treatment in ug point of view

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

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

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

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

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

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

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.

35. Balloon angioplasty

36. Coronary artery bypass graph (CABG)

37. ATHERECTOMY
Rotational Atherectomy Directional
Coronary
Atherectomy
Extraction Atherectomy

38. THANK
YOU