Early Management of Early Management of Suspected Myocardial Suspected Myocardial Infarction Infarction DR Ihab Suliman DR Ihab Suliman MBBS(KHAR),ECFMG(USA)MRCP(UK),Bo MBBS(KHAR),ECFMG(USA)MRCP(UK),Bo ard Certified nuclear ard Certified nuclear cardiology(USA) cardiology(USA) Associate Consultant Adult Associate Consultant Adult Cardiology Cardiology National Guard Hospital National Guard Hospital Member of the European Atherosclerosis Member of the European Atherosclerosis Society. Society. Member of the European Society of Cardiology. Member of the European Society of Cardiology. Member of the Member of the European working group on Nuclear Cardiology& European working group on Nuclear Cardiology& Cardiac CT. Cardiac CT. Member of the European Working Member of the European Working
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Early Management of Suspected Early Management of Suspected Myocardial InfarctionMyocardial Infarction
DR Ihab Suliman DR Ihab Suliman MBBS(KHAR),ECFMG(USA)MRCP(UK),BMBBS(KHAR),ECFMG(USA)MRCP(UK),B
19 years old female,single ,pharmacy 19 years old female,single ,pharmacy student came with chest pain ,LDL 2.0,ECG student came with chest pain ,LDL 2.0,ECG
A 26 year old woman presented 1 week post A 26 year old woman presented 1 week post delivery of her first baby. She has sharp L sided delivery of her first baby. She has sharp L sided
chest pain and she is short of breath.chest pain and she is short of breath.
Stabilizing Measures for Stabilizing Measures for ACS(STEMI)ACS(STEMI)
Aspirin 325 Aspirin 325 mg(saves lives)mg(saves lives)IV: NS or RL KVOIV: NS or RL KVO
OO22: 4-6 LPM via : 4-6 LPM via mask or N.C.mask or N.C.Monitor (V Fib)Monitor (V Fib)Pulse oxPulse ox
Base treatment on hx and clinical Base treatment on hx and clinical setting - setting - NOTNOT EKG findings! EKG findings!
initial EKG may be initial EKG may be normalnormal in AMI in AMI
>1 mm ST elevation in 2 leads - acute >1 mm ST elevation in 2 leads - acute transmural MItransmural MI only seen in 40-50% at presentationonly seen in 40-50% at presentation
Primary value is to R/O pneumonia, Primary value is to R/O pneumonia, PTX, wide mediastinumPTX, wide mediastinum
May see cardiomegaly (with IHD, May see cardiomegaly (with IHD, HTN, old MI) or CHFHTN, old MI) or CHF
26 yr old thin man with sudden onset of 26 yr old thin man with sudden onset of severe R sided sharp chest pain ,tachypnoeic.severe R sided sharp chest pain ,tachypnoeic.
Aspirin 325 mg POAspirin 325 mg PO GIVE TO ALL PTS UNLESS GIVE TO ALL PTS UNLESS
CONTRAINDICATED!CONTRAINDICATED!
reduces MI mortality, strokereduces MI mortality, stroke
Heparin IVHeparin IV
Reperfusion
STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact.
Modified recommendation
STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center for intervention within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation, unless contraindicated.
major trauma or major trauma or surgery w/in 2 wkssurgery w/in 2 wks
recent head injuryrecent head injury
pregnancypregnancy
anticoagulationanticoagulation
bleeding disorderbleeding disorder
traumatic CPRtraumatic CPR
drug allergydrug allergy(age)(age)
Anticoagulants as Ancillary Therapy
Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 hours, and preferably for the duration of the index hospitalization, up to 8 days. New Recommendation
Regimens other than UFH are recommended if therapy is given for more than 48 hours because of risk of heparin-induced thrombocytopenia.New Recommendation
Regimens with established efficacy include:UFH, enoxaparin, fondaparinux (see full text Update for dosing recommendations)
Ace inhibitors should be started and continued indefinitely in all patients recovering from STEMI with LVEF </ 40%, and for patients with preserved LVEF with hypertension, diabetes, or chronic kidney disease, unless contraindicated.
Modified recommendation
ACE inhibitors should be started and continued indefinitely in patients recovering from STEMI who are not lower risk unless contraindicated (low risk defined as those with normal LVEF in whom cardiovascular risk factors are well-controlled and revascularization has been performed).
New recommendation
Among lower risk patients recovering from STEMI, use of ACE inhibitors is reasonable.
New recommendation
III IIaIIaIIa IIbIIbIIbIIIIIIIIIIII IIaIIaIIa IIbIIbIIbIIIIIIIIIIII IIaIIaIIa IIbIIbIIbIIIIIIIIIIIaIIaIIa IIbIIbIIbIIIIIIIII
Use of aldosterone blockade in post-MI patients Use of aldosterone blockade in post-MI patients without significant renal dysfunction or without significant renal dysfunction or hyperkalemia is recommended in patients who:hyperkalemia is recommended in patients who:
are already receiving therapeutic doses of are already receiving therapeutic doses of an ACE inhibitor and beta blockeran ACE inhibitor and beta blocker
have a LVEF of less than or equal to 40%have a LVEF of less than or equal to 40%
have either diabetes or HFhave either diabetes or HF
Clopidogrel (75mg daily) should be added to aspirin in patients with STEMI regardless of whether or not reperfusion therapy is received.
New recommendation
Treatment with clopidogrel should continue for at least 14 days.
New recommendation
In patients taking clopidogrel in whom CABG is planned, the drug should be withheld for at least 5 days (preferably 7 days), unless the urgency for revascularization outweighs the risks of excess bleeding.
New Recommendations in 2007 New Recommendations in 2007 Update for Lipid ManagementUpdate for Lipid Management
A fasting lipid panel should be assessed in all A fasting lipid panel should be assessed in all patients and within 24 hours of hospitalization, and patients and within 24 hours of hospitalization, and lipid-lowering medication should be initiated prior to lipid-lowering medication should be initiated prior to discharge.discharge.
LDL-C should be <100mg/dL, LDL-C should be <100mg/dL, and further reduction and further reduction to <70mg/dL is reasonable.to <70mg/dL is reasonable.
If baseline LDL-C is 70 - 100 mg/dL, it is If baseline LDL-C is 70 - 100 mg/dL, it is reasonable to treat to <70 mg/dL.reasonable to treat to <70 mg/dL.
Maintain high index of Maintain high index of suspicionsuspicion
Document risk factors in Document risk factors in everyevery CP patient CP patient
Mentally rule out 5 life-Mentally rule out 5 life-threatening causes in threatening causes in everyevery CP patient CP patient
Stabilize with Stabilize with IV/OIV/O22/monitor/pulse ox/monitor/pulse ox
Pitfalls and PearlsPitfalls and Pearls
Normal EKG does not R/O Normal EKG does not R/O AMIAMI
Single CK-MB does not R/O Single CK-MB does not R/O AMIAMI
ASA,B-blockers,Clopidogrel ASA,B-blockers,Clopidogrel plus ACEI lower mortality & plus ACEI lower mortality & CHEAPCHEAP
QUIZZQUIZZ
QUIZZQUIZZ
50 years old female with chronic renal 50 years old female with chronic renal failure,chest pain & dizzinessfailure,chest pain & dizziness
she is hypertensive on lisinoprilshe is hypertensive on lisinopril
26 Old army officer had flu last week,felt chest pain while driving his 26 Old army officer had flu last week,felt chest pain while driving his car,pain increased by deep breath,he has no history of DM or car,pain increased by deep breath,he has no history of DM or