Early Management Of Of Mi
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Transcript of Early Management Of Of Mi
Early Management of Suspected Early Management of Suspected Myocardial InfarctionMyocardial Infarction
DR Ihab Suliman DR Ihab Suliman MBBS(KHAR),ECFMG(USA)MRCP(UK),BMBBS(KHAR),ECFMG(USA)MRCP(UK),B
oard Certified nuclear cardiology(USA)oard Certified nuclear cardiology(USA)
Associate Consultant Adult CardiologyAssociate Consultant Adult Cardiology
National Guard HospitalNational Guard Hospital Member of the European Atherosclerosis Society.Member of the European Atherosclerosis Society.
Member of the European Society of Cardiology.Member of the European Society of Cardiology.
Member of the European working group on Member of the European working group on Nuclear Cardiology& Cardiac CT.Nuclear Cardiology& Cardiac CT.
Member of the European Working group on Heart Member of the European Working group on Heart failure.failure.
Member of the American Society of Cardiovascular CTMember of the American Society of Cardiovascular CT
Member of the American Society of nuclear cardiologyMember of the American Society of nuclear cardiology
Cardiac Risk Factors(Cardiac Risk Factors(CRFCRF))
Family hx (1st degree relative < 55 yrs)Family hx (1st degree relative < 55 yrs)Smoking *Smoking *HTN *HTN *Cholesterol *Cholesterol *DM *DM *Male genderMale genderObesity(Beating us)Obesity(Beating us) * *
Document CRFs in Document CRFs in EveryEvery CP Patient! CP Patient! (* modifiable risks)(* modifiable risks)
19 years old female,single ,pharmacy 19 years old female,single ,pharmacy student came with chest pain ,LDL student came with chest pain ,LDL
2.0(Never ignore chest pain)2.0(Never ignore chest pain)
19 years old female,single ,pharmacy 19 years old female,single ,pharmacy student came with chest pain ,LDL 2.0,ECG student came with chest pain ,LDL 2.0,ECG
done on discharge.done on discharge.
Clinical Presentation - Chest Clinical Presentation - Chest PainPain
SubsternalSubsternalVisceral - vague burning, squeezing, Visceral - vague burning, squeezing, tightness, heavinesstightness, heavinessRadiates to neck, jaw(very specific for Radiates to neck, jaw(very specific for cardiac pain), L shoulder/armcardiac pain), L shoulder/armUpper abdominal pain - think IMIUpper abdominal pain - think IMIAtypical pain - coronary spasm, female, Atypical pain - coronary spasm, female, elderly, DMelderly, DM
NOTNOT Suggestive of Cardiac Suggestive of Cardiac Ischemia:Ischemia:
Stabbing, knife-Stabbing, knife-like painlike pain
Radiation outside Radiation outside cervicothoracic cervicothoracic segmentssegments
Very brief (< 5 sec)Very brief (< 5 sec)
PleuriticPleuritic
Reproduced by Reproduced by bending or bending or palpationpalpation
Relieved by Relieved by exertionexertion
Prompt relief Prompt relief with NTG or O2with NTG or O2
Additional HistoryAdditional History
Associated sx:Associated sx: SOB, N/V, diaphoresisSOB, N/V, diaphoresis
PMH, medsPMH, meds
Recent (< 6 mos):Recent (< 6 mos): traumatrauma surgerysurgery bleedingbleeding
A l a m e d a C o u n t y E M S
W H O C r i t e r i aW H O C r i t e r i a
• M u s t m e e t 2 o u t o f 3 c r i t e r i a C l i n i c a l h i s t o r y o f i s c h e m i c t y p e c h e s t
p a i n > 2 0 m i n u t e s
C h a n g e s o n s e r i a l E C G t r a c i n g s
R i s e a n d f a l l o f s e r u m c a r d i a c e n z y m e s ( b i o m a r k e r s )
Life-Threatening Causes of CPLife-Threatening Causes of CP
Cardiac ischemiaCardiac ischemia
Esophageal ruptureEsophageal rupture
Aortic dissectionAortic dissection
Massive Pulmonary embolusMassive Pulmonary embolus
Tension PneumothoraxTension Pneumothorax
A 26 year old woman presented 1 week post A 26 year old woman presented 1 week post delivery of her first baby. She has sharp L sided delivery of her first baby. She has sharp L sided
chest pain and she is short of breath.chest pain and she is short of breath.
Stabilizing Measures for Stabilizing Measures for ACS(STEMI)ACS(STEMI)
Aspirin 325 Aspirin 325 mg(saves lives)mg(saves lives)IV: NS or RL KVOIV: NS or RL KVO
OO22: 4-6 LPM via : 4-6 LPM via mask or N.C.mask or N.C.Monitor (V Fib)Monitor (V Fib)Pulse oxPulse ox
Diagnostic Approach - EKGDiagnostic Approach - EKG
Base treatment on hx and clinical Base treatment on hx and clinical setting - setting - NOTNOT EKG findings! EKG findings!
initial EKG may be initial EKG may be normalnormal in AMI in AMI
>1 mm ST elevation in 2 leads - acute >1 mm ST elevation in 2 leads - acute transmural MItransmural MI only seen in 40-50% at presentationonly seen in 40-50% at presentation
Diagnostic Approach - CXRDiagnostic Approach - CXR
Primary value is to R/O pneumonia, Primary value is to R/O pneumonia, PTX, wide mediastinumPTX, wide mediastinum
May see cardiomegaly (with IHD, May see cardiomegaly (with IHD, HTN, old MI) or CHFHTN, old MI) or CHF
26 yr old thin man with sudden onset of 26 yr old thin man with sudden onset of severe R sided sharp chest pain ,tachypnoeic.severe R sided sharp chest pain ,tachypnoeic.
Initial Management: Pain ReliefInitial Management: Pain Relief
NTG SL - 0.3-0.4 mg q5 min x 3NTG SL - 0.3-0.4 mg q5 min x 3
NTG IV - start at 10-20 mcg/min, NTG IV - start at 10-20 mcg/min, titrate 5-10 mcg/min q 5-10 mintitrate 5-10 mcg/min q 5-10 min
Safe w/o hemodynamic monitoringSafe w/o hemodynamic monitoring
Beware hypotension, bradycardiaBeware hypotension, bradycardia
Initial Management - Initial Management - AnticoagulationAnticoagulation
Aspirin 325 mg POAspirin 325 mg PO GIVE TO ALL PTS UNLESS GIVE TO ALL PTS UNLESS
CONTRAINDICATED!CONTRAINDICATED!
reduces MI mortality, strokereduces MI mortality, stroke
Heparin IVHeparin IV
Reperfusion
STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact.
Modified recommendation
STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center for intervention within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation, unless contraindicated.
Modified recommendation
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Thrombolytic TherapyThrombolytic Therapy
PROMPT ADMINISTRATION IS PROMPT ADMINISTRATION IS MORE IMPORTANT THAN MORE IMPORTANT THAN CHOICE OF AGENT(TPA,SK,TNK)CHOICE OF AGENT(TPA,SK,TNK)
ADJUNCTIVE RX FURTHER ADJUNCTIVE RX FURTHER REDUCES MORTALITY SEEN REDUCES MORTALITY SEEN WITH THROMBOLYTICS ALONEWITH THROMBOLYTICS ALONE
Indications forIndications forThrombolytic TherapyThrombolytic Therapy
Chest pain >30 min and Chest pain >30 min and <12 hrs duration<12 hrs duration
ST elevation >1 mm in two ST elevation >1 mm in two contiguous limb leadscontiguous limb leads
ST elevation >2 mm in two ST elevation >2 mm in two contiguous chest leadscontiguous chest leads
New LBBB(previous ECG)New LBBB(previous ECG)
Contraindications to Thrombolytic Contraindications to Thrombolytic TherapyTherapy
altered LOCaltered LOC
aortic dissectionaortic dissection
CNS mass or bleedCNS mass or bleed
active GI bleedingactive GI bleeding
spinal or cranial spinal or cranial surgery w/in 2 mos.surgery w/in 2 mos.
SBP>200 mmHg, SBP>200 mmHg, DBP>120 mmHgDBP>120 mmHg
major trauma or major trauma or surgery w/in 2 wkssurgery w/in 2 wks
recent head injuryrecent head injury
pregnancypregnancy
anticoagulationanticoagulation
bleeding disorderbleeding disorder
traumatic CPRtraumatic CPR
drug allergydrug allergy(age)(age)
Anticoagulants as Ancillary Therapy
Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 hours, and preferably for the duration of the index hospitalization, up to 8 days. New Recommendation
Regimens other than UFH are recommended if therapy is given for more than 48 hours because of risk of heparin-induced thrombocytopenia.New Recommendation
Regimens with established efficacy include:UFH, enoxaparin, fondaparinux (see full text Update for dosing recommendations)
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
ACE Inhibitors
Ace inhibitors should be started and continued indefinitely in all patients recovering from STEMI with LVEF </ 40%, and for patients with preserved LVEF with hypertension, diabetes, or chronic kidney disease, unless contraindicated.
Modified recommendation
ACE inhibitors should be started and continued indefinitely in patients recovering from STEMI who are not lower risk unless contraindicated (low risk defined as those with normal LVEF in whom cardiovascular risk factors are well-controlled and revascularization has been performed).
New recommendation
Among lower risk patients recovering from STEMI, use of ACE inhibitors is reasonable.
New recommendation
III IIaIIaIIa IIbIIbIIbIIIIIIIIIIII IIaIIaIIa IIbIIbIIbIIIIIIIIIIII IIaIIaIIa IIbIIbIIbIIIIIIIIIIIaIIaIIa IIbIIbIIbIIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Beta-Blockers
Oral beta-blocker therapy should be initiated in the first 24 hours for patients who do not have the following:
Signs of heart failureEvidence of low output stateIncreased risk for cardiogenic shock
Age >70 yearsSystolic blood pressure <120 mm HgSinus tachycardia (heart rate >110 or < 60 bpm)
Increased time since onset of symptoms of STEMIRelative contraindications to beta-blockade
PR interval >0.24 secondssecond- or third-degree heart blockactive asthma or reactive airway disease
Modified recommendation
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Aldosterone BlockadeAldosterone Blockade
Use of aldosterone blockade in post-MI patients Use of aldosterone blockade in post-MI patients without significant renal dysfunction or without significant renal dysfunction or hyperkalemia is recommended in patients who:hyperkalemia is recommended in patients who:
are already receiving therapeutic doses of are already receiving therapeutic doses of an ACE inhibitor and beta blockeran ACE inhibitor and beta blocker
have a LVEF of less than or equal to 40%have a LVEF of less than or equal to 40%
have either diabetes or HFhave either diabetes or HF
Modified recommendationModified recommendation
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Thienopyridines
Clopidogrel (75mg daily) should be added to aspirin in patients with STEMI regardless of whether or not reperfusion therapy is received.
New recommendation
Treatment with clopidogrel should continue for at least 14 days.
New recommendation
In patients taking clopidogrel in whom CABG is planned, the drug should be withheld for at least 5 days (preferably 7 days), unless the urgency for revascularization outweighs the risks of excess bleeding.
No change in recommendation
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
New Recommendations in 2007 New Recommendations in 2007 Update for Lipid ManagementUpdate for Lipid Management
A fasting lipid panel should be assessed in all A fasting lipid panel should be assessed in all patients and within 24 hours of hospitalization, and patients and within 24 hours of hospitalization, and lipid-lowering medication should be initiated prior to lipid-lowering medication should be initiated prior to discharge.discharge.
LDL-C should be <100mg/dL, LDL-C should be <100mg/dL, and further reduction and further reduction to <70mg/dL is reasonable.to <70mg/dL is reasonable.
If baseline LDL-C is 70 - 100 mg/dL, it is If baseline LDL-C is 70 - 100 mg/dL, it is reasonable to treat to <70 mg/dL.reasonable to treat to <70 mg/dL.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Pitfalls and PearlsPitfalls and Pearls
Maintain high index of Maintain high index of suspicionsuspicion
Document risk factors in Document risk factors in everyevery CP patient CP patient
Mentally rule out 5 life-Mentally rule out 5 life-threatening causes in threatening causes in everyevery CP patient CP patient
Stabilize with Stabilize with IV/OIV/O22/monitor/pulse ox/monitor/pulse ox
Pitfalls and PearlsPitfalls and Pearls
Normal EKG does not R/O Normal EKG does not R/O AMIAMI
Single CK-MB does not R/O Single CK-MB does not R/O AMIAMI
ASA,B-blockers,Clopidogrel ASA,B-blockers,Clopidogrel plus ACEI lower mortality & plus ACEI lower mortality & CHEAPCHEAP
50 years old female with chronic renal 50 years old female with chronic renal failure,chest pain & dizzinessfailure,chest pain & dizziness
she is hypertensive on lisinoprilshe is hypertensive on lisinopril
26 Old army officer had flu last week,felt chest pain while driving his 26 Old army officer had flu last week,felt chest pain while driving his car,pain increased by deep breath,he has no history of DM or car,pain increased by deep breath,he has no history of DM or
HTN,nonsmoker,lipid profile LDL 2.0 MMMOL/HTN,nonsmoker,lipid profile LDL 2.0 MMMOL/LL