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Treatment of myocardial infarction
1. UNDER THE GUIDANCE OF :
Dr. V.KRISHNA RAO
PROF & HOD OF EMERGENCY MEDICINE
CHAIRPERSON :
Dr. B.R. SHIVAKUMAR
PROF & HOD OF DEPT OF MEDICINE
By,
Dr. Mohammed Yaqub
Intern (2011 batch)
Intern
2. Prehospital chest pain evaluation
and treatment
Prehospital EMS providers … 75 to 325 mg of aspirin
(chewed) … non–enteric-coated formulations.
(goal is to quickly block thromboxane A2 formation in
platelets)
Previously on NTG : take 1 tab S/L ; Not improving
after 5 min Seek medical help
3.
4. Fibrinolysis preferred
Early presentation (≤3hr from symptom onset and delay to
invasive strategy)
Invasive strategy is not an option
Catheterization laboratory occupied or not available
Vascular access difficulties
Lack of access to a skilled PCI laboratory
Delay to invasive strategy
Prolonged transport
(Door-to-balloon)–(door-to-needle) more than 1hr
Medical contact-to-balloon or door-to-balloon more
than 90 min
5. Invasive strategy preferred
Skilled PCI laboratory is available with surgical backup
Medical contact-to-balloon or door-to-balloon
less than 90min
High risk from STEMI
Cardiogenic shock
Killip class ≥ 3
Contraindications to fibrinolysis
Late presentation (> 3 hr)
Diagnosis of STEMI is in doubt
6. Initial recognition and
management in ER
1. Airway, Breathing, Circulation (ABC)
2. Vital signs, general observation
3. Presence or absence of jugular venous
distension
4. Pulmonary auscultation for rales
5. Cardiac auscultation for murmurs and
gallops
6. Presence or absence of stroke
7. Laboratory Investigations
(should be performed, but should not delay the
implementation of reperfusion therapy.)
ECG
Serum biomarkers for cardiac damage
Complete blood count (CBC) with platelets
International normalized ratio (INR)
Activated partial thromboplastintime (aPTT)
Electrolytes and magnesium
Blood urea nitrogen (BUN),creatinine
Glucose
Complete Lipid Profile
8.
9. Control of cardiac pain
Pain contribute to the heightened sympathetic activity
Typically accomplished with combination of nitrates,
analgesics, oxygen and β-blockers
Oxygen
Arterial oxygen desaturation (SaO2< 90%)
Uncomplicated STEMI during the first 6 hours
10. Control of cardiac pain
Nitroglycerin
Patients with ongoing ischemic discomfort
s/l 0.4 mg every 5 minutes for a total of 3 doses
Intravenous NTG : 0.6 to 1.2 mg/hour
ongoing ischemic discomfort that responds to nitrate therapy
control of hypertension
Nitrates should not be administered to patients with:
systolic pressure < 90 mm Hg or ≥ to 30 mm Hg below baseline
severe bradycardia(< 50 bpm)
tachycardia (> 100 bpm)
suspected RV infarction.
who have received a phosphodiesterase
11. Control of cardiac pain
Analgesia
Morphine sulfate (2 to 4 mg intravenously)
NSAIDS Increase risk of cardiovascular events so
should be discontinued
[A sub study analysis from the ExTRACTTIMI-
25trial showed increased risk of death, reinfarction,
heart failure, or shock among patients on NSAID is
within 7 days of enrollment].
12. Reperfusion therapy
The principal goal of fibrinolysis is prompt restoration
of full IRA patency
Streptokinase , tPA(alteplase), TNK(tenecteplase),
rPA(reteplase)
TNK and rPA-bolus fibrinolytics
Promote conversion of plasminogen to plasmin, which
subsequently lyses fibrin thrombi
13.
14.
15. Contraindications and cautions for
fibrinolysis in STEMI
Absolute Contraindications:
Any prior intracranial hemorrhage
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months EXCEPT acute ischemic
stroke within 3 hours
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed-head or facial trauma within 3 months
Note: Age restriction for fibrinolysis has been removed compared with
prior guidelines.
16. Relative Contraindications:
Severe uncontrolled hypertension on presentation
(SBP > 180 or DBP > 110)
Prior ischemic stroke >3 months
Traumatic or prolonged (> 10 mt.) CPR or major
surgery (< 3 weeks)
Recent (< 2 to 4 weeks) internal bleeding
Noncompressible vascular punctures
For streptokinase/anistreplase: prior exposure (> 5
days ago) or prior allergic reaction to these agents
Pregnancy, Active peptic ulcer
Current use of anticoagulants
17.
18. Choice of fibrinolytics
WP- 4 hr. t-PA is the preferred treatment
streptokinase t-PA equivalent choices -risk of death is
low , and increased risk of ICH .
WP-4 to 12 hr . streptokinase and t-PA are equivalent
options, but streptokinase is probably preferable to t-
PA because of cost considerations
19. Assesment of reperfusion after
fibrinolysis
Noninvasive findings, s/o reperfusion include:
Relief of symptoms
Maintenance and restoration of hemodynamic and/or
electrical instability
Reduction of ≥50 % of the initial STE pattern on
follow-up ECG 60 to 90 minutes after initiation of
therapy
20.
21.
22. Anticoagulant therapy
Prevention of DVT, pulmonary embolism, ventricular
thrombus, cerebral embolization.
Establishing & maintaining patency of IRA.
Trials shown that more prolonged anticoagulant
therapy is beneficial (duration of index hospita-
lization) in patients receiving thrombolytic therapy
23.
24. IV Unfractionated Heparin
Selective Fibrinolytic –Bolus of 60 U/kg (maximum
4000 U) followed by an infusion of 12 U/kg/hr
(maximum 1000 U)
Nonselective fibrinolytic agents-who are at high risk
for systemic emboli (large or anterior MI,
atrialfibrillation (AF), previous embolus, or known LV
thrombus).
LMWH-30mg iv followed by 1mg/kg every 12hr
25. Antiplatelets
Aspirin should be given indefinitely to all STEMI pts.
without a true aspirin allergy.
Patients undergoing PCI are also given aspirin loading
Patients not on aspirin therapy should be given non
enteric aspirin 325 mg before PCI.
After PCI, use of aspirin should be continued
indefinitely
Clopidogrel 300mg loading dose given orally.
26. Thienopyridines
Addition of P2Y12 inhibitor to aspirin warranted for most
patients with STEMI
In patients for whom PCI is planned, clopidogrel should be
started and continued.
Patients receiving a stent (BMS or DES) clopidogrel 75 mg
daily or prasugrel 10 mg for at least 12 months;
If the risk of bleeding outweighs the anticipated benefit
afforded by thienopyridine therapy, earlier
discontinuation.
Continuation of thienopyridines beyond 15 months may be
considered in patients undergoing DES placement
27. Prior history of stroke and TIA for whom primary PCI
is planned, prasugrel is not recommended
CABG planned ?... the drug should be withheld for at
least 5 days in patients receiving clopidogrel and at
least 7 days in patients receiving prasugrel.
Probably indicated in patients receiving fibrinolytic
therapy who are unable to take aspirin because of
hypersensitivity or GI intolerance
28. Glycoprotien IIb/IIIa inhibitors
It is reasonable to start abciximab as early as possible
before primary PCI (with or without stenting) in
patients with STEMI.
Tirofibanor eptifibatide may be considered before
primary PCI (with or without stenting) in patients
with STEMI.
29. ß-blockers
Relieve ischemic pain, reduce need for analgesics,
reduce infarct size and life-threatening arrhythmias
Contra indications:
o signs of heart failure
o evidence of a low output state
o increased risk for cardiogenic shock
o other relative contraindications (PR interval > 0.24 S.
2ndor 3rddegree AV block, or reactive airway disease)
30. Favorable effects with metoprolol , atenolol , carvedilol
and timolol,
Beta blockers with intrinsic sympathomimetic activity
probably should not be chosen.
Trial of esmolol in the presence of relative
contraindications.
31. CCBs
Immediate-release preparation of nifedipine increased
risk of in-hospital mortality
Verapamil & diltiazem can be given for relief of
ongoing ischemia or slowing of a rapid ventricular
response in AF in patients with contraindication to
beta blockers.
INTERCEPT trial compared 300mg of diltiazem with
placebo and Diltiazem did not reduce cardiac death,
nonfatal reinfarction, during a 6-month follow-up
32. ACE Inhibitors
Improves MI by reducing myocardial remodelling
Recommended <24hrs in patient with acute MI with or
without CHF
Captopril 12.5mg
33. Statins
Atorvastatin 40-80mg <24hrs in patients with
ST elevation MI
Besides lowering cholesterol,beneficial affect are also
related to direct affects on endothelial
function,oxidative stress,inflammation,thrombosis as
well as plaque stabilization.
34. Intensive glucose control in STEMI
It is reasonable to use an insulin based regimen to
achieve and maintain glucose levels less than 180
mg/dl while avoiding hypoglycemia for patients with
STEMI with either a complicated or uncomplicated
course.