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BRADYCARDIASSlow(absolute bradycardia=rate < 60 bpm
orRelatively slow(rate less than expected relative to
underlying condition or cause)
PRIMARY ABCD SURVEY Assess ABCs ecure air!ay noninvasively "nsure monitor # de$ibrillator is available
SECONDARY ABCD SURVEY Assess secondary ABCs (invasive air!ay
management needed%) &xygen ' access ' monitor ' $luids
ital signs* pulse oximeter* monitor B+ &btain and revie! ,-'lead "C. &btain and revie! portable chest x'ray +roblem'$ocused history +roblem'$ocused physical examination Consider causes (di$$erential diagnoses)
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SERIOUS SIGNS OR SYMPTOMS ?SERIOUS SIGNS OR SYMPTOMS ?
/ue to the bradycardia%/ue to the bradycardia%
Tye II se!o"d#de$%ee AV &lo!'Tye II se!o"d#de$%ee AV &lo!'
ororT(i%d#de$%ee AV &lo!'?T(i%d#de$%ee AV &lo!'?
I"te%ve"tio" Se)*e"!eI"te%ve"tio" Se)*e"!e
At%oi"eAt%oi"e01 2 ,0 mg01 2 ,0 mg T%a"s!*ta"eo*s a!i"$T%a"s!*ta"eo*s a!i"$i$ availablei$ available Doa+i"eDoa+i"e1'-0 3g#4g per minute1'-0 3g#4g per minute Ei"e(%i"eEi"e(%i"e -',0 3g#min-',0 3g#min Iso%ote%e"olIso%ote%e"ol -',0 3g#min-',0 3g#min
NoNo YesYes
+repare $or transvenous pacer+repare $or transvenous pacer $ symptoms develop* use$ symptoms develop* use
transcutaneous pacema4er untiltranscutaneous pacema4er until
transvenous pacer placedtransvenous pacer placed
&bserve&bserve
NoNo YesYes
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Eval*ate atie"tEval*ate atie"t s patient stable or unstable%s patient stable or unstable%
Are there serious signs or symptoms%Are there serious signs or symptoms% Are signs and symptoms due to tachycardia%Are signs and symptoms due to tachycardia%
Sta&le atie"t, "o se%io*s si$"s o% sy+to+sSta&le atie"t, "o se%io*s si$"s o% sy+to+s nitial assessment identi$ies , o$ 5 types o$nitial assessment identi$ies , o$ 5 types o$
tachycardiastachycardias
U"sta&le atie"t, se%io*s si$"s o% sy+to+sU"sta&le atie"t, se%io*s si$"s o% sy+to+s "stablish rapid heart rate as cause o$ signs and"stablish rapid heart rate as cause o$ signs and
symptomssymptoms ate'related signs and symptoms occur at many rates*ate'related signs and symptoms occur at many rates*
seldom < ,10 bpmseldom < ,10 bpmPrepare for immediate cardioversion (see Fig. 10)Prepare for immediate cardioversion (see Fig. 10)
,, Atrial $ibrillationAtrial $ibrillation
Atrial $lutterAtrial $lutter-- 7arro!'complex7arro!'complex
tachycardiatachycardia88 table !ide'complextable !ide'complex
tachycardia9 un4no!n typetachycardia9 un4no!n type55 table monomorphic :table monomorphic :
and#or polymorphic :and#or polymorphic :
StableStable UnstableUnstable
Next slideNext slide
:he :achycardias9 &vervie! Algorithm:he :achycardias9 &vervie! Algorithm
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Evaluation focus: 4 clinicalEvaluation focus: 4 clinical
featuresfeatures
,, +atient clinically unstable%+atient clinically unstable%
-- Cardiac $unction impaired%Cardiac $unction impaired%
88 ;+; present%;+; present%
55 /uration
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Tachycardia: Atrial )ibrillation and )lutter
Atrial $ibrillation#Atrial $ibrillation#atrial $lutter !ithatrial $lutter !ith
Normal heartNormal heart
,, Control ateControl ate - Convert hythm- Convert hythm
Impaired heartImpaired heart WPWWPW eart unctioneart unction+reserved+reserved mpairedmpairedeart "eart "
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or additionalor additionaldrugs that aredrugs that areClass bClass brecommendationrecommendations*s*
see .uidelinessee .uidelinesor ACF textor ACF text
or additionalor additionaldrugs that aredrugs that are
Class bClass brecommendationrecommendations * sees * see
.uidelines or.uidelines orACF textACF text
Ea%ly !a%dioves%sio"Ea%ly !a%dioves%sio"
.. Begin heparin at onceBegin heparin at once
:"" to exclude atrial clot:"" to exclude atrial clot
T(e"T(e"
Cardioversion !ithin -5 hoursCardioversion !ithin -5 hours
T(e"T(e"
Anticoagulation x 5 more !ee4sAnticoagulation x 5 more !ee4s
mpairedmpairedheart ("heart ("
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Atrial fibrillationAtrial fibrillationatrial flutter 'ithatrial flutter 'ith
.. Normal heartNormal heart
Impaired heartImpaired heart
WPWWPW
/0 "ontrol *ate/0 "ontrol *ate 10 "onvert *hythm10 "onvert *hythm
2eart )unction2eart )unction(reserved(reserved
3mpaired 2eart E)3mpaired 2eart E)456 or "2)456 or "2)
Duration 47 2oursDuration 47 2ours Duration 847Duration 8472ours or Un&no'n2ours or Un&no'n
#(##(# Note:Note: If AF >!If AF >!ho"rs# d"ration$ "seho"rs# d"ration$ "se
agents %ith potentialagents %ith potentialto convert rh&thmto convert rh&thm%ith e'treme ca"tion%ith e'treme ca"tionin patients notin patients notreceiving ade"atereceiving ade"ateanticoag"lationanticoag"lationeca"se of possileeca"se of possileemolicemolic
complicationscomplications /C cardioversion/C cardioversion
O%O%
.. (rimary(rimaryantiarrhytmicantiarrhytmicagentsagents
Note:Note: If AF >! ho"rs#If AF >! ho"rs#d"ration$ "se agentsd"ration$ "se agents
%ith potential to%ith potential toconvert rh&thm %ithconvert rh&thm %ithe'treme ca"tion ine'treme ca"tion in
patients not receivingpatients not receivingade"ateade"ateanticoag"lationanticoag"lationeca"se of possileeca"se of possileemolicemolic
complicationscomplications /C cardioversion/C cardioversion
O%O%
AmiodaroneAmiodarone
(Class b)(Class b)
../C cardioversion/C cardioversion
O%O%
.. (rimary(rimaryantiarrhythmic agentsantiarrhythmic agents
*se onl& 1 of the*se onl& 1 of thefollo%ing agents (seefollo%ing agents (seenote elo%)+note elo%)+
AmiodaroneAmiodarone
(Class b)(Class b)
lecainidelecainide
(Class b)(Class b)
+rocainamide+rocainamide
(Class b)(Class b)
+ropa$enone+ropa$enone
(Class b)(Class b)
otalolotalol
Class bClass b
.. AvoidAvoidnonemergentnonemergent
CardioversionCardioversionunlessunlessanticoagulation oranticoagulation orclot precautions areclot precautions areta4en (see above)ta4en (see above)
AnticolagulationAnticolagulationas described above*as described above*
$ollo!ed by$ollo!ed by D" cardioversionD" cardioversion
Tachycardia: Atrial )ibrillation and flutter
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*se onl& 1 of the*se onl& 1 of thefollo%ing agentsfollo%ing agents(see note elo%)+(see note elo%)+
Amiodarone (ClassAmiodarone (Classb)b)
lecainidelecainide(Class b)(Class b)
+rocainamide+rocainamide(Class b)(Class b)
+ro$enone+ro$enone
(Class b)(Class b)
otalol (Class b)otalol (Class b)
Class Class
(can e harmf"l)(can e harmf"l)
AdenosineAdenosine
D'Bloc4ersD'Bloc4ers
Calcium bloc4ersCalcium bloc4ers
/igoxin/igoxin
mpaired heartmpaired heart
(2F 304 or -5F)(2F 304 or -5F)
/C cardioversion/C cardioversion
Amiodarone (ClassAmiodarone (Classb)b)
Class Class
(can e harmf"l)(can e harmf"l)
AdenosineAdenosine
D'Bloc4ersD'Bloc4ers
Calcium bloc4ersCalcium bloc4ers /igoxin/igoxin
;+; indicates ;ol$$'+ar4inson';hite syndrome9 A* atrial $ibrillationH 7* normal sinus rhythmH :""* transesophageal;+; indicates ;ol$$'+ar4inson';hite syndrome9 A* atrial $ibrillationH 7* normal sinus rhythmH :""* transesophageal
echocardiogramH and "* e?ection $ractionechocardiogramH and "* e?ection $raction
7ote9 &ccasionally - o$ the named antiarrithmic agents may be used* but use o$ these agents in combination may have7ote9 &ccasionally - o$ the named antiarrithmic agents may be used* but use o$ these agents in combination may have
proarrhythmic potential :he classes listed represent the Class o$ ecommendation rather than the aughn';illiamsproarrhythmic potential :he classes listed represent the Class o$ ecommendation rather than the aughn';illiams
classi$ication o$ antiarrhythmicsclassi$ication o$ antiarrhythmics
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Narro'$"omple% TachycardiaNarro'$"omple% Tachycardia
Narro'$"omple% SupraventricularTachycardia9Narro'$"omple% SupraventricularTachycardia9 Sta&leSta&le
.. # Blo!'e%# Blo!'e%
-- Ca.Ca.//!(a""el &lo!'e%!(a""el &lo!'e%
--A+ioda%o"eA+ioda%o"e
N, D" cardioversionN, D" cardioversion
Attempt therapeutic diagnostic maneuverAttempt therapeutic diagnostic maneuver
.. Va$al sti+*latio"Va$al sti+*latio"
--Ade"osi"eAde"osi"e
..A+ioda%o"eA+ioda%o"e
N, D" cardiversionN, D" cardiversion
nctnct;unctional tachycardia;unctional tachycardia
+reserved+reserved
eart $unctioneart $unction
"
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(aro%yamal supraventricular(aro%yamal supraventricular
tachycardiatachycardia(riority order:(riority order:
.. DC !a%diove%sio"DC !a%diove%sio"
-- Di$oxi"Di$oxi"
--A+ioda%o"eA+ioda%o"e
-- Diltia0e+Diltia0e+
(riority order:(riority order:
..AV "odal &lo!'adeAV "odal &lo!'ade
11 2#Blo!'e%2#Blo!'e%
11 Ca3/ !(a""el &lo!'e%Ca3/ !(a""el &lo!'e%
11 Di$oxi"Di$oxi"
-- DC !a%diove%sio"DC !a%diove%sio"--A"tia%%(yt(+i!sA"tia%%(yt(+i!s::
consider procainamide9consider procainamide9
amiodarone9 sotalolamiodarone9 sotalol
(reserved(reserved
heart functionheart function
E) 4569 "2)E) 4569 "2)
Ectopic or multifocalEctopic or multifocal
atrial tachycardiaatrial tachycardia
.. 2#Blo!'e%2#Blo!'e%
-- Ca3/ !(a""el &lo!'e%Ca3/ !(a""el &lo!'e%
--A+ioda%o"eA+ioda%o"e
N, D" cardioversionN, D" cardioversion
(reserved(reserved
2eart function2eart function
E) 4569 "2)E) 4569 "2)
..A+ioda%o"eA+ioda%o"e
-- Diltia0e+Diltia0e+
N, D" cardioversionN, D" cardioversion
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table entricular :achycardia9 >onomorphic and +olymorphictable entricular :achycardia9 >onomorphic and +olymorphic
table entricular :achycardiatable entricular :achycardia>onomorphic or +olymorphic%>onomorphic or +olymorphic%
>edications9 any one>edications9 any one ProcainamideProcainamide otalolotalol
&thers acceptable&thers acceptableAmiodaroneAmiodarone 6idocaine6idocaine
+olymorphic :+olymorphic : s Baseline I: interval prolonged%s Baseline I: interval prolonged%
7oteJ7oteJ7a& go direcl& to7a& go direcl& to
cardioversioncardioversion
>onomorphic :>onomorphic : s cardiac $unctions cardiac $unction impairedimpaired
7ormal baseline I: nterval7ormal baseline I: nterval
:reat ischemia:reat ischemia Correct electrolytesCorrect electrolytes
>edications9 any one>edications9 any one 89:locers89:locersoror 6idocaine6idocaineoror ProcainamideProcainamideoror otalolotalol
Fong baseline I: intervalFong baseline I: interval
Correct abnormal electrolytesCorrect abnormal electrolytes
:herapies9 any one:herapies9 any one 7agnesi"m7agnesi"m ;verdrive;verdrive IsoproterenolIsoproterenol Phen&toinPhen&toin 6idocaine6idocaine
+reserved+reservedheart $unctionheart $unction +oor e?ection $raction+oor e?ection $raction
7ormal baseline7ormal baselineI: intervalI: interval
+rolonged baseline+rolonged baseline
I: interval(suggests torsades)I: interval(suggests torsades)
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A+ioda%o"eA+ioda%o"e
,10 mg over ,0 minutes,10 mg over ,0 minutes
oror4ido!ai"e4ido!ai"e
01 to 0K1 mg#4g push01 to 0K1 mg#4g push
:hen use:hen use
Sy"!(%o"i0ed !a%diove%sio"Sy"!(%o"i0ed !a%diove%sio"
Cardiac $unctionCardiac $unction
impairedimpaired
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Acute (ulmonary Edema9 2ypotension9 Shoc&
"linical signs9 hoc$ h&poperf"sion$
congestive heart fail"re$ ac"te p"lmonar& edema
>ost li4ely problem%
Acute pulmonary edema !olume (roblem (ump problem *ate problem
Tachycardia
(see algorithm)
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ystolic B+ B+
de$ines -ndline
o$ action (ee
belo!)
ystolic B+
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3schemic "hest (ain Algorithm3schemic "hest (ain Algorithm
Chest painChest pain
suggestive o$ ischemiasuggestive o$ ischemia
mmediate assessment (easure vital signs (automatic#standard B+ cu$$)
>easure oxygen saturation>easure oxygen saturation
&btain access&btain access
&btain ,-'lead "C. (physician revie!s)&btain ,-'lead "C. (physician revie!s)
+er$orm brie$* targeted history and physical examH+er$orm brie$* targeted history and physical examH
$ocus on eligibility $or $ibrinolytic therapy$ocus on eligibility $or $ibrinolytic therapy &btain initial serum cardiac mar4er levels&btain initial serum cardiac mar4er levels
"valuate initial electrolyte and coagulation studies"valuate initial electrolyte and coagulation studies
eLuest* revie! portable chest x'ray (
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Start ad?unctive treatmentsStart ad?unctive treatments
(as indicated9 no reper$usion delay)(as indicated9 no reper$usion delay)
2#Ad%e"o!eto% &lo!'e%s IV2#Ad%e"o!eto% &lo!'e%s IV
--
Nit%o$ly!e%i" IVNit%o$ly!e%i" IV
-- 6ea%i" IV6ea%i" IV
--ACE i"(i&ito%sACE i"(i&ito%s(a$ter 6 hours or(a$ter 6 hours or
!hen stable)!hen stable)
Start ad?unctive treatmentsStart ad?unctive treatments
(as indicated9 no contraindications)(as indicated9 no contraindications)
6ea%i"6ea%i"(*F5=67W5)(*F5=67W5)
Asi%i"Asi%i",60 to 8-1 mg Ld,60 to 8-1 mg Ld
Gly!o%otei" II&7IIIa %e!eto%Gly!o%otei" II&7IIIa %e!eto%
i"(i&ito%si"(i&ito%s
-- Nit%o$ly!e%i" IVNit%o$ly!e%i" IV
-- 2#Ad%e"e%$i! %e!eto% &lo!'e%s2#Ad%e"e%$i! %e!eto% &lo!'e%s
Meets !%ite%ia 8o% *"sta&leMeets !%ite%ia 8o% *"sta&le
o% "ew#o"set a"$i"a?o% "ew#o"set a"$i"a?
O%O%
T%oo"i" ositive?T%oo"i" ositive?
YesYes
:ime $rom onset o$ symptoms:ime $rom onset o$ symptoms Assess clinical statusAssess clinical status
elect a reper$usionelect a reper$usion
strategy based on localstrategy based on local
resources9resources9
AngiographyAngiography
+C (angioplasty O stent)+C (angioplasty O stent)
Cardiothoracic surgeryCardiothoracic surgery
bac4upbac4up
i$ signs o$ cardiogenic shoc4i$ signs o$ cardiogenic shoc4
or contraindications toor contraindications to
$ibrinolytics* +C is treatment$ibrinolytics* +C is treatment
o$ choice (Class ) i$ availableo$ choice (Class ) i$ available
$ +C is not available* use$ +C is not available* use
$ibrinolystics (i$ no$ibrinolystics (i$ nocontraindications)contraindications)
6i$(#%is' atie"t, de8i"ed6i$(#%is' atie"t, de8i"ed
&y&y
+ersistent symptoms+ersistent symptoms
ecurrent ischemiaecurrent ischemia
/epressed F $unction/epressed F $unction
;idespread "C. changes;idespread "C. changes
+rior A>* +C* CAB.+rior A>* +C* CAB.
"linically"linically
stablestable
Admit to "/ chest painAdmit to "/ chest pain
unitunit
&r to monitored bed&r to monitored bed
In 2, follo%In 2, follo%
serial cardiac mar4ersserial cardiac mar4ers
(including troponin)(including troponin)
epeat "C.#continuosepeat "C.#continuos
: monitoring: monitoring
Consider imagingConsider imaging
study (-study (-//
echocardiogharphy orechocardiogharphy or
radionuclide)radionuclide)
,- hours,- hours
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ibrinolytic therapy selectedibrinolytic therapy selected
ront'loadedront'loaded alteplasealteplaseoror
treptoinasetreptoinaseoror
APA-APA- oror
/eteplase/eteplaseoror
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The Acute "oronary SyndromesThe Acute "oronary Syndromes
3nitial @anagement in the )ield and Emergency Department3nitial @anagement in the )ield and Emergency Department
I++ediate T%eat+e"tI++ediate T%eat+e"t P%e(osital 5i&%i"olyti! T(e%ayP%e(osital 5i&%i"olyti! T(e%ay
(memory aid9 >&7A greets all patients(memory aid9 >&7A greets all patients >orphine>orphine &xygen&xygen 7itroglycerin7itroglycerin AspirinAspirin
I++ediate Assess+e"tI++ediate Assess+e"t ital signs* including blood pressureital signs* including blood pressure &xygen saturation&xygen saturation access access ,-'lead "C.,-'lead "C. Brie$* targeted history and physical exam (toBrie$* targeted history and physical exam (to
identi$y reper$usion candidates)identi$y reper$usion candidates) nitial cardiac mar4ersnitial cardiac mar4ers
nitial electrolyte and coagulation studiesnitial electrolyte and coagulation studies +ortable chest x'ray
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,%ygen,%ygen
I++ediate Ge"e%al T%eat+e"t 8o%I++ediate Ge"e%al T%eat+e"t 8o%
S*se!ted Is!(e+i! C(est Pai"S*se!ted Is!(e+i! C(est Pai" &xygen at 5 F#min per nasal cannula&xygen at 5 F#min per nasal cannula
If no contraindications$ addIf no contraindications$ add
Aspirin ,60 to 8-1 mgAspirin ,60 to 8-1 mg
7itroglycerin F or spray7itroglycerin F or spray
>orphine (pain unrelieved by>orphine (pain unrelieved bynitroglycerin)nitroglycerin)
Ratio"aleRatio"ale
upplementary oxygen may limit ischemicupplementary oxygen may limit ischemicmyocardial in?urymyocardial in?ury
&xygen reduces the amount o$ :'&xygen reduces the amount o$ :'segment elevation (e$$ect on morbidity orsegment elevation (e$$ect on morbidity ormortality in acute in$arction un4no!n)mortality in acute in$arction un4no!n)
,%ygen,%ygen
Re!o++e"datio"Re!o++e"datio"
ncomplicatedncomplicated
&xygen at 5 F#min per nasal cannula $or&xygen at 5 F#min per nasal cannula $or
$irst - to 8 hours (Class a)$irst - to 8 hours (Class a) +robably not help$ul beyond 8 to 6 hours+robably not help$ul beyond 8 to 6 hours
Co+li!ated MI 9Ove%t P*l+o"a%yCo+li!ated MI 9Ove%t P*l+o"a%yCo"$estio": SaOCo"$estio": SaO33;;
&xygen at 5 F#min per nasal cannula*&xygen at 5 F#min per nasal cannula*
titrate as needed (Class )titrate as needed (Class ) Continue therapy until patient is stable orContinue therapy until patient is stable or
hypoxemia correctedhypoxemia corrected
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The Acute "oronary SyndromesThe Acute "oronary Syndromes
Nitrates and NitroglycerinNitrates and Nitroglycerin
Re!o++e"datio"sRe!o++e"datio"s EffectsEffects
asodilatation through nitric oxide'asodilatation through nitric oxide'
induced relaxation o$ vascular smoothinduced relaxation o$ vascular smooth
muscle in veins* arteries* and arteriolesmuscle in veins* arteries* and arterioles 3ndications3ndications
' nitial antianginal $or suspected' nitial antianginal $or suspected
ischemic painischemic pain
' or the $irst -5 to 5 hours in patients' or the $irst -5 to 5 hours in patients
!ith acute!ith acute MI a"d C65MI a"d C65* large anterior* large anterior
!all in$arction* persistent or recurrent!all in$arction* persistent or recurrentischemia* or hypertensionischemia* or hypertension
' Continued use (beyond 5 hours) $or' Continued use (beyond 5 hours) $or
patients !ith recurrent angina orpatients !ith recurrent angina or
persistent pulmonary congestionpersistent pulmonary congestion
3nitial dose9 route3nitial dose9 route
' 9 ,-1 to -10' 9 ,-1 to -10 g bolus* ,0 to -0g bolus* ,0 to -0
g#min in$usion* titratedg#min in$usion* titrated oror
99 F9 05 mg* repeat x - at 1 minuteF9 05 mg* repeat x - at 1 minute
intervalsintervals oror
' pray9 - metered doses under or' pray9 - metered doses under or
onto tongueonto tongue "ontraindications"ontraindications
' ystolic blood pressure
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@orphine@orphine
.. Effects:Effects:AnalgesiaH venodilation reducesAnalgesiaH venodilation reduces
ventricular preload and oxygenventricular preload and oxygen
reLuirementsreLuirements
.. 3ndications:3ndications: :reatment o$ ischemic pain:reatment o$ ischemic painnot relieved by nitroglycerinH also use$ul tonot relieved by nitroglycerinH also use$ul to
redistribute blood volume in patients !ithredistribute blood volume in patients !ith
pulmonary edemapulmonary edema
.. "autions and complications:"autions and complications:/o not use/o not use
in patients !ith suspected hypovolemia $in patients !ith suspected hypovolemia $hypotension develops in absence o$hypotension develops in absence o$
pulmonary congestion* elevate patientEs legspulmonary congestion* elevate patientEs legs
and administer normal saline (-00 to 100 mFand administer normal saline (-00 to 100 mF
bolus)bolus)
@orphine@orphine
*ecommendations*ecommendations
.. ActionAction' +redominantly a venodilator that decreases F' +redominantly a venodilator that decreases Fpreloadpreload' /ecreases systemic vascular resistance* reducing' /ecreases systemic vascular resistance* reducingF a$terloadF a$terload' C7 analgesia S decreases anxiety by' C7 analgesia S decreases anxiety by
sympatholytic e$$ectssympatholytic e$$ects.. 3ndications3ndications
' schemic chest pain' schemic chest pain' A> !ithout hypotension' A> !ithout hypotension' Acute pulmonary edema' Acute pulmonary edema
.. DoseDose
' - to 5 mg * titrated to e$$ectH based on the' - to 5 mg * titrated to e$$ectH based on theACC#AA +ractice .uidelinesACC#AA +ractice .uidelines' epeat every 1 minutes to e$$ect' epeat every 1 minutes to e$$ect
.. (recautions(recautions' /o not administer i$ hypotensive' /o not administer i$ hypotensive' Fo! volume statesH respiratory depression' Fo! volume statesH respiratory depression$ hypotension develops* give -00 to 100 mF normal$ hypotension develops* give -00 to 100 mF normal
saline i$ no pulmonary congestionsaline i$ no pulmonary congestion
The Acute "oronary SyndromesThe Acute "oronary Syndromes
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AspirinAspirin
*ecommendations*ecommendations
.. ActionActionSS rreversibly inhibits platelet cyclo'oxygenaserreversibly inhibits platelet cyclo'oxygenaseSS nhibits thromboxane Anhibits thromboxane A-- pletelet aggregationpletelet aggregation
.. 3ndications3ndications
Acute :'elevation in$ractionAcute :'elevation in$ractionSS Coronary angioplastyCoronary angioplasty uspected ischemic'type painuspected ischemic'type pain
DoseDoseSS ,60 to 8-1 mg orally* crushed or che!ed,60 to 8-1 mg orally* crushed or che!edSS 8-1 mg suppository i$ nausea* vomiting8-1 mg suppository i$ nausea* vomiting
(recautions(recautions Active peptic ulcer disease (use rectalActive peptic ulcer disease (use rectalsuppositories)suppositories)SS istory o$ hypersensitivity or allergyistory o$ hypersensitivity or allergySS Bleeding disorders* serve hepatic diseaseBleeding disorders* serve hepatic disease
AspirinAspirin
Ratio"aleRatio"ale
.. Effects:Effects:A dose o$ ,60 to 8-1 mg causes immediateA dose o$ ,60 to 8-1 mg causes immediate
and near'total inhibition o$ thromboxane A- productionand near'total inhibition o$ thromboxane A- production:his rapid inhibition reduces coronary reocclusion and:his rapid inhibition reduces coronary reocclusion and
recurrent eents a$ter $ibrinolitic therapy Also e$$ectiverecurrent eents a$ter $ibrinolitic therapy Also e$$ective
$or patients !ith unstable angina$or patients !ith unstable angina
3ndications:3ndications:Administer to all !ith suspectedAdminister to all !ith suspected
AC* particulary reper$usion candidates* unlessAC* particulary reper$usion candidates* unless
hypersensitive to aspirin (ticlopidine#clopidogrel mayhypersensitive to aspirin (ticlopidine#clopidogrel maybe help$ul)be help$ul)
Dose9 route:Dose9 route:n the early hours a$ter in$raction* aspirinn the early hours a$ter in$raction* aspirin
is absorbed more Luic4ly !hen che!ed than !henis absorbed more Luic4ly !hen che!ed than !hen
s!allo!ed* particularly i$ morphine has been givens!allo!ed* particularly i$ morphine has been given
Aspirin suppositories (8-1 mg) are recommended $orAspirin suppositories (8-1 mg) are recommended $orpatients !ith severe nausea* vomiting* or upper .patients !ith severe nausea* vomiting* or upper .
disordersdisorders
"autions9 contraindications:"autions9 contraindications:elativelyelatively
contraindicated in patients !ith active peptic ulcercontraindicated in patients !ith active peptic ulcer
disease* a history consistent !ith aspirindisease* a history consistent !ith aspirin
hypersensitivity* or bleeding disordershypersensitivity* or bleeding disorders
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The Acute "oronary Syndromes
Assess the initial "C.Assess the initial "C.
:he ,-'lead "C. is central to triage o$ AC in the "mergency:he ,-'lead "C. is central to triage o$ AC in the "mergency/epartment/epartment
Classi$y patients as being in , o$ 8 syndromes !ithin ,0 minutes o$Classi$y patients as being in , o$ 8 syndromes !ithin ,0 minutes o$arrivalarrival
:'segment elevation or:'segment elevation orne! FBBBne! FBBB
7ondiagnostic or normal7ondiagnostic or normal"C."C.
:'segment depression#:'segment depression#dynamic :'!ave nversion9dynamic :'!ave nversion9
strongly suspicious $orstrongly suspicious $or
ischemiaischemia
: elevation: elevation , mm in - or, mm in - ormore contiguous leadsmore contiguous leads
7e! or presumably ne!7e! or presumably ne!
FBBB (BBB obscuring :'FBBB (BBB obscuring :'
segment analysis)segment analysis)
: depression , mm: depression , mm
>ar4ed symmetrical :'!ave>ar4ed symmetrical :'!ave
inversion in multiple precordial leadsinversion in multiple precordial leads
/ynamic :': changes !ith pain/ynamic :': changes !ith pain
: depression 01 to ,0 mm: depression 01 to ,0 mm
:'!ave inversion or $lattening:'!ave inversion or $lattening
in leads !ith dominant !avesin leads !ith dominant !aves
7ormal "C.7ormal "C.
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eper$usion therapyeper$usion therapy
AspirinAspirin eparin (i$ using $ibrin'eparin (i$ using $ibrin'speci$ic lytics)speci$ic lytics)
'Bloc4ers'Bloc4ers
7itrates as indicated7itrates as indicated
Antithrombin therapy !ithAntithrombin therapy !ithheparinheparin
Antiplatelet therapy !ithAntiplatelet therapy !ithaspirinaspirin
.lycoprotein ib#ia nhibitors.lycoprotein ib#ia nhibitors
'Bloc4ers'Bloc4ers
7itrates7itrates
AspirinAspirin
&ther therapy as&ther therapy asappropiteappropite
+atients !ith positive+atients !ith positiveserum mar4ers* "C.serum mar4ers* "C.changes* or $unctionalchanges* or $unctionalstudy9 manage as highstudy9 manage as highris4ris4
P0@ o$ patients !ith ischemic'P0@ o$ patients !ith ischemic'type chest pain and :'segmenttype chest pain and :'segmentelevation !ill develop ne! I !aveselevation !ill develop ne! I !avesor positive serum mar4ers $or A>or positive serum mar4ers $or A>
+atients !ith hyperacute : !aves+atients !ith hyperacute : !avesbene$it !hen A> diagnosis isbene$it !hen A> diagnosis iscertain epeat "C. may becertain epeat "C. may behelp$ulhelp$ul
+atients !ith : depression in+atients !ith : depression inearly precordial leads !ho haveearly precordial leads !ho have
posterior > bene$it !hen A>posterior > bene$it !hen A>diagnosis is certaindiagnosis is certain
igh'ris4 subgroup !ith increasedigh'ris4 subgroup !ith increasedmortality9mortality9
+ersistent symptoms* recurrent+ersistent symptoms* recurrent
ischemiaischemia
/i$$use or !idespread "./i$$use or !idespread ".abnormalitiesabnormalities
/epressed F $unction/epressed F $unction
Congestive heart $ailureCongestive heart $ailure
erum mar4er release9 positiveerum mar4er release9 positivetroponin or CT'>BUtroponin or CT'>BU
eterogeneous group9 rapideterogeneous group9 rapidassessment needed byassessment needed by
erial "C.serial "C.s
:'segment monitoring:'segment monitoring
erum cardiac mar4erserum cardiac mar4ers
urther ris4 assessment help$ulurther ris4 assessment help$ul
+er$usion radionuclide imaging+er$usion radionuclide imaging
tress echocardiographytress echocardiography
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The Acute "oronary SyndromesThe Acute "oronary Syndromes
ST$segment Depression9 Dynamic T$#ave "hanges:ST$segment Depression9 Dynamic T$#ave "hanges:
Non$$#ave 3nfarction = Unstable AnginaNon$$#ave 3nfarction = Unstable Angina
Non$$#ave 3nfarctionNon$$#ave 3nfarction
Eide+iolo$yEide+iolo$y nstable angina and non'I'!ave in$arction are pathological processes on a continuum9nstable angina and non'I'!ave in$arction are pathological processes on a continuum9
chronic stalechronic stale minimal m&ocardial damageminimal m&ocardial damage "nstale angina ? no"nstale angina ? no non9@9%avenon9@9%ave t&pical @9%avet&pical @9%aveanginaangina (troponin positive=-97: (troponin positive=-97: ser"m marer release infarction 7I ser"m marer release infarction 7I
negative)negative)
ncidence o$ non'I'!ave > is increasing $or several reasons9ncidence o$ non'I'!ave > is increasing $or several reasons9
' increasing pool o$ patients !ho are older and have more advanced disease' increasing pool o$ patients !ho are older and have more advanced disease
' !ider use o$ acute reper$usion strategies $or :'elevation in$arction (limited in$arction)9' !ider use o$ acute reper$usion strategies $or :'elevation in$arction (limited in$arction)9$ibrinolytic therapy and angioplasty$ibrinolytic therapy and angioplasty
' prophylactic e$$ects o$ greater use o$ aspirin*' prophylactic e$$ects o$ greater use o$ aspirin* 'bloc4er'bloc4er
&n presentation these patients are in a high'ris4 subgroup !ith a relatively high mortality&n presentation these patients are in a high'ris4 subgroup !ith a relatively high mortality
raterate Next slide
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MANAGEMENTMANAGEMENT
Ma@o% li+itatio",Ma@o% li+itatio",$ibrinolytic therapy does$ibrinolytic therapy does "ot"otbene$it patients !ith :'segment depressionbene$it patients !ith :'segment depression
$bloc&ade:$bloc&ade: start as 4ey ad?unctive therapy and optimiGestart as 4ey ad?unctive therapy and optimiGe
AddAddcalcium channel bloc&erscalcium channel bloc&ers$or persistent symptoms i$ any o$ the $ollo!ing are present9$or persistent symptoms i$ any o$ the $ollo!ing are present9'' 'bloc4ade intolerance'bloc4ade intolerance' contraindications to' contraindications to 'bloc4ers'bloc4ers' adeLuate bloc4ade $ails to reduce symptoms' adeLuate bloc4ade $ails to reduce symptoms
(otential benefit:(otential benefit:ne! antithrombin and antiplatelet agents have sho!n signi$icant bene$it inne! antithrombin and antiplatelet agents have sho!n signi$icant bene$it inselected patients !ithselected patients !ith "o"#ST#elevatio" MI"o"#ST#elevatio" MIandand*"sta&le a"$i"a*"sta&le a"$i"a' antiplatelet therapy !ith' antiplatelet therapy !ith C( 33b333a inhibitors0C( 33b333a inhibitors0' antithrombin therapy !ith' antithrombin therapy !ith lo' molecular 'eight heparin0lo' molecular 'eight heparin0
e$er toe$er to emergency coronary angiographyemergency coronary angiographyand possibleand possible revasculariFationrevasculariFation (!ith(!ith ("3("3oror
"A
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The Acute "oronary SyndromesThe Acute "oronary Syndromes
n general* treat these patientsn general* treat these patients!ith!ith bothboth
$ Antithrombin +heparin-$ Antithrombin +heparin- and anand an
$ Antiplatelet agent +aspirin-$ Antiplatelet agent +aspirin-
>odi$y this treatment i$ patient>odi$y this treatment i$ patientmeets criteria $ormeets criteria $or high ris&high ris&
Antithrombin +heparin-Antithrombin +heparin-plusplus
Antiplatelet +aspirin-Antiplatelet +aspirin-
2igh$*is& "riteria2igh$*is& "riteria : depression: depression , mm, mm +ersistent symptomsH recurrent+ersistent symptomsH recurrent
ischemiaischemia
/i$$use or !idespread "C./i$$use or !idespread "C.
abnormalitiesabnormalities /epressed F $unction/epressed F $unction Congestive heart $ailureCongestive heart $ailure Cardiac mar4er release9 positiveCardiac mar4er release9 positive
troponin or CT'>BUtroponin or CT'>BU
ST$segment Depression9 Dynamic T$#ave "hanges:ST$segment Depression9 Dynamic T$#ave "hanges:
Non$$#ave 3nfarction = Unstable AnginaNon$$#ave 3nfarction = Unstable Angina
Re!o++e"datio"s 8o% I"itial Ma"a$e+e"t a"d T(e%ayRe!o++e"datio"s 8o% I"itial Ma"a$e+e"t a"d T(e%ay
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+atients !ho meet high'ris4 criteria+atients !ho meet high'ris4 criteriabene$it $rom treatment !ithbene$it $rom treatment !ith AspirinAspirinandand C( 33b333a inhibitorsC( 33b333a inhibitorsandandunfractionated heparinunfractionated heparinoror Bo' molecular 'eight heparinBo' molecular 'eight heparin(e$$icacy and sa$ety combined !ith(e$$icacy and sa$ety combined !ith.+ b#a inhibitors under revie!).+ b#a inhibitors under revie!)
All patients 'ithout contraindicationsAll patients 'ithout contraindicationsshould receiveshould receive
(atients 'ho suffer recurrent angina(atients 'ho suffer recurrent angina
should also receiveshould also receive
As a third agent to use for refractoryAs a third agent to use for refractoryangina or in patients 'ith aangina or in patients 'ith a
contraindications to G$bloc&erscontraindications to G$bloc&ers
Antithrombin +heparin-Antithrombin +heparin-
plusplus
Antiplatelet +aspirin-Antiplatelet +aspirin-
(lus(lus
Clycoprotein 33b333a inhibitorsClycoprotein 33b333a inhibitors
$
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)A*@A,B,C3 A"BS)A*@A,B,C3 A"BS
3ngat tu?uan utama dalam A"BS:3ngat tu?uan utama dalam A"BS: Tore4si hipose4miaTore4si hipose4mia
>embuat sir4ulasi spontan dengan te4anan darah yang ade4uat>embuat sir4ulasi spontan dengan te4anan darah yang ade4uat
>engoptimal4an $ungsi ?antung>engoptimal4an $ungsi ?antung >ene4an dan mencegah aritmia yang berma4na>ene4an dan mencegah aritmia yang berma4na
>enghilang4an sa4it>enghilang4an sa4it
>engore4si asidosis>engore4si asidosis
>engobati gagal ?antung 4ongesti$>engobati gagal ?antung 4ongesti$
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lasifi&asi re&omendasi penggunaan obat$obatan atau tinda&an:lasifi&asi re&omendasi penggunaan obat$obatan atau tinda&an:
"lass 3:"lass 3:ndicated* acceptable* use$ul V e$$ectivendicated* acceptable* use$ul V e$$ective
"lass 33:"lass 33:Acceptable* uncertain e$$icacy* maybe controversialAcceptable* uncertain e$$icacy* maybe controversial"lass 33a:"lass 33a:avour o$ its use$ulness V e$icacyavour o$ its use$ulness V e$icacy
"lass 33b:"lass 33b:>aybe help$ul* probably not harm$ul>aybe help$ul* probably not harm$ul
"lass 333:"lass 333:nappropriate* no scienti$ic supporting data* maybe harm$ulnappropriate* no scienti$ic supporting data* maybe harm$ul
(ende&atan untu& mempela?ari farma&ologi dalam A"BS dengan(ende&atan untu& mempela?ari farma&ologi dalam A"BS dengan
w(y: w(e": (ow: wat!( o*t,w(y: w(e": (ow: wat!( o*t,
(y(yan agent is used (action) # 4enapa suatu obat diguna4anan agent is used (action) # 4enapa suatu obat diguna4an (e"(e"to use an agent (indication) # 4apan obat tersebut diguna4anto use an agent (indication) # 4apan obat tersebut diguna4an
6ow6owto use an agent (dosage) # bagaimana mengguna4annyato use an agent (dosage) # bagaimana mengguna4annya
;hat to;hat to wat!( o*twat!( o*tforfor(precaution) # a!asi(precaution) # a!asi
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, H Y C E N, H Y C E N(y(y
>ening4at4an te4anan o4sigen arterial>ening4at4an te4anan o4sigen arterial >ening4at4an 4andungan o4sigen arterial>ening4at4an 4andungan o4sigen arterial
>emperbai4i o4sigen ?aringan>emperbai4i o4sigen ?aringan
(e"(e"
7yeri dada a4ut yang mung4in disebab4an oleh is4emia ?antung7yeri dada a4ut yang mung4in disebab4an oleh is4emia ?antung
ipose4mia oleh berbagai sebabipose4mia oleh berbagai sebab
enti ?antung dan na$asenti ?antung dan na$as
6ow6ow
:anpa henti ?antung 9 - F # m:anpa henti ?antung 9 - F # m
/engan gangguan na$as ringan 9 12 6 F # m/engan gangguan na$as ringan 9 12 6 F # m
at!( O*tat!( O*t
Teracunan o4sigenTeracunan o4sigen
>engurangi rangsangan perna$asan pada pasien dengan retensi C&->engurangi rangsangan perna$asan pada pasien dengan retensi C&-
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E(3NE(2*3NEE(3NE(2*3NE(y(y
>ening4at4an 9>ening4at4an 9
esistensi vas4uler sistemi4esistensi vas4uler sistemi4
:e4anan darah sistoli4 dan diastoli4:e4anan darah sistoli4 dan diastoli4
A4tivitas darah 4e seberal dan 4oronerA4tivitas darah 4e seberal dan 4oroner
Aliran darah 4e serebral dan 4oronerAliran darah 4e serebral dan 4oroner
Te4uatan 4ontra4si mio4ardTe4uatan 4ontra4si mio4ard Tebutuhan o4sigen mio4ardTebutuhan o4sigen mio4ard
&tomatisitas&tomatisitas
(e"(e"
entricular ectopy* !ide complex tachycardias* ventricular tachycardia dan entricular ectopy* !ide complex tachycardias* ventricular tachycardia dan +ulseless : dan yang re$ra4ter terhadap terapi listri4 dan epine$rin+ulseless : dan yang re$ra4ter terhadap terapi listri4 dan epine$rin
+asien dengan risi4o ter?adinya aritmia ventri4el yang maligna+asien dengan risi4o ter?adinya aritmia ventri4el yang maligna
:a4 dire4omendasi4an lagi untu4 pemberian pencegahan rutin pada pasien dengan:a4 dire4omendasi4an lagi untu4 pemberian pencegahan rutin pada pasien dengan
>A>A
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E(3NE(2*3NEE(3NE(2*3NE
6ow6ow
/osis a!al 9 ,*0',*1 mg# 4g bolus/osis a!al 9 ,*0',*1 mg# 4g bolus
ia "": 9 -'-*1 x doseia "": 9 -'-*1 x dose
Bolus 4edua 9 0*1'0*K1 mg# 4g setelah ,0EBolus 4edua 9 0*1'0*K1 mg# 4g setelah ,0E Bolus tambahan 9 0*1'0*K1 mg# 4g every 1E',0E (bila masih tetap ada aritmia)* sampaiBolus tambahan 9 0*1'0*K1 mg# 4g every 1E',0E (bila masih tetap ada aritmia)* sampai
total98 mg#4gtotal98 mg#4g
Continuous iv in$usion 9 -'5 mg#min (pada sir4ulasi spontan)Continuous iv in$usion 9 -'5 mg#min (pada sir4ulasi spontan)
at!( o*tat!( o*t +erubahan neurologis+erubahan neurologis
/epresi mio4ard V sir4ulasi/epresi mio4ard V sir4ulasi
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ADEN,S3NEADEN,S3NE
(y(y
>emperlambat 4ondu4si melalui A node>emperlambat 4ondu4si melalui A node
>enghenti4an ?alur re'entri di A node>enghenti4an ?alur re'entri di A node
>engembali4an 4e irama sinus pada pasien dengan +:>engembali4an 4e irama sinus pada pasien dengan +:
espon $arma4ologinya sing4atespon $arma4ologinya sing4at
at!( o*tat!( o*t
Atrial $lutter # $ibrillation dengan sindrom ;+;Atrial $lutter # $ibrillation dengan sindrom ;+;
:* dapat menyebab4an hipotensi atau :* dapat menyebab4an hipotensi atau
ypotension* A' bloc4ypotension* A' bloc4
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A@3,DA*,NEA@3,DA*,NE(y(y "$e4ti$ untu4 supraventricular arrhythmia* ventricular arrhythmia"$e4ti$ untu4 supraventricular arrhythmia* ventricular arrhythmia entricular rate controlentricular rate control Tardioversi $arma4ologi4Tardioversi $arma4ologi4
>enguah 4ondu4si yang melalui accesory path!ay>enguah 4ondu4si yang melalui accesory path!ay
(e"(e" :erapi tambahan setelah electrical cardioversion pada +: yang re$ra4ter ( a):erapi tambahan setelah electrical cardioversion pada +: yang re$ra4ter ( a) Tardioversi $arma4ologis untu4 A (a)Tardioversi $arma4ologis untu4 A (a) Atrial tachycardia ( b)Atrial tachycardia ( b)
entricular rate control pada rapid atril arrhythmia pada pasien dengan $ungsientricular rate control pada rapid atril arrhythmia pada pasien dengan $ungsiventri4el yang buru4* atau pada pasien dengan 4ondu4si accesory path!ayventri4el yang buru4* atau pada pasien dengan 4ondu4si accesory path!ay
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A@3,DA*,NEA@3,DA*,NE
(e"(e" >enghenti4an : yang melibat4an ?alur rentri A node>enghenti4an : yang melibat4an ?alur rentri A node
6ow6ow
/osis a!al 9 6 mg bolus cepat dalam ,'8N dii4uti $lush cepat normal/osis a!al 9 6 mg bolus cepat dalam ,'8N dii4uti $lush cepat normalsalinesaline
/osis ulangan 9 ,-mg* ?i4a ta4 berespon dalam ,'- menit/osis ulangan 9 ,-mg* ?i4a ta4 berespon dalam ,'- menit
:eo$ilin menyebab4an 4urang sensiti$:eo$ilin menyebab4an 4urang sensiti$
at!( o*tat!( o*t
lushing* dyspnea* chest pain (biasanya hilang dalam ,'- menit)lushing* dyspnea* chest pain (biasanya hilang dalam ,'- menit)
:ransient bradycardia dan ventricular ectopy:ransient bradycardia dan ventricular ectopy
:a4 terlalu berpengaruh pada hemodinami4:a4 terlalu berpengaruh pada hemodinami4
! i l )ib ill i ( l l ! i l T h di! t i l )ib ill ti ( l l ! t i l T h di
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(rimary A
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Secondary A
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