Presentation is loading. Please wait.

Presentation is loading. Please wait.

Acute coronary syndrome Management Dr Pham Duc Tuan A&E dept. FVHospital 22/12/09.

Similar presentations


Presentation on theme: "Acute coronary syndrome Management Dr Pham Duc Tuan A&E dept. FVHospital 22/12/09."— Presentation transcript:

1 Acute coronary syndrome Management Dr Pham Duc Tuan A&E dept. FVHospital 22/12/09

2 Introduction The spectrum clinical conditions ranging from : The spectrum clinical conditions ranging from : ST elevation MI ( 1/3 cases ) ST elevation MI ( 1/3 cases ) Non ST elevation MI ( 2/3 cases ) Non ST elevation MI ( 2/3 cases ) Characterized by the common physiopathology of disrupted atherosclerotic plaque Characterized by the common physiopathology of disrupted atherosclerotic plaque

3

4 Diagnosis of ACS History of cardiac chest pain: accompanied by SOB, diaphoresis, palpitation, nausea, lightheadedness- radiates to arm, neck, jaw – is worse with exertion- may improve with NG administration History of cardiac chest pain: accompanied by SOB, diaphoresis, palpitation, nausea, lightheadedness- radiates to arm, neck, jaw – is worse with exertion- may improve with NG administration Cardiac risk factor : Age ( men >55, women >65 )-DM- Smoking-HTN- Hypercholesterolemia – Family history early of CAD.Approximately one half of all pts with ACS have no established risk factors other than age & gender. Cardiac risk factor : Age ( men >55, women >65 )-DM- Smoking-HTN- Hypercholesterolemia – Family history early of CAD.Approximately one half of all pts with ACS have no established risk factors other than age & gender. Physical examination : vital signs – heart failure. Physical examination : vital signs – heart failure. Atypical presentation : absence of chest pain silent MI, SOB, cardiogenic shock, altered mental stastus, epigastric pain, fatigue, nausea, palpitation ( especially in DM, elderly patients, post operations ). Atypical presentation : absence of chest pain silent MI, SOB, cardiogenic shock, altered mental stastus, epigastric pain, fatigue, nausea, palpitation ( especially in DM, elderly patients, post operations ).

5 Diagnosis of ACS Differential diagnosis : Differential diagnosis : Non cardiac life threatening causes : Aortic dissection, PE, Tension pneumothorax Non cardiac life threatening causes : Aortic dissection, PE, Tension pneumothorax Cardiac causes : pericarditis, tamponade, myocarditis. Cardiac causes : pericarditis, tamponade, myocarditis. Common non cardiac causes: GI ( GERD, cholecystitis, pancreatitis )- Musculoskeletal ( costeochondritis) – Pulmonary ( Pleurisy, pneumonia )- Psychiatric ( Panic attacks ) Common non cardiac causes: GI ( GERD, cholecystitis, pancreatitis )- Musculoskeletal ( costeochondritis) – Pulmonary ( Pleurisy, pneumonia )- Psychiatric ( Panic attacks )

6 Diagnosis of ACS Cardiac biomarkers

7 ST elevation MI Cardiac biomarkers: Cardiac biomarkers: An elevated level of Troponine correlates with increased risk of death, greater elevation predict greater risk of adverse outcome. An elevated level of Troponine correlates with increased risk of death, greater elevation predict greater risk of adverse outcome. They are insensitive during the first 4-6 hrs of presentation. They are insensitive during the first 4-6 hrs of presentation. Serial marker testing over time improves sensitivity but remains insensitive in the first 4-6 hrs Serial marker testing over time improves sensitivity but remains insensitive in the first 4-6 hrs

8 Conditions that cause an increased level of Troponine I,T outside ACS Renal insufficiency Renal insufficiency PE PE Myopericarditis Myopericarditis Decompensated HF Decompensated HF Coronary spasm Coronary spasm Critical illness ( including burns & sepsis ) Critical illness ( including burns & sepsis ) Cardiac contusion, trauma, surgery Cardiac contusion, trauma, surgery Electrocardioversion/ defibrillation Electrocardioversion/ defibrillation Electrophysiological procedures ( including arrhythmia ablation procedures ) Electrophysiological procedures ( including arrhythmia ablation procedures )

9 STEMI ECG : ECG : The 12 lead ECG is central to the triage of pts with chest discomfort. The 12 lead ECG is central to the triage of pts with chest discomfort. A 12 lead ECG should be performed & shown to an experienced EP within 10 mins of ED arrival of all pts with chest discomfort. A 12 lead ECG should be performed & shown to an experienced EP within 10 mins of ED arrival of all pts with chest discomfort. A normal ECG doesnt preclude the diagnosis of ACS. Serial assessments improve sensitivity & specificity for detecting ACS. A normal ECG doesnt preclude the diagnosis of ACS. Serial assessments improve sensitivity & specificity for detecting ACS.

10 Hyperacute Anterior MI Hyperacute Anterior MI

11 Difficult ECG interpretations ST elevation in absence of AMI : early repolarization, LVH, pericarditis, myocarditis, LV aneurysm, hypertrophic CM, ventricular paced rhythms, LBBB, hypothermia ST elevation in absence of AMI : early repolarization, LVH, pericarditis, myocarditis, LV aneurysm, hypertrophic CM, ventricular paced rhythms, LBBB, hypothermia ST depression in absence of ischemia : hypokalemia, digoxin effect, cor pulmonale, LVH, LBBB ST depression in absence of ischemia : hypokalemia, digoxin effect, cor pulmonale, LVH, LBBB T waves inversion without ischemia : CNS hemorrhage, mitral valve prolapse, pericarditis, PE, LVH, RBBB, LBB T waves inversion without ischemia : CNS hemorrhage, mitral valve prolapse, pericarditis, PE, LVH, RBBB, LBB

12 STEMI ECG criteria for diagnosis of MI in the presence of LBBB. ECG criteria for diagnosis of MI in the presence of LBBB. ST elevation of 1mm in leads with positive QRS ST elevation of 1mm in leads with positive QRS ST depression 1mm in leads V1 to V3 ST depression 1mm in leads V1 to V3 ST elevation > 5mm in leads with a negative QRS ST elevation > 5mm in leads with a negative QRS

13 NSTEMI Presentation : Presentation : Rest angina : prolonged (>20 min ) discomfort during lack of physical activity Rest angina : prolonged (>20 min ) discomfort during lack of physical activity New onset angina: newly diagnosed severe discomfort causing marked limitation of physical activity New onset angina: newly diagnosed severe discomfort causing marked limitation of physical activity Worsening angina : intense prolonged with less strenous activity Worsening angina : intense prolonged with less strenous activity

14

15 High risk patients with NSTEMI Refractory ischemic chest pain Refractory ischemic chest pain Recurrent/ Persistent ST deviation Recurrent/ Persistent ST deviation Ventricular tachycardia Ventricular tachycardia Hemodynamic instability Hemodynamic instability Signs of pump failure Signs of pump failure Positive cardiac biomarkers Positive cardiac biomarkers TIMI 5 TIMI 5 Early invasive strategies. Early invasive strategies.

16

17 NSTEMI TIMI Risk Score : Risk Status TIMI Risk Score : Risk Status 0 or 1 Low 0 or 1 Low 2 3 Intermediate 3 Intermediate 4 5 High 5 High 6 or 7 6 or 7

18 NSTEMI ECG : ST depression consistent with high risk UA/NSTEMI ECG : ST depression consistent with high risk UA/NSTEMI Non diagnostic or Normal ECG Non diagnostic or Normal ECG 10% of ACS pts may present with normal ECG 10% of ACS pts may present with normal ECG Repeating the ECG at 5-10 mins Repeating the ECG at 5-10 mins

19 NSTEMI

20

21 Initial general therapy Aspirine: 160-325mg Aspirine: 160-325mg Nitroglycerine: No apparent impact on mortality in pts with ACS. Nitroglycerine: No apparent impact on mortality in pts with ACS. Indication : ongoing chest discomfort, HTN, pulmonary congestion. Indication : ongoing chest discomfort, HTN, pulmonary congestion. CI: hypotension, severe bradycardia 100 bpm, RV infarction. CI: hypotension, severe bradycardia 100 bpm, RV infarction. Morphine Sulphate Morphine Sulphate

22 Reperfusion therapies Fibrinolytics Fibrinolytics Percutaneous Coronary Intervention : Percutaneous Coronary Intervention : Superior to fibrinolytics in combined end points of deah, stroke & reinfarction in many studies ( with skilled providers at a skilled PCI facility ) Superior to fibrinolytics in combined end points of deah, stroke & reinfarction in many studies ( with skilled providers at a skilled PCI facility ) Preferred in patient with STEMI, symptoms duration 12hs, door to balloon time 90 mins. Preferred in patient with STEMI, symptoms duration 12hs, door to balloon time 90 mins. Preferred in patients with CI of fibrinolytics, cardiogenic shock, HF. Preferred in patients with CI of fibrinolytics, cardiogenic shock, HF.

23

24

25 Adjunctive therapies Clopidogrel : oral loading dose 300 mg Clopidogrel : oral loading dose 300 mg B Adrenergic Receptor Blokers B Adrenergic Receptor Blokers Low Molecular Weight Heparin : Enoxaparin ( Lovenox ) Low Molecular Weight Heparin : Enoxaparin ( Lovenox ) NSTEMI 1mg/kg SC bid CrCl <30ml/min 1mg/kg qd NSTEMI 1mg/kg SC bid CrCl <30ml/min 1mg/kg qd STEMI: STEMI: <75ys 30mg single bolus plus 1mg/kg SC then 1mg/kg SC q12h <75ys 30mg single bolus plus 1mg/kg SC then 1mg/kg SC q12h <75ys CrCl <30ml/min 30mg single bolus then 1mg/kg then 1mg qd <75ys CrCl <30ml/min 30mg single bolus then 1mg/kg then 1mg qd 75ys 0.75mg/kg SC q12h ( no initial bolus ) 75ys 0.75mg/kg SC q12h ( no initial bolus ) 75ys CrCl <30ml/min 1mg SC qd 75ys CrCl <30ml/min 1mg SC qd Glycoprotein IIB/IIIA Inhibitors Glycoprotein IIB/IIIA Inhibitors ACE Inhibitor ACE Inhibitor Statins Statins

26 Complications Cardiogenic shock, LV failure, CHF Cardiogenic shock, LV failure, CHF RV infarction : should be suspected in inferior and or/ posterior MI. RV infarction : should be suspected in inferior and or/ posterior MI. Mechanical complications: rupture of free wall, IV septum, papillary muscle. Mechanical complications: rupture of free wall, IV septum, papillary muscle. Arrythmias : Arrythmias : VF&VT : majority of early death, highest in the first 4 hrs, lidocaine plays no role in prophylaxis. VF&VT : majority of early death, highest in the first 4 hrs, lidocaine plays no role in prophylaxis. AF AF Bradyarrythmias : sinus bradycardia, AV block Bradyarrythmias : sinus bradycardia, AV block

27

28 Conclusions Once the pts with ACS contacts with the health care system. Health care providers must focus on support of cardiopulmonary function, rapid transport, early classification based on ECG characteristics. Once the pts with ACS contacts with the health care system. Health care providers must focus on support of cardiopulmonary function, rapid transport, early classification based on ECG characteristics. Patients with STEMI require prompt reperfusion, the shorter the interval from onset to reperfusion, the greater the benefit. Patients with STEMI require prompt reperfusion, the shorter the interval from onset to reperfusion, the greater the benefit. Patients with NSEMI require risk stratification, appropriate monitoring & therapy. Patients with NSEMI require risk stratification, appropriate monitoring & therapy. Health care providers can improve survival rates, myocardial function of ACS patients by providing skilled, efficient, coordinated out of hospital & in hospital care Health care providers can improve survival rates, myocardial function of ACS patients by providing skilled, efficient, coordinated out of hospital & in hospital care


Download ppt "Acute coronary syndrome Management Dr Pham Duc Tuan A&E dept. FVHospital 22/12/09."

Similar presentations


Ads by Google