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The Acute Coronary Syndromes, Including Acute MI


The Acute Coronary Syndromes, Including Acute MI 2000 ACLS Text Consensus Guidelines Acute Coronary Syndromes Unstable angina Non-Q-wave MI Q-wave MI Acute Coronary ... – PowerPoint PPT presentation

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Title: The Acute Coronary Syndromes, Including Acute MI

The Acute Coronary Syndromes, Including Acute MI
  • 2000 ACLS Text
  • Consensus Guidelines

Acute Coronary Syndromes
  • Unstable angina
  • Non-Q-wave MI
  • Q-wave MI

Acute Coronary Syndromes
  • Are a continuum initiated by
  • rupture of an unstable, lipid-rich atheromatous
    plaque in epicardial artery activating platelet
    adhesion, fibrin clot formation and coronary

Suspicious Chest Pains
  • Classic angina - dull, pressure, substernal arm
    or neck radiation SOB, palpitations, sweating,
    nausea or vomiting
  • Angina Equivalent - no pain but sudden
    ventricular failure or ventricular dysrhythmias
  • Atypical chest pain - precordial area but with
    musculoskeletal, positional, or pleuritic features

CAD Risk Stratification
  • High Risk (?1 of the following features)
  • Prior MI, VT or VF or known CAD
  • Definite clinical angina
  • Dynamic ST changes
  • Marked anterior T-wave changes

CAD Risk Stratification
  • Intermediate Risk (no high-risk features plus 1
    of the following)
  • Definite angina (young age)
  • Probable angina (older age)
  • Possible angina (DM or 3 other risk factors)
  • ST depression ? 1 mm or T inversion ? 1 mm

CAD Risk Stratification
  • Low Risk (no high- or intermediate-risk
    features plus 1 of the following)
  • Possible angina
  • One risk factor (not DM)
  • T-wave inversion lt 1mm
  • Normal ECG

Short-Term Risk of Death
  • High Risk (?1 of the following)
  • Prolonged continuing pain not relieved by rest
    (gt20 min)
  • Pulmonary edema, S3 or rales
  • Hypotension with angina
  • Dynamic ST changes gt 1 mm
  • Elevated serum troponin T or I

Short-Term Risk of Death
  • Intermediate risk (no high-risk features plus 1
    of the following)
  • Prolonged (gt 20 min) but resolved or stuttering
  • Rest angina gt 20 min or relieved with NTG
  • Age gt 65
  • Dynamic T-wave changes and angina
  • Q waves or ST depression lt 1mm multiple-lead

Short-Term Risk of Death
  • Low Risk (no high- or intermediate-risk features
    plus 1 of the following)
  • Angina increased in frequency, severity, or
  • Lower activity threshold before angina
  • 1 risk factor, no DM
  • New-onset angina gt 2 wk to 2 mo
  • Normal or unchanged ECG

Primary goals of therapy for ACS
  • Reduction of myocardial necrosis in patients with
    ongoing infarction
  • Prevention of major adverse cardiac events
  • Death
  • Nonfatal MI
  • Need for urgent revascularization
  • Rapid defibrillation when VF occurs

Out-of-Hospital Management
  • Early defibrillation
  • Prehospital death 52
  • Primary VF 4-18 of patients with MI
  • In-hospital VF 5
  • EMS system for immediate defibrillation is
  • Early access to AED through out the community

Out-of-Hospital Management (contd)
  • Delays in therapy
  • From onset of symptoms to patient recognition
  • Median time ? 2 hrs
  • During out-of-hospital transport 5
  • During in-hospital evaluation door to data, to
    decision and to drug (4 Ds) 25-33
  • Patient education is important to minimize the

Out-of-Hospital Management (contd)
  • Out-of-hospital fibrinolysis
  • Appears to reduce mortality when transport times
    are long
  • Recommended when a physician is present or
    out-of-hospital transport time is ? 60min (Class

Out-of-Hospital Management (contd)
  • Out-of-hospital ECGs
  • Increases the time spent at the scene by 0 to 4
  • Diagnosis of AMI can be made sooner
  • Recommended in urban and suburban paramedic
    systems (Class I)

Out-of-Hospital Management (contd)
  • Cardiogenic shock and out-of-hospital facility
  • Transfer patients at high risk (shock, HR gt 100,
    SBP lt 100, age lt 75) to facility capable of PCI
    or CABG (Class I)
  • Transfer patients with contraindications to
    fibrinolytic therapy to interventional facilities
    (Class IIa)

ER Patient Care
  • Initial assessment (lt 10 min)
  • Measure vital signs
  • Measure SpO2
  • Obtain IV access
  • Obtain 12-lead ECG
  • Perform brief, targeted history and PE)
  • Obtain initial cardiac marker levels
  • Evaluate initial electrolyte and coagulation
  • Request, review portable chest x-ray (lt30 min

ER patient care
  • Initial general treatment (memory aid MONA
    greets all patients
  • Morphine, 2-4 mg repeated q 5-10 min
  • Oxygen, 4 L/min continue if SaO2 lt 90
  • NTG, SL or spray, followed by IV for persistent
    or recurrent discomfort
  • Aspirin, 160 to 325 mg (chew and swallow)

Triage by ECG
  • ST elevation or new LBBB
  • ST elevation ?1 mm in 2 or more contiguous leads
  • ST depression or dynamic T-wave inversion
  • ST depression gt 1 mm
  • Marked symmetrical T-wave inversion in multiple
    precordial leads
  • Dynamic ST-T changes with pain
  • Nondiagnostic ECG or normal ECG

ST elevation or new LBBB
  • Start adjunctive treatment
  • If time lt 12 hr
  • Select a reperfusion strategy based on local
  • If time gt 12 hr
  • Assess clinical status, either high-risk or
    clinically stable

ST elevation or new LBBB
  • Adjunctive treatments
  • ß-blockers
  • NTG IV
  • Heparin IV
  • ACE inhibitors (after 6 hours or when stable)

ST elevation or new LBBB, time lt 12 hr
  • Reperfusion strategy based on local resources
  • Thrombolytics (lt 30 min)
  • TPA 15 mg bolus 0.75 mg/Kg over 30 min 0.5
    mg/Kg over 60 min or
  • SK 1.5 million IU over 1 h
  • Primary percutaneous coronary intervention (PCI,
    angioplasty stent) (90 ? 30 min)
  • Cardiothoracic surgery backup

ST elevation or new LBBB, time gt 12 hr
  • Perform cardiac catheterization for high-risk
  • Persistent symptoms
  • Depressed LV function
  • Widespread ECG changes
  • Prior AMI, PCI, CABG
  • Admit to CCU/ monitored bed if clinically stable
  • Continue or start adjunctive treatments
  • Serial serum markers
  • Serial ECG
  • Consider imaging study (2D echocardiography or

Benefit of Thrombolytics
Thrombolytics and Stroke
  • Risk factors
  • gt 65 years
  • BW lt 70 Kg
  • BP gt 180/110
  • on anticoagulants
  • Strokes
  • no risks 0.25
  • 3 risks 2.5

Contraindications to Thrombolytics
  • Absolute
  • Previous hemorrhagic stroke
  • CVA within past 1 year
  • Brain neoplasm
  • Active internal bleeding
  • Suspected aortic dissection

Contraindications to Thrombolytics
  • Relative
  • BP gt 180/110 or chronic severe hypertension
  • On anticoagulants
  • Trauma or internal bleeding lt 2-4 wks
  • Traumatic CPR (gt10 min)
  • Major surgery lt 3 wks
  • Previous SK
  • Active ulcer
  • Pregnancy
  • Hidden puncture

ST depression or dynamic T-wave inversion
  • Thrombolytics contraindicated
  • Adjunctive therapy
  • Heparin (UFH/LMWH)
  • Aspirin 160-325 mg qd
  • Glycoprotein IIb/IIIa receptor inhibitors
  • NTG IV
  • ?-blockers
  • Cardiac catheterization for high-risk patients or
    monitoring for clinically stable patients

Glycoprotein IIb/IIIa receptor inhibitors
  • Inhibits the GP IIb/IIIa receptor in the membrane
    of platelets
  • Inhibits final common pathway activation of
    platelet aggregation
  • Available approved agents
  • Abciximab (ReoPro)
  • Eptifibitide (Integrilin)
  • Tirofiban (Aggrastat)

Low Molecular Weight Heparin
  • Not neutralized by heparin-binding proteins
  • More predictable effects
  • Measurement of aPTT not required
  • Administered subcutaneously, avoiding difficulty
    with continuous IV administration
  • Available agents
  • Enoxaparin (Loxinox), dalteparin (Fragmin),
    nadroparin (Fraxiparine)

Low Molecular Weight Heparin
  • Inhibits thrombin indirectly through complex,
    with antithrombin III
  • Compared with unfractionated heparin, has more
    inhibition of factor Xa
  • Each molecule of Xa inhibited have led to many
    molecules of thrombin

Lower dose of heparin
  • To reduce the incidence of ICH
  • Bolus dose 60 U/kg (maximum 4000U)
  • Maintenance dose 12 U/kg/hr (maximum 1000 U/hr
    for patients weighing lt 70 kg)
  • Optimal aPTT 50-70 sec

Nondiagnostic ECG or normal ECG
  • Meets criteria for unstable or new-onset angina?
    Or troponin positive?
  • Yes, start adjunctive treatments and assess
    clinical status
  • Cardiac catheterization for high-risk patients or
    monitoring for clinically stable patients
  • No, admit to ER chest pain unit for monitoring
  • If no evidence of ischemia or infarction
  • Discharge and arrange follow-up

Cardiac Markers
  • Myoglobin
  • Nonspecific
  • Rapid-release kinetics
  • Useful for its negative predictive accuracy in
    the early hours after symptom onset
  • Useful marker for reperfusion
  • Inflammatory Markers
  • Can indicate plaque or systemic inflammation
    associated with ACS
  • CRP identifies a subgroup of patients with
    unstable angina at high risk for adverse
    cardiac events

Cardiac Markers
  • CK-MB Isoforms
  • Improved sensitivity compared with CK-MB
  • Only one form in the myocardium
  • CK-MB2 gt 1U/L or CK-MB2/CK-MB1 gt 1.5
  • Troponins
  • Troponin I/Troponin T
  • Increased sensitivity compared with CK-MB
  • Detect minimal myocardial damage
  • Useful in risk stratification
  • Biphasic release kinetics

Acute stroke
  • Major guidelines changes
  • IV administration of tPA for ischemic stroke
  • within 3 hrs of onset of stroke symptoms (Class
  • Between 3-6 hrs of onset of stoke symptoms (class
  • IA fibrinolysis within 3-6 hrs may be beneficial
    in patients with occlusion of MCA (Class IIb)