Pre Hospital and Initial Management of Acute Coronary Syndrome
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1 Pre Hospital and Initial Management of Acute Coronary Syndrome Dr. Muhammad Fadil, SpJP 3rd SymCARD 2013
2 Classification of ACS ESC Guidelines for the management of Acute Coronary Syndrome in patients without persistent ST Elevation.2011
3 Atherosclerosis risk factors Unmodified risk factors Aging male > 45 yrs female > 55 yrs Family history of ACS male < 55 yrs female < 65 yrs Modified risk factors Smoking Hypertension Dyslipidemia Diabetes Miletus
4 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation
5 Clinical Symptom Associated symptoms Sweating Palpitation Syncope Vasovagal syncope Arrhythmia 1. Site is retrosternal chest discomfort (may radiate to neck, jaw, epigastrium, or arms) 2. Characteristic quality (squeezing, pressure-like, heavy) 3. Duration (usually 2 20 min) 4. Worsened by physical exertion or emotional stress 5. Relieved by rest or nitroglycerin
6 Clinical signs Vital sign Arrhythmia Hypertension, hypotension Tachypnea Low grade fever Cardiovascular Murmur S3 or S4 gallop Lung congestion: Killip I-IV
7 Investigations Electrocardiography Cadiac enzyme Chest x-ray Echocardiography Coronary angiography, CAG Other risk factors: Lipid profiles
8 Electrocardiography The most important Serial EKG is routinely Classify ACS Determine severity and prognosis
9 ST-segment elevation at the J point in two contiguous leads 0.25 mv in men below the age of 40 years, 0.2 mv in men over the age of 40 years, or 0.15 mv in women in leads V2 V3 and/or 0.1 mv in other leads Advisable to record right precordial leads (V3R and V4R) seeking ST elevation identify concomitant right ventricular New ST Horizontal/downsloping depression 0.1 mv in 2 contigous lead T Inverted 0.1 mv ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation
10 Cardiac marker In patients with MI, an initial rise in troponins occurs within 4 hours after symptom onset. Troponins may remain elevated for up to 2 weeks Serial every 6-12 hrs at least 2 times CK-MB subform and Troponin are very helpful in diagnosis ESC Guidelines for the management of Acute Coronary Syndrome in patients without persistent ST Elevation.2011
11 Chest X-Ray Cardiac abnormality Determine acute heart failure
12 Echocardiography
13 Coronary angiogram
14 How to Manage?
15 Reperfusion Therapy for Patients with STEMI *Patients with cardiogenic shock or severe heart failure initially seen at a non PCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). Angiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. DIDO = door-in-door-out
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17 Principle of ACS management ACS Adjuvant Rx Aspirin Nitrates Mo Clopidogrel Beta blockers ACEI Antithrombin GPII/IIIa Hemodynamic stabilization Medical Ventilator IABP Pace maker Early Invasive Primary PCI Facilitate PCI Rescue PCI CABG Early Conservative Fibrinolytic drugs Risk stratification Initial Therapy MoNACO Elective CAG +/- PCI or CABG
18 AHA. Advanced Cardiac Life Support.2010
19 Anti Ischemic ESC Guidelines for the management of Acute Coronary Syndrome in patients without persistent ST Elevation.2011
20 Anti Ischemic (Acute Heart Failure) ESC Guidelines for the management of Acute Coronary Syndrome in patients without persistent ST Elevation.2011
21 Anti platelet ESC Guidelines for the management of Acute Coronary Syndrome in patients without persistent ST Elevation.2011
22 ESC Guidelines for the management of Acute Coronary Syndrome in patients without persistent ST Elevation.2011
23 Complication Following ST Elevation Myocardial Infarction
24 Acute Heart Failure Furosemid SpO2<90% Morphine 4-8 mg Ex:Dobutamine,
25 Right Ventricular Infarct STEMI Inferior ( II,III,aVF) RV Infarction (ST elevation on lead V3R & V4R) ST Elevation 1 mv on V3R & V4R
26 Trias RV Infarct 1. Hypotension 2. Clear Lung 3. Raised Jugular Venous Pressure Treatment 1. Fluid Loading ( Up to 2 Lt) 2. Avoid Diuretic & Vasodilator (Nitrate, Ace Inhibitor)
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33 Thank You
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