 30 daysbenefit was lost at 30 days..
N Engl J Med 1998;338:1498-505
Unstable AnginaUnstable AnginaAnti-coagulant TherapyAnti-coagulant Therapy
Low-molecular-weight heparinLow-molecular-weight heparinadvantages over heparinadvantages over heparin::better bio-availabilitybetter bio-availability
higher ratio (3:1) of anti-Xa to anti-IIa higher ratio (3:1) of anti-Xa to anti-IIa activityactivity
longer anti-Xa activity, avoid reboundlonger anti-Xa activity, avoid rebound
induces less platelet activationinduces less platelet activation
ease of use (subcutaneous - qd or bid)ease of use (subcutaneous - qd or bid)
no need for monitoringno need for monitoring
NSTSMI
MYOCARDIAL PROTEINSMYOCARDIAL PROTEINS
Myoglobin
Actin,Myosin
Troponin
LDH
CK, AST
MYOFIBER STRUCTUREMYOFIBER STRUCTURE
TnI
ActinTropomyosin
TnC TnT
•
•
0 6 12 18 24 2 3 4 5 6 7 8 9 10
RE
LATI
VE
CO
NC
EN
TRAT
ION
DaysHours
TIME AFTER INFARCT
Normal
TroponinMyoglobin
CK, ASTLDH
STSEMI
In-stent Restenosis in small In-stent Restenosis in small vessels treated with vessels treated with rotational atherectomyrotational atherectomy
StentsStents
Coronary stents haveCoronary stents have
revolutionized the fieldrevolutionized the field
of coronary angioplastyof coronary angioplasty
due to their ability todue to their ability to
prevent abrupt closure ofprevent abrupt closure of
the artery afterthe artery after
angioplasty and also byangioplasty and also by
reducing restenosisreducing restenosis
Late LossLate Loss
• In- stent restenosis is a In- stent restenosis is a proliferative disease disorderproliferative disease disorder
• Late loss of between 0.8–1.0mm Late loss of between 0.8–1.0mm occurs in bare stentsoccurs in bare stents
• Lumen area reduction Lumen area reduction
Definite ACSDefinite ACSPossible ACSPossible ACS
(–) ECG;Normal biomarkers
(–) ECG;Normal biomarkers
Observe; repeat ECG, markers at 4-8 hrs
Observe; repeat ECG, markers at 4-8 hrs
No recurrent pain;(–) follow-up studiesNo recurrent pain;
(–) follow-up studiesRecurrent pain;
(+) follow-up studiesRecurrent pain;
(+) follow-up studies
Stress test; LVfunction if ischemia
Stress test; LVfunction if ischemia
(–) test: outpt follow-up(–) test: outpt follow-up
(+) test(+) test
Admit, Use AcuteIschemia PathwayAdmit, Use AcuteIschemia Pathway
ST ST
Use MI Guidelines
Use MI Guidelines
No ST No ST
ST-T ’s,chest pain, markers
ST-T ’s,chest pain, markers
Symptoms Suggestive of ACSSymptoms Suggestive of ACS
Emergency Room Triage of Patients with Acute Chest Pain by Means of Rapid Testing for Cardiac Troponin T or Troponin IChristian W. Hamm, M.D., Britta U. Goldmann, M.D., Christopher Heeschen, M.D., Georg Kreymann, M.D., Jürgen Berger, Ph.D., and Thomas Meinertz, M.D.
NEJM,Volume 337:1648-1653, Number 23December 4, 1997773 consecutive patients who had had acute chest
pain for less than 12 hours without ST-segment elevation on their electrocardiograms, troponin T and troponin I status (positive or negative) was determined at least twice by sensitive, qualitative
bedside tests based on the use of specific monoclonal antibodies.
TOTAL TOTAL PATIENTSPATIENTS
MI.PATIENTSMI.PATIENTSUNSTABLE UNSTABLE ANGINAANGINA
NONO..7737734747315315
Tn.I +VETn.I +VE171171= = 22%22% 4747==100%100%114114= = 3636% %
Tn.T +VETn.T +VE123123= = 1616 %%4444= = 9494% % 7070= = 2222% %
ConclusionsConclusions Bedside tests for cardiac-specific Bedside tests for cardiac-specific troponins aretroponins are highly sensitive for the early detection highly sensitive for the early detection of myocardial-cellof myocardial-cell injury in acute coronary injury in acute coronary syndromes. Negative test results aresyndromes. Negative test results are associated with associated with low risk and allow rapid and safe dischargelow risk and allow rapid and safe discharge of of patients with an episode of acute chest pain from the patients with an episode of acute chest pain from the emergencyemergency roomroom..
Missed Diagnoses of Acute Cardiac Ischemia in the Emergency Department.Pope ET AL.
Volume 342:1163-1170, Number 16, NEJM
April 20, 2000
Missed Diagnoses of Acute Cardiac Ischemia in the Emergency Department. Pope ET AL. Volume 342:1163-1170, Number 16, NEJM April 20, 2000
TOTAL NO.=10,689TOTAL NO.=10,689 % %FROM TOTALFROM TOTAL
ACUTE CARDIAC ISCHACUTE CARDIAC ISCH..1717
MIMI88
UNSTABLE ANGINAUNSTABLE ANGINA99
STABLE ANGINASTABLE ANGINA66
NON ISCH.CARDIACNON ISCH.CARDIAC2121
NON CARDIACNON CARDIAC5555
NO.NO.DISCHARGE DISCHARGE FROM EDFROM ED
% OF TOTAL% OF TOTAL
ACUTE MIACUTE MI88988919192.1%2.1%
UNSTABLE ANGINAUNSTABLE ANGINA96696622222.3%2.3%
It appears that the incidence of missed diagnoses of acute cardiac ischemia in the emergency department may be reduced by:
1 -Interpreting the electrocardiogram more accurately.
2 -Addressing clinical factors or preconceptions that obscure the recognition of acute myocardial infarction and unstable angina in women and nonwhite patients.
3 -Considering the possibility that acute cardiac ischemia may be present in patients with chief symptoms other than chest pain.
4 -Assessing recent changes in the clinical course of
angina more carefully.
العالمين رب لله الحمد