Mokhtar overview & acs-2012-final

M. Sherif Mokhtar, MDProfessor of Cardiology,

Professor of Critical Care Medicine,Cairo University

M. Sherif Mokhtar, MDProfessor of Cardiology,

Professor of Critical Care Medicine,Cairo University

1. Relief of ischemic pain.

2. Assessment of the hemodynamic state and correction of abnormalities that are present.

3. Initiation of Reperfusion Therapy with primary percutaneous coronary intervention (PCI) or thrombolysis

4. Antithrombotic Therapy to prevent rethrombosis of an ulcerated plaque or subtotal stenosis

1. Relief of ischemic pain.

2. Assessment of the hemodynamic state and correction of abnormalities that are present.

3. Initiation of Reperfusion Therapy with primary percutaneous coronary intervention (PCI) or thrombolysis

4. Antithrombotic Therapy to prevent rethrombosis of an ulcerated plaque or subtotal stenosis

(Antman et al., 2004; ACC/AHA task force)(Antman et al., 2004; ACC/AHA task force)

This is then followed by the administration of

different drugs that may improve the long-term

prognosis:

5. Prevention of Left Ventricular Remodeling with

an angiotensin converting enzyme (ACE) Inhibitor

6. Prevention of Recurrent Ischemia and life-

threatening ventricular arrhythmias with Beta

Blockers

This is then followed by the administration of

different drugs that may improve the long-term

prognosis:

5. Prevention of Left Ventricular Remodeling with

an angiotensin converting enzyme (ACE) Inhibitor

6. Prevention of Recurrent Ischemia and life-

threatening ventricular arrhythmias with Beta

Blockers

Administration of different drugs that may improve

the long-term prognosis:

7. Cholesterol Lowering with a Statin to prevent

or slow disease progression.

8. Anticoagulation in the presence of left

ventricular thrombus or chronic AF.

Administration of different drugs that may improve

the long-term prognosis:

7. Cholesterol Lowering with a Statin to prevent

or slow disease progression.

8. Anticoagulation in the presence of left

ventricular thrombus or chronic AF.

9. Long-term Therapy: in collaboration with a cardiac

rehabilitation program, involves Atherothrombotic

Risk Reduction including cessation of smoking,

control of hypertension and diabetes, nutritional

counseling, and an exercise and stress reduction

program.

9. Long-term Therapy: in collaboration with a cardiac

rehabilitation program, involves Atherothrombotic

Risk Reduction including cessation of smoking,

control of hypertension and diabetes, nutritional

counseling, and an exercise and stress reduction

program.

10. Additional Therapy is based upon the

identification of patients at continued ischemic

risk with:

• Assessment of clinical factors.

• A predischarge exercise tolerance test.

• Measurement of left ventricular function.

10. Additional Therapy is based upon the

identification of patients at continued ischemic

risk with:

• Assessment of clinical factors.

• A predischarge exercise tolerance test.

• Measurement of left ventricular function.

I) Initial Assessment.

II) Initial therapy.

III) Reperfusion therapy.

IV) Anticoagulation.

V) Arrhythmia management.

VI) Further medical therapy.

VII) Angiography after thrombolysis.

VIII) Managing recurrent chest pain.









• Begins as soon as the patient arrives in the

emergency department.

• Continues in the coronary care unit.

• Consists Of Acute Triage And Early Risk

Stratification.

• Begins as soon as the patient arrives in the

emergency department.

• Continues in the coronary care unit.

• Consists Of Acute Triage And Early Risk

Stratification.

A focused evaluation on presentation:

A. Responsiveness, Airway, Breathing and

Circulation: in patients in respiratory or

cardiorespiratory arrest (the appropriate CPR

algorithms should be followed).

A focused evaluation on presentation:

A. Responsiveness, Airway, Breathing and

Circulation: in patients in respiratory or

cardiorespiratory arrest (the appropriate CPR

algorithms should be followed).

I) Acute Triage I) Acute Triage

B. Evidence of Systemic Hypoperfusion

(cardiogenic shock complicating acute MI

requires aggressive evaluation and

management).

B. Evidence of Systemic Hypoperfusion

(cardiogenic shock complicating acute MI

requires aggressive evaluation and

management).

Acute Triage Acute Triage

C. Sustained Ventricular Tachyarrhythmias in the

periinfarction period must be treated immediately:

• Deleterious effect on cardiac output,

• Possible exacerbation of myocardial ischemia,

and

• The risk of deterioration into VF.

C. Sustained Ventricular Tachyarrhythmias in the

periinfarction period must be treated immediately:

• Deleterious effect on cardiac output,

• Possible exacerbation of myocardial ischemia,

and

• The risk of deterioration into VF.

Acute Triage Acute Triage

• High Risk Features include older age, low blood

pressure, tachycardia, heart failure (HF), and an

anterior MI.

• Specific Scoring Systems, such as the TIMI Risk

Score, permit a fairly precise determination of the

risk of in-hospital mortality.

• High Risk Features include older age, low blood

pressure, tachycardia, heart failure (HF), and an

anterior MI.

• Specific Scoring Systems, such as the TIMI Risk

Score, permit a fairly precise determination of the

risk of in-hospital mortality.

(Morrow et al., 2001; Wu et al.,2002)(Morrow et al., 2001; Wu et al.,2002)

II) Early Risk StratificationII) Early Risk Stratification

• Patients at high risk are usually considered to

require, Aggressive Management Strategy in

addition to standard medical management.

• Direct Transport or, less optimally, prompt

Interhospital Transfer to a facility with

revascularization capabilities is recommended for

such patients.

• Patients at high risk are usually considered to

require, Aggressive Management Strategy in

addition to standard medical management.

• Direct Transport or, less optimally, prompt

Interhospital Transfer to a facility with

revascularization capabilities is recommended for

such patients.

(Antman et al., 2004)(Antman et al., 2004)

Early Risk StratificationEarly Risk Stratification

















The patient with an STEMI should be started on

therapy to:

• Relieve ischemic pain,

• Stabilize hemodynamic status, and

• Reduce ischemia while being assessed as a

candidate for Thrombolysis or Direct PCI.

The patient with an STEMI should be started on

therapy to:

• Relieve ischemic pain,

• Stabilize hemodynamic status, and

• Reduce ischemia while being assessed as a

candidate for Thrombolysis or Direct PCI.


Other routine hospital measures include:

• Anxiolytics,

• Oxygen,

• ECG, and BP monitoring, and

• Intravenous access.

All initial therapy can be carried out in the emergency department based upon a predetermined, Institution-Specific, written protocol.

Other routine hospital measures include:

• Anxiolytics,

• Oxygen,

• ECG, and BP monitoring, and

• Intravenous access.

All initial therapy can be carried out in the emergency department based upon a predetermined, Institution-Specific, written protocol.

(The 2004 ACC/AHA guidelines)(The 2004 ACC/AHA guidelines)

Reperfusion Therapy with either (PCI) or thrombolysis,

if less than 12 hours has elapsed from the onset of

symptoms. Primary PCI is preferred to thrombolysis when

readily available.

Antiplatelet Therapy including aspirin, clopidogrel, and,

in patients undergoing primary PCI, a GP IIb/IIIa inhibitor.

Sublingual Nitroglycerin followed by IV Nitroglycerin

in patients with persistent chest pain after three sublingual

nitroglycerin tablets, as well as in patients with hypertension

or HF.

Reperfusion Therapy with either (PCI) or thrombolysis,

if less than 12 hours has elapsed from the onset of

symptoms. Primary PCI is preferred to thrombolysis when

readily available.

Antiplatelet Therapy including aspirin, clopidogrel, and,

in patients undergoing primary PCI, a GP IIb/IIIa inhibitor.

Sublingual Nitroglycerin followed by IV Nitroglycerin

in patients with persistent chest pain after three sublingual

nitroglycerin tablets, as well as in patients with hypertension

or HF.

Nitrates must be used with caution or

avoided in settings in which hypotension is likely or

could result in serious hemodynamic decompensation,

such as RV Infarction or severe Aortic Stenosis.

Nitrates are contraindicated in patients who

have taken a phosphodiesterase inhibitor for erectile

dysfunction within the previous 24 hours.

Nitrates must be used with caution or

avoided in settings in which hypotension is likely or

could result in serious hemodynamic decompensation,

such as RV Infarction or severe Aortic Stenosis.

Nitrates are contraindicated in patients who

have taken a phosphodiesterase inhibitor for erectile

dysfunction within the previous 24 hours.

Intravenous Morphine Sulfate at an initial dose of 2

to 4 mg, with increments of 2 to 8 mg repeated at 5 to 15

minute intervals, to relieve chest pain and anxiety.

Beta Blockers are administered universally to all

pts without contraindications who experience an acute

STEMI, irrespective of concomitant fibrinolytic therapy or

performance of primary PCI.

Treatment should include Early Intravenous Beta

Blockade.

Intravenous Morphine Sulfate at an initial dose of 2

to 4 mg, with increments of 2 to 8 mg repeated at 5 to 15

minute intervals, to relieve chest pain and anxiety.

Beta Blockers are administered universally to all

pts without contraindications who experience an acute

STEMI, irrespective of concomitant fibrinolytic therapy or

performance of primary PCI.

Treatment should include Early Intravenous Beta

Blockade.(Antman et al., 2004)(Antman et al., 2004)

Although there are no clinical trials documenting

the benefits of Electrolyte Replacement in acute MI,

the ACC/AHA guidelines recommend maintaining the

serum Potassium concentration above 4.0 meq/L and a

serum Magnesium concentration above 2.0 meq/L (2.4

mg/dL or 1 mmol/L).

Although there are no clinical trials documenting

the benefits of Electrolyte Replacement in acute MI,

the ACC/AHA guidelines recommend maintaining the

serum Potassium concentration above 4.0 meq/L and a

serum Magnesium concentration above 2.0 meq/L (2.4

mg/dL or 1 mmol/L).

Electrolyte ReplacementElectrolyte Replacement


Randomized trials have demonstrated that both

diabetics and nondiabetics who have had an acute MI or

are critically ill benefit from Tight Blood Glucose control.

Randomized trials have demonstrated that both

diabetics and nondiabetics who have had an acute MI or

are critically ill benefit from Tight Blood Glucose control.

Glucose ControlGlucose Control

A class I recommendation to the use of an Insulin

Infusion to normalize blood glucose in patients with an

STEMI and a complicated course, regardless of whether

they have a diagnosis of diabetes mellitus

A class I recommendation to the use of an Insulin

Infusion to normalize blood glucose in patients with an

STEMI and a complicated course, regardless of whether

they have a diagnosis of diabetes mellitus


















The ACC/AHA task force gave a class I recommendation to the use of Primary PCI for:

Any patient with an acute STEMI (defined as >1 mm ST elevation in two contiguous leads after nitroglycerin to rule out coronary vasospasm).

• Who presents within 12 hours of symptom onset and

• Who can undergo the procedure within 90 minutes of presentation.

• By persons skilled in the procedure.

The ACC/AHA task force gave a class I recommendation to the use of Primary PCI for:

Any patient with an acute STEMI (defined as >1 mm ST elevation in two contiguous leads after nitroglycerin to rule out coronary vasospasm).

• Who presents within 12 hours of symptom onset and

• Who can undergo the procedure within 90 minutes of presentation.

• By persons skilled in the procedure.

Percutaneous Coronary Intervention

PCIPercutaneous Coronary Intervention

PCI

For patients presenting 12 to 24 hours after

symptom onset, the performance of primary PCI is

reasonable if the patient has:

• Severe Heart Failure,

• Hemodynamic or Electrical Instability, or

• Persistent Ischemic Symptoms.

For patients presenting 12 to 24 hours after

symptom onset, the performance of primary PCI is

reasonable if the patient has:

• Severe Heart Failure,

• Hemodynamic or Electrical Instability, or

• Persistent Ischemic Symptoms.


All patients are pretreated at diagnosis

with aspirin, clopidogrel, and a GP IIb/IIIa

inhibitor.

There appears to be No Role for

Pretreatment Thrombolysis before planned

primary PCI (Facilitated PCI).

All patients are pretreated at diagnosis

with aspirin, clopidogrel, and a GP IIb/IIIa

inhibitor.

There appears to be No Role for

Pretreatment Thrombolysis before planned

primary PCI (Facilitated PCI).

Any patient with an Acute Coronary Syndrome and: • ST elevation in at least two contiguous or adjacent leads, • New or presumably new LBBB, or • A true posterior MI.

Any patient with an Acute Coronary Syndrome and: • ST elevation in at least two contiguous or adjacent leads, • New or presumably new LBBB, or • A true posterior MI.

Recommended for:Recommended for:

(Antman et al., 2004; Menon et al., 2004)(Antman et al., 2004; Menon et al., 2004)

Who presents within 12 hours of symptom onset, • Has no contraindications for thrombolysis, and • Presents to a facility without the capability for expert,

prompt intervention with primary PCI within 90 minutes of first medical contact.

Who presents within 12 hours of symptom onset, • Has no contraindications for thrombolysis, and • Presents to a facility without the capability for expert,

prompt intervention with primary PCI within 90 minutes of first medical contact.

Patients who present to a facility in which the

relative delay necessary to perform primary PCI (the

expected Door-to-Balloon time minus the expected

door-to-needle time) is greater than one hour.

Patients who present to a facility in which the

relative delay necessary to perform primary PCI (the

expected Door-to-Balloon time minus the expected

door-to-needle time) is greater than one hour.

Indicated also for:Indicated also for:

The survival benefit is greatest when thrombolytic

agents are administered within the first four hours after

the onset of symptoms, particularly within the first 70

minutes.

The survival benefit is greatest when thrombolytic

agents are administered within the first four hours after

the onset of symptoms, particularly within the first 70

minutes.

1) The benefit of thrombolysis is greatest when

therapy is given within the First Four Hours

after the onset of symptoms, particularly within the

first 70 minutes as the resistance of cross-linked

fibrin is time-dependent

1) The benefit of thrombolysis is greatest when

therapy is given within the First Four Hours

after the onset of symptoms, particularly within the

first 70 minutes as the resistance of cross-linked

fibrin is time-dependent

(Boersma et al., 1996; Weaver et al., 1993)(Boersma et al., 1996; Weaver et al., 1993)

2) Although patency is restored in up to 87

percent of infarct-related arteries, normalization

of blood flow (as assessed by the TIMI flow

grade) occurs in only 50 to 60 percent.

2) Although patency is restored in up to 87

percent of infarct-related arteries, normalization

of blood flow (as assessed by the TIMI flow

grade) occurs in only 50 to 60 percent.

(The GUSTO Investigators et al., 1993; Chesebro et al., 1987)(The GUSTO Investigators et al., 1993; Chesebro et al., 1987)

3) After apparently successful thrombolysis, Early

Recurrence of Ischemia or ST segment shifts

(Threatened Reocclusion) have been observed in

20 to 30 percent of patients, with frank Thrombotic

Coronary Reocclusion in 5 to 15 percent, and

reinfarction in 3 to 5 percent.

3) After apparently successful thrombolysis, Early

Recurrence of Ischemia or ST segment shifts

(Threatened Reocclusion) have been observed in

20 to 30 percent of patients, with frank Thrombotic

Coronary Reocclusion in 5 to 15 percent, and

reinfarction in 3 to 5 percent.

(Gibson et al., 2003)(Gibson et al., 2003)

4) Major Hemorrhagic Complications occur in 2 to 3

percent. The most serious is intracerebral hemorrhage,

which occurs in:

• As many as 1 percent overall,

• 1.4 percent of the elderly, and

• Over 4 percent in patients with multiple risk factors.

4) Major Hemorrhagic Complications occur in 2 to 3

percent. The most serious is intracerebral hemorrhage,

which occurs in:

• As many as 1 percent overall,

• 1.4 percent of the elderly, and

• Over 4 percent in patients with multiple risk factors.

(Brass et al., 2000)(Brass et al., 2000)

5) As many as 20 to 30 percent of patients

presenting with an acute STEMI, particularly the

elderly, are not candidates for thrombolytic

therapy because of contraindications such as

active internal bleeding, a recent stroke, or

hypertension.

5) As many as 20 to 30 percent of patients

presenting with an acute STEMI, particularly the

elderly, are not candidates for thrombolytic

therapy because of contraindications such as

active internal bleeding, a recent stroke, or

hypertension.

(Cannon et al., 2002)(Cannon et al., 2002)

6) Efficacy of Thrombolytic Therapy has not been

demonstrated in patients in cardiogenic shock

(unless coronary perfusion pressure is increased

with an IABP) or those with prior coronary artery

bypass surgery.

6) Efficacy of Thrombolytic Therapy has not been

demonstrated in patients in cardiogenic shock

(unless coronary perfusion pressure is increased

with an IABP) or those with prior coronary artery

bypass surgery.

Recovery of LV function decreases with later

PCI, but late PCI may still be beneficial at a time

when thrombolytic therapy is no longer effective.

This is an important issue, since registry data

suggest that 9 to 31 percent of patients with an STEMI

present more than 12 hours after the onset of

symptoms.

Recovery of LV function decreases with later

PCI, but late PCI may still be beneficial at a time

when thrombolytic therapy is no longer effective.

This is an important issue, since registry data

suggest that 9 to 31 percent of patients with an STEMI

present more than 12 hours after the onset of

symptoms.

(Schomig et al., 2003)(Schomig et al., 2003)

Possible mechanisms for benefit:

1) Residual antegrade or collateral blood flow, which was present in 73 percent of patients in the BRAVE-2 trial.

The low rate of persistent flow may maintain myocardial viability and therefore infarct size until blood flow is restored by late PCI.

2) Prevention of ventricular remodeling, also may be involved.

3) A potential benefit of late primary PCI is a reduction in the risk of free wall rupture.

Possible mechanisms for benefit:

1) Residual antegrade or collateral blood flow, which was present in 73 percent of patients in the BRAVE-2 trial.

The low rate of persistent flow may maintain myocardial viability and therefore infarct size until blood flow is restored by late PCI.

2) Prevention of ventricular remodeling, also may be involved.

3) A potential benefit of late primary PCI is a reduction in the risk of free wall rupture.

(Gibbons et al., 2005)(Gibbons et al., 2005)

















In the following patients:

• Those with an STEMI undergoing PCI or surgical

revascularization.

• Those treated with thrombolytic therapy with

alteplase, Release, or Tenecteplase.

• Patients who receive No Reperfusion Therapy.

In the following patients:

• Those with an STEMI undergoing PCI or surgical

revascularization.

• Those treated with thrombolytic therapy with

alteplase, Release, or Tenecteplase.

• Patients who receive No Reperfusion Therapy.

(The ACC/AHA and ACCP guidelines)(The ACC/AHA and ACCP guidelines)

(Antman et al., 2004; Popma et al., 2004)(Antman et al., 2004; Popma et al., 2004)

Intravenous Unfractionated HeparinIntravenous Unfractionated Heparin

• A class IIb recommendation: In patients with

STEMI treated with thrombolytic therapy (usefulness

or effectiveness is not well established).

• It may be reasonable to use LMWH in patients who

do not receive reperfusion therapy.

• LMWH should be used only in patients under 75

yeas of age who are without significant renal

dysfunction.

• A class IIb recommendation: In patients with

STEMI treated with thrombolytic therapy (usefulness

or effectiveness is not well established).

• It may be reasonable to use LMWH in patients who

do not receive reperfusion therapy.

• LMWH should be used only in patients under 75

yeas of age who are without significant renal

dysfunction. (The ACC/AHA , 2004)(The ACC/AHA , 2004)

Low Molecular Weight HeparinLow Molecular Weight Heparin

Bivalirudin is an acceptable alternative to heparin

plus GP IIb/IIIa inhibitor in patients undergoing

primary PCI (Initial bolus of 0.75 mg/kg IV

followed by IV infusion of 1.75 mg/kg per hour;

can be discontinued after PCI).

Bivalirudin is an acceptable alternative to heparin

plus GP IIb/IIIa inhibitor in patients undergoing

primary PCI (Initial bolus of 0.75 mg/kg IV

followed by IV infusion of 1.75 mg/kg per hour;

can be discontinued after PCI).

Bivalirudin

Enoxaparin for patients not managed with PCI and <75 years give 30 mg IV bolus followed immediately by 1 mg/kg subcutaneously every 12 hours.

In patients ≥75 years of age, do not use an initial IV bolus. Initiate dosing with 0.75 mg/kg subcutaneous every 12 hours (maximum 75 mg for the first two doses only).

Enoxaparin for patients not managed with PCI and <75 years give 30 mg IV bolus followed immediately by 1 mg/kg subcutaneously every 12 hours.

In patients ≥75 years of age, do not use an initial IV bolus. Initiate dosing with 0.75 mg/kg subcutaneous every 12 hours (maximum 75 mg for the first two doses only).

Enoxaparin

1. Patients treated with fibrinolytic therapy: Give

clopidogrel loading dose 300 mg if age less than

75 years; if age 75 years or older, give loading

dose of 75 mg.

2. Patients treated with no reperfusion therapy:

Give ticagrelor loading dose 180 mg.

1. Patients treated with fibrinolytic therapy: Give

clopidogrel loading dose 300 mg if age less than

75 years; if age 75 years or older, give loading

dose of 75 mg.

2. Patients treated with no reperfusion therapy:

Give ticagrelor loading dose 180 mg.

Give antiplatelet therapy (in addition to aspirin) to all patients:

Give antiplatelet therapy (in addition to aspirin)to all patients:

3. Patients treated with primary percutaneous

coronary intervention: Give ticagrelor loading

dose of 180 mg or prasugrel loading dose of 60 mg

(if no contraindications: prior stroke or TIA, or

relative contraindications for prasugrel such as

those age 75 years or older, weight less than 60

kg). For patients at high risk of bleeding,

clopidogrel 300 to 600 mg (600 mg preferred) is

preferred to ticagrelor or praugrel.

3. Patients treated with primary percutaneous

coronary intervention: Give ticagrelor loading

dose of 180 mg or prasugrel loading dose of 60 mg

(if no contraindications: prior stroke or TIA, or

relative contraindications for prasugrel such as

those age 75 years or older, weight less than 60

kg). For patients at high risk of bleeding,

clopidogrel 300 to 600 mg (600 mg preferred) is

preferred to ticagrelor or praugrel.

Indications include:

• Left Ventricular Thrombus Or Aneurysm.

• Left Ventricular Ejection Fraction below 30 percent

with or without heart failure.

• A history of a thromboembolism.

• Chronic Atrial Fibrillation, in which warfarin therapy

is continued for an indefinite period of time.

Indications include:

• Left Ventricular Thrombus Or Aneurysm.

• Left Ventricular Ejection Fraction below 30 percent

with or without heart failure.

• A history of a thromboembolism.

• Chronic Atrial Fibrillation, in which warfarin therapy

is continued for an indefinite period of time.

WarfarinWarfarin

















Prophylactic IV or ion Lidocaine to prevent

VT/VF in the acute MI patient is not recommended.

Recommended prophylactic measures include:

• Early administration of an intravenous Beta Blocker

and

• Correction of Hypokalemia and Hypomagnesemia.

Prophylactic IV or ion Lidocaine to prevent

VT/VF in the acute MI patient is not recommended.

Recommended prophylactic measures include:

• Early administration of an intravenous Beta Blocker

and

• Correction of Hypokalemia and Hypomagnesemia.

















a) Oral Beta Blockers:

An oral Cardioselective Beta Blocker, such as:

• Metoprolol (25 to 50 mg BID with the short-

acting preparation) or

• Atenolol (50 to 100 mg daily),

should be continued or begun if the patient has not

received early intravenous therapy.

a) Oral Beta Blockers:

An oral Cardioselective Beta Blocker, such as:

• Metoprolol (25 to 50 mg BID with the short-

acting preparation) or

• Atenolol (50 to 100 mg daily),

should be continued or begun if the patient has not

received early intravenous therapy.

b) Nitrates:

• Should be given for 24 to 48 hours in patients with:

• Recurrent ischemia,

• Hypertension, or

• Heart failure.

• Long-term Nitrate Therapy is useful for the treatment of Recurrent ischemia or Heart Failure.

b) Nitrates:

• Should be given for 24 to 48 hours in patients with:

• Recurrent ischemia,

• Hypertension, or

• Heart failure.

• Long-term Nitrate Therapy is useful for the treatment of Recurrent ischemia or Heart Failure.

c) ACE inhibitors:

A class I recommendation is given to the administration of oral ACE inhibitors within the first 24 hours of MI onset in patients with the following characteristics.

• ST elevation in two or more anterior precordial leads (anterior STEMI)

• Clinical heart failure or pulmonary congestion

• Left ventricular ejection fraction less than 40 percent

c) ACE inhibitors:

A class I recommendation is given to the administration of oral ACE inhibitors within the first 24 hours of MI onset in patients with the following characteristics.

• ST elevation in two or more anterior precordial leads (anterior STEMI)

• Clinical heart failure or pulmonary congestion

• Left ventricular ejection fraction less than 40 percent

(The ACC/AHA guidelines)(The ACC/AHA guidelines)


Recommendation:

An ACE inhibitor should be given to all patients with

an STEMI without a contraindication. Treatment

should be begun within the first 24 hours, since

there is appreciable benefit in high-risk patients who

cannot always be accurately identified in the first day.

Recommendation:

An ACE inhibitor should be given to all patients with

an STEMI without a contraindication. Treatment

should be begun within the first 24 hours, since

there is appreciable benefit in high-risk patients who

cannot always be accurately identified in the first day.


However,

• Caution is necessary to avoid causing hypotension

in the first few hours after the infarction.

• Concern about concurrent aspirin therapy

attenuating the effect of an ACE inhibitor appears

largely unwarranted.

However,

• Caution is necessary to avoid causing hypotension

in the first few hours after the infarction.

• Concern about concurrent aspirin therapy

attenuating the effect of an ACE inhibitor appears

largely unwarranted.

(Latini et al., 2000)(Latini et al., 2000)

d) Angiotensin II Receptor Blockers:

The role for an Angiotensin II Receptor Blocker (ARB) in

patients with an STEMI is more limited.

Class I Recommendation:

In patients with an STEMI who are intolerant of ACE

inhibitors and who have clinical or radiological signs of

heart failure or a left ventricular ejection fraction less than

40 percent.

d) Angiotensin II Receptor Blockers:

The role for an Angiotensin II Receptor Blocker (ARB) in

patients with an STEMI is more limited.

Class I Recommendation:

In patients with an STEMI who are intolerant of ACE

inhibitors and who have clinical or radiological signs of

heart failure or a left ventricular ejection fraction less than

40 percent.



e) Statin Therapy:

Should be initiated prior to hospital discharge

in all patients with an STEMI (Atorvastatin 80 mg/day,

which was used in the PROVE IT-TIMI 22 and MIRACL

trials).

e) Statin Therapy:

Should be initiated prior to hospital discharge

in all patients with an STEMI (Atorvastatin 80 mg/day,

which was used in the PROVE IT-TIMI 22 and MIRACL

trials).

(Antman et al., 2004)

(Cannon et al., 2004)

(Schwartz et al., 2001)

(Antman et al., 2004)

(Cannon et al., 2004)

(Schwartz et al., 2001)

f) Calcium Channel Blockers:

• Primarily serve as adjunctive therapy in patients with

ongoing or recurrent symptoms of ischemia despite

optimal therapy with beta blockers (with or without

nitrates),

• In patients who are unable to tolerate adequate

doses of one or both of these agents, or

• In patients with rapid AF when beta blockers are

contraindicated.

f) Calcium Channel Blockers:

• Primarily serve as adjunctive therapy in patients with

ongoing or recurrent symptoms of ischemia despite

optimal therapy with beta blockers (with or without

nitrates),

• In patients who are unable to tolerate adequate

doses of one or both of these agents, or

• In patients with rapid AF when beta blockers are

contraindicated.

















Coronary angiography and, if appropriate, PCI after

thrombolysis in patients with:

• Recurrent MI,

• Moderate or severe spontaneous or provocable

myocardial ischemia during recovery, or

• Cardiogenic Shock or Hemodynamic Instability.

Coronary angiography and, if appropriate, PCI after

thrombolysis in patients with:

• Recurrent MI,

• Moderate or severe spontaneous or provocable

myocardial ischemia during recovery, or

• Cardiogenic Shock or Hemodynamic Instability.

(A class I recommendation) The 2004 ACC/AHA guidelines)(A class I recommendation) The 2004 ACC/AHA guidelines)

















Typically caused by either:

• Recurrent Ischemia And Reinfarction Or

• Infarction Pericarditis.

Typically caused by either:

• Recurrent Ischemia And Reinfarction Or

• Infarction Pericarditis.

Recurrent chest pain within the first 12 hours of

onset of MI is considered to be related to the original

infarct and not evidence of reinfarction.

Pericarditis is probably not responsible for

significant chest discomfort in the first 24 hours.

Recurrent chest pain within the first 12 hours of

onset of MI is considered to be related to the original

infarct and not evidence of reinfarction.

Pericarditis is probably not responsible for

significant chest discomfort in the first 24 hours.

Among patients with an STEMI who have undergone apparently successful thrombolysis:Among patients with an STEMI who have undergone apparently successful thrombolysis:

(Armstrong et al., 1998; Langer et al., 1998)(Armstrong et al., 1998; Langer et al., 1998)

(Topol et al., 1987; Ohman et al., 1990; The GUSTO Angiographic Investigators. 1993)(Topol et al., 1987; Ohman et al., 1990; The GUSTO Angiographic Investigators. 1993)

(Gibson et al., 2003; Donges et al., 2001; Hudson et al., 2001; Barbash et al.,m 2001)(Gibson et al., 2003; Donges et al., 2001; Hudson et al., 2001; Barbash et al.,m 2001)

• Early recurrence of ischemia (Threatened Reocclusion)

has been observed in 20 to 30 percent of patients,

• Early recurrence of ischemia (Threatened Reocclusion)

has been observed in 20 to 30 percent of patients,

• Thrombotic Coronary Reocclusion in 5 to 15 percent, and

• Reinfarction in 3 to 5 percent.

• Thrombotic Coronary Reocclusion in 5 to 15 percent, and

• Reinfarction in 3 to 5 percent.

1. Escalation of Therapy: with beta blockers and nitrates to decrease myocardial oxygen demand and reduce ischemia.

2. Intravenous Anticoagulation: should be initiated if it is not already being administered.

3. Insertion Of An Intraaortic Balloon Pump should also be considered for patients with:

• Hemodynamic instability,

• Poor LV function, or

• A large area of myocardium at risk.

1. Escalation of Therapy: with beta blockers and nitrates to decrease myocardial oxygen demand and reduce ischemia.

2. Intravenous Anticoagulation: should be initiated if it is not already being administered.

3. Insertion Of An Intraaortic Balloon Pump should also be considered for patients with:

• Hemodynamic instability,

• Poor LV function, or

• A large area of myocardium at risk. (Antman et al., 2004)(Antman et al., 2004)

Therapeutic Strategy Therapeutic Strategy

Management Strategy:

4. PCI is the treatment of choice for patients with recurrent

ischemia or emergent CABG for reinfarction or

threatened reinfarction in the following settings, provided

that coronary anatomy is suitable:

• When there is objective evidence of recurrent MI.

• For moderate or severe spontaneous or provocable

ischemia.

• For cardiogenic shock or hemodynamic instability.


4. PCI is the treatment of choice for patients with recurrent

ischemia or emergent CABG for reinfarction or

threatened reinfarction in the following settings, provided

that coronary anatomy is suitable:

• When there is objective evidence of recurrent MI.

• For moderate or severe spontaneous or provocable

ischemia.

• For cardiogenic shock or hemodynamic instability.

(The ACC/AHA guidelines a class I recommendation)(The ACC/AHA guidelines a class I recommendation)(Antman et al., 2004)(Antman et al., 2004)


5. Patients with recurrent ST elevation can also be treated or

retreated with Thrombolytic Therapy.

However, an invasive strategy of angiography and

revascularization is usually preferred.

Patients should not be Retreated with Streptokinase.


5. Patients with recurrent ST elevation can also be treated or

retreated with Thrombolytic Therapy.

However, an invasive strategy of angiography and

revascularization is usually preferred.

Patients should not be Retreated with Streptokinase.

(Antman et al., 2004; Barbash et al., 2001)(Antman et al., 2004; Barbash et al., 2001)

1. Heart Failure and Cardiogenic Shock:

Class III patients should be considered for

hemodynamic monitoring if they do not respond

promptly to medical therapy.

Killip class IV patients generally require invasive

monitoring with pulmonary artery catheterization and

arterial blood pressure monitoring.

Heart Failure and Cardiogenic Shock:

Invasive hemodynamic monitoring may also be

warranted for patients with suspected mechanical

complications of MI resulting in shock, such as:

Papillary muscle rupture or Dysfunction,

Ventricular septal defect, or

Cardiac tamponade.

Killip-Kimball Hemodynamic Subsets

Description Class

No dyspnea; physical examination results are normal I

No dyspnea; bibasilar crackles or S3 on examination II

Dyspnea present; bibasilar crackles or S3 on examination; no hypotension

III

Cardiogenic shock IV

Should be tailored to the patient's clinical and hemodynamic state.

Patients with: Systolic arterial pressure >100 mmHg, Pulmonary artery occlusion pressure >15 mm Hg, and Cardiac index <2.5 L/min/mz.

Should be treated initially with a vasodilator, either intravenous nitroglycerin or intravenous nitroprusside.

Pharmacologic Treatment:

Inotropic support:

If arterial pressure decreases or the increase in

cardiac output is inadequate, inotropic support with

dobutamine should be initiated at 1 to 2 pg/kg/min and

titrated to 5_15 pg/kg/min. Milrinone is an alternative

inotropic agent.

Loop diuretics, such as furosemide (20-40 mg

intravenously or orally every 2-4 hours), should be used to

reduce pulmonary congestion. Diuretics should be used

with caution in hypotensive patients.

Systolic arterial pressure <90 mm Hg,

Pulmonary arterial occlusion pressure >15 mm Hg, and

Cardiac index <2.5 L/min/m2.

These patients should be treated as soon as possible

with Intra-aortic Balloon Counterpulsation (IABC).

Severely hypotensive patients (systolic arterial

pressure <70 mmHg) should be treated with

norepinephrine to rapidly raise the systolic arterial

pressure. If the systolic arterial pressure is 70 to 90 mmHg

with signs of shock, dopamine may be considered initially.

Once the systolic blood pressure has stabilized to at

least 90 mm Hg, dobutamine can be added to further

increase cardiac output and reduce the dosage of

vasopressor.

Patients with STEMI who develop shock within 36 hours of MI:

Benefit from Early Invasive Reperfusion performed within 18 hours of onset of shock.

In patients with 1- or 2-vessel disease, PCI is preferred.

Patients who remain symptomatic and have 3-vessel disease or significant left main coronary artery disease should undergo urgent coronary bypass surgery.

Volume Expansion until the blood pressure is

stabilized, pulmonary arterial occlusion pressure

is >20 mmHg, or right atrial pressure is >20

mmHg.

Associated Bradycardia or high-degree heart

block may require chemical or electrical

intervention.

Agents such as nitrates and diuretics that reduce

preload should be avoided.

If volume expansion is inadequate to stabilize a

patient, dobutamine can be administered.

lntra-aortic balloon counterpulsation should - be

considered for refractory hypotension.

Occurs in < 20% of patients treated with thrombolytic therapy.

Patients treated with primary PCI have a lower incidence of recurrent ischemia.

Reinfarction may present special diagnostic difficulties (cardiac troponin levels can be elevated for 5 to 14 days).

Pericarditis should also be considered as a potential cause of recurrent chest pain after an MI.

Medical treatment is similar to management of unstable angina.

But also includes cardiac catheterization and reperfusion,

Recurrent infarction with ST elevation on ECG can be treated with repeat thrornbolysis. Streptokinase-based drugs should not be used a second time because of the risk of allergic reactions.

Acute reperfusion with PCI or CABG maybe required for stabilization.

Hemodynamically significant bradycardia or A-

V Block:

Can be initially treated with intravenous

atropine in a dose of 0.5 mg every 3-5 minutes to

a total dose of 3 mg while preparing for

transcutaneous pacing.

Atropine rarely corrects complete heart

block or type II second-degree A-V block.

Temporary Transvenous Pacing is indicated for:

Complete heart block,

Bilateral Bundle Branch Block,

New or indeterminate-age Bifascicular Block with first-degree A-V block,

Type II second-degree AN block, and

Symptomatic sinus bradycardia that is unresponsive to atropine.

Immediate Cardioversion is indicated in unstable patients.

Depending upon the specific arrhythmia, intravenous adenosine, b-blockers, or diltiazem may be effective.

Ventricular tachycardia and ventricular fibrillation should be treated according to current ACLS guidelines.

After defibrillation, if indicated, amiodarone is the drug of choice in patients with an MI.

Can occur prior to surgery, intraoperatively, and during the postoperative period.

Postoperative MI is the most common, with the peak incidence on the third postoperative day.

Perioperative MI is often associated with atypical presentations and is frequently painless.

New-onset, or an increase in, Ventricular Arrhythmias is often the presenting finding, as is postoperative Pulmonary Edema.

The diagnosis can be confirmed with serial ECG and cardiac marker determinations.

Treatment is similar to standard treatment.

Thrombolytic therapy may be contraindicated depending on the type of surgery.

Primary PCI should be considered.

The mortality for perioperative MI is very high, up to 60% in some studies.

1. The preliminary diagnosis of unstable angina/non-ST-elevation MI is based on the clinical symptoms, assessment of risk factors for coronary artery disease, and ECG interpretation.

2. A 12-lead ECG should be obtained and interpreted within 10 minutes in patients with possible myocardial ischemia.

3. Non-enteric-coated aspirin at a dose of 162 to 325 mg should be initially administered (by chewing) as soon as possible to all patients with suspected or diagnosed ACS.

4. High-risk patients (continuing ischemia, elevated troponin levels) with UA/NSTEMI may be candidates for additional therapy with (GP) IIb/lIIa inhibitors and an early invasive strategy.

5. The combination of aspirin and heparin is more beneficial in ACS than aspirin alone.

6. b-Blockers should be administered to all patients with ACS unless there are strong contraindications.

7. A plan for early reperfusion of patients with STEMI should be developed by healthcare providers based on resources available in their facility and community.

8. A goal of 90 minutes or less from hospital presentation to balloon inflation is optimum for primary PCI for STEMI.

9. Thrombolytic therapy for reperfusion in SI'EMI should ideally be initiated within 30 minutes of the patient's arrival to the hospital.

10. Patients who undergo PCI with angioplasty with or without stent placement should be treated with a GP IIb/IIIa inhibitor and an antiplatelet agent such as clopidogrel.

11. Use of angiotensin-converting enzyme inhibitdrs decreases mortality in all patients with STEMI.

12. Evidence suggests that patients with STEMI who develop shock within 36 hours of MI benefit from early invasive reperfusion performed within 18 hours of onset of shock.

Myocardial infarction (MI) with LV failure

remains the most common cause of CS. In

general, CS complicates 8.6% of ST-segment

elevation MIs (STEMI)2 and 2.5% of non–ST

segment elevation MIs.3

(Hasdai et al., 2000)

It is increasingly clear that CS represents a wide

clinical spectrum, including preshock (patients at

significant risk of developing CS), mild CS

(responsive to low-dose inotropes/vasopressors),

profound CS (responsive to high-dose inotropes/

vasopressors and IABP, and severe refractory CS

(SRCS; unresponsive to high-dose inotropes/

vasopressors and IABP).

The first published clinical trial of IABPs in

patients with CS demonstrated augmentation

of cardiac output by 0.5 L/min7.

(Scheidt et al., 1973)

Subsequent data from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) Trial Registry demonstrated lower in-hospital mortality in patients with MI who received IABP in combination with thrombolytic therapy or early revascularization with percutaneous transluminal coronary angioplasty/coronary artery bypass graft surgery8. (Sanborn et al., 2000)

Similarly, in the Global Utilization of

Streptokinase and TPA for Occluded Coronary

Arteries (GUSTO-I) trial, early institution of IABP

and thrombolytic therapy in patients with acute

MI (AMI) complicated by CS was associated with

an increased risk of bleeding and adverse

events but also a trend toward lower 3-day and

1-year all-cause mortality9.(Anderson et al., 1997)

Common Causes of Cardiogenic Shock

MI without mechanical complications

MI with mechanical complications (ventricular septal rupture or papillary muscle/chordal rupture).

Acute decompensation of chronic heart failure


Acute myocardities

Postcardiotomy

Takotsubo/stress-induced cardiomyopathy

Peripartum cardiomyopahty


Refractory arrhythmias

Cardiac tamponade

Massive pulmonary embolism


Acute rejection after orthotopic heart transplantation

Hypertrophic cardiomyopathy with severe outflow obstruction

Aortic dissection complicated by acute severe aortic insufficiency and/or MI

A recent meta-analysis suggested that

although IABPs may have a beneficial effect

on hemodynamic parameters in infarct-

related CS, the existing data to not support a

mortality benefit12.

(Unverzagt et al., 2011)

Finally, another recent meta-analysis

evaluating the use of IABPs in patients with

STEMI complicated by CS suggested no

improvement in 30-day survival or LV ejection

fraction and an increased risk of stroke and

bleeding complications13.(Sjauw et al., 2009)

Given the minimal circulatory support

afforded by IABPs, next generation of

external VADs was designed to be surgically

implanted and powerful enough to provide full

circulatory support.

Despite advances in surgically implanted

external VAD technology and improvement in

the morbidity and mortality attributable to

these devices, important clinical problem

remain.

Including the need for general anesthesia,

systemic inflammation associated with an

open surgical procedure, and the often

prolonged delay associated with operating

room activation.

Widely regarded as the first PVAD, the

Hemopump Cardiac Assist System (Johnson

and Johnson Interventional Systems. Rancho

Cordova, CA) was a catheter-mounted, axial

flow device positioned across the aortic valve

and capable of providing up to 3.5 L/min of

short-term (hours to days) cardiac support for

patients with CS25.(Wampler et al., 1994)

The TendemHeart PVAD (CardiaAssist, Inc,

Pittsburgh, PA) is a left atrial-femoral bypass

centrifugal pump capable of providing up to

3.5 to 4.5 L/min of cardiac output when

inserted percutaneously.

Inflow/outflow cannula

configurations for the

TandemHeart and

Impella Recover 2.5

percutaneous

ventricular assist

devices (PVADs)

Although ECMO technology was developed

in the 1960s, there has been a recent

resurgence of this technology owing to better

cannulation techniques, smaller cannulas,

improved oxygenator machines, and device

miniaturization.

Together, these improvements have resulted

in lightweight, portable, reliable, and rapidly

implantable percutaneous ECMO systems in

2 possible configurations: veno-venous for

pulmonary support and veno-arterial for

cardiac and pulmonary support.

The major advantage of these systems over

other modern PVADs is the lack of need for

transseptal puncture or transfer to a cardiac

catheterization laboratory.

Health & Medicine

Mokhtar overview & acs-2012-final