Early Treatment Of M Iassir

Early Management of Suspected Early Management of Suspected Myocardial InfarctionMyocardial Infarction

DR Ihab Suliman DR Ihab Suliman MBBS(KHAR),ECFMG(USA)MRCP(UK),MBBS(KHAR),ECFMG(USA)MRCP(UK),

Board Certified nuclear cardiology(USA)Board 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 Association on Heart failure.Member of the European Association on Heart 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 Very brief (< 5 sec)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, SOB, N/V,

diaphoresisdiaphoresis

PMH, medsPMH, meds

Recent (< 6 mos):Recent (< 6 mos):◆traumatrauma

◆surgerysurgery

◆bleedingbleeding

Alameda County EMS

WHO CriteriaWHO Criteria• Must meet 2 out of 3 criteria

Clinical history of ischemic type chest pain > 20 minutes

Changes on serial ECG tracings

Rise and fall of serum cardiac enzymes (biomarkers)

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 KVOOO22: 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


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 CNS mass or bleedbleed

active GI bleedingactive GI bleeding

spinal or cranial spinal or cranial surgery w/in 2 surgery w/in 2 mos.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)

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



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


Aldosterone BlockadeAldosterone Blockade

Use of aldosterone blockade in post-MI patients Use of aldosterone blockade in post-MI patients without significant renal dysfunction or hyperkalemia without significant renal dysfunction or hyperkalemia is recommended in patients who: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


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




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 reasonable If baseline LDL-C is 70 - 100 mg/dL, it is reasonable to treat to <70 mg/dL.to treat to <70 mg/dL.



Pitfalls and PearlsPitfalls and Pearls

Maintain high index of Maintain high index of suspicionsuspicion

Document risk factors Document risk factors in in everyevery CP patient CP patient

Mentally rule out 5 Mentally rule out 5 life-threatening life-threatening causes in causes in everyevery CP CP patientpatient

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

QUIZZQUIZZ

QUIZZQUIZZ

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

Health & Medicine

Early Treatment Of M Iassir