Emergency in medicine

4 April 2012

Scope
Cardiopulmonary resuscitation Cardiac arrhythmia Acute coronary syndrome Fast track MI

Cardiopulmonary resuscitation

VF/ Pulseless VT

Ventricular Fibrillation
Multiple ventricular foci rapidly discharge producing a totally erratic ventricular rhythm without identifiable waves

Ventricular tachycardia

Ventricular Tachycardia (VT)

Regular rhythm (may be slightly irregular) Rate ~150-250/min Wide QRS complex

Polymorphic VT

+ Prolong QT = Torsades de pointes

Defibrillation
Provide most effective treatment for ventricular fibrillation as soon as possible

Automated External Defibrillator

Manual Defibrillator

Manual Defibrillators

Step Manual Defibrillation

1.Turn on or monitor on

2. Set lead select

Paddle lead
Lead I, II, III

3. Analyze rhythm 4. If VF or pulseless VT Defibrillation

Select energy level

Monophasic :360J Biphasic:120-200 J (If unknown use 200J)

5. Apply gel to paddle or use adhesive pad 6. Apply paddle or pad at correct position

7.Charge defibrillator by Press button on control panel Or at right hand apex paddle

8. When fully charged : voice & number 9. Say One , I am clear Two , you are clear Three , everybody is clear

10. Press 2 discharge button simultaneously 11. Check monitor. If VF/VT remains , start CPR for 5 cycles

VF/Pulseless VT

Give 1 shock

Manual biphasic:120-200J Monophasic:360J AED: device specific

Resume CPR immediately

Give 5 cycles of CPR

Shockable rhythm? Shockable Give 1 shock Resume CPR immediately after the shock Vasopressor when IV/IO available
Epinephrine 1mg IV/IO every 3-5 min or Vasopressin 40 U IV/IO

Give 5 cycles of CPR Shockable rhythm? Shockable Give 1 shock Resume CPR immediately after the shock Consider antiarrhythmics

Amiodarone 300 mg IV/IO then consider additional 150 mg IV/IO Lidocaine (1-1.5 mg/kg then 0.5-0.75 mg/kg IV/IO) Magnesium 1-2 g IV/IO for torsades de pointes

Asystole/ PEA

Asystole

Confirm true asystole

Check lead & cable connections Monitor power on? Monitor gain up? Verify asystole in another lead?

Pulseless Electrical activity (PEA)

Electrical mechanical dissociation Treatment goal is to bring back perfusion (pulse and blood pressure) Correct the reversible cause is the key factor for success resuscitation The process is to perform cardiopulmonary support and try to identify and correct the causes

Search for & treat possible contributing factors

5H
Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypoglycemia Hypothermia

5T
Toxins Tamponade (cardiac) Tension pneumothorax Thrombosis (coronary or pulmonary) Trauma (hypovolemia, increased ICP)

Key changes from the 2005 ACLS Guidelines

Continuous quantitative waveform capnography for confirmation and
monitoring of endotracheal tube placement

Emphasize the importance of high-quality CPR (including chest

compressions of adequate rate and depth, allowing complete chest recoil after each compression, minimizing interruptions in chest compressions and avoiding excessive ventilation) management of pulseless electrical activity (PEA)/asystole optimize CPR quality and detect ROSC

Atropine is no longer recommended for routine use in the

There is an increased emphasis on physiologic monitoring to

Cardiac arrhythmia
Tachyarrhythmia Bradyarrhythmia

Approach to cardiac arrhythmia

Rhythm quick look Flat line
Use electrode and look for 2 leads

VF
Rate > 100 Tachycardia Narrow QRS Regular Irregular

QRS complex
Rate < 60 Bradycardia

Look for connection

Wide QRS Regular Irregular

Still flat line = Asystole

SVT

AF
Atrial flutter MAT

VT
SVT with aberrant SVT with BBB

AF with WPW

Tachyarrhythmia

Tachyarrhythmia-Management in CPR
Identify the hemodynamic effects of tachyarrhythmia Electrical therapy should be performed at any time if the patient becomes unstable. Antiarrhythmic medication could be used initially in stable tachyarrhythmia

Unstable Tachycardia

Cardioversion

Step Cardioversion
! Consider sedation 1. Turn on or Monitor on

2. Attach monitor leads

3. Press sync button at control panel

4. Look for marker on R wave

5. Adjust monitor gain until sync marker occur

6. Select energy level and charge

7. Apply gel and place paddle at correct position 8. Clear : One , Two , Three

9. Press discharge botton 10. Analyze rhythm again

Narrow regular 50-100 j Narrow irregular 120-200 j (Bi), 200 j (Mo) Wide regular 100 j Wide irregular Defib

Synchronized

Stable Tachycardia

Narrow QRS complex Wide QRS complex

Narrow QRS-Complex Tachycardia

Narrow Complex Tachycardia

Regular

Irregular
P wave

No P wave
-AF

Sinus tachycardia A.Flutter 2:1

-PAC -MAT -AT with block -A.Flutter + block

PSVT
-AVNRT -AVRT -AT

Irregular Narrow QRSComplex Tachycardia

Atrial Fibrillation (AF)

Irregular rhythm Not seen P wave (fibrillate baseline) Atrial rate ~350500/min Ventricular rate variable

Atrial Fibrillation (AF)

Irregular rhythm Not seen P wave (fibrillate baseline) Atrial rate ~350-500/min Ventricular rate variable

Atrial Flutter
Regular or irregular rhythm Atrial rate 250350/min Ventricular rate 1/2, 1/3, of atrial rate Saw tooth appearance AV block 2:1, 3:1,

Atrial Flutter

Regular or irregular rhythm

Atrial rate 250-350/min

Ventricular rate 1/2, 1/3, of atrial rate Saw tooth appearance AV block 2:1, 3:1,

Recommendations for Pharmacological or Electrical Cardioversion of AF

Class I 1. Immediate electrical cardioversion in patients with paroxysmal AF and a rapid ventricular response who have ECG evidence of acute MI or symptomatic hypotension, angina, or HF that does not respond promptly to pharmacological measures. (Level of Evidence: C ) 2. Cardioversion in patients without hemodynamic instability when symptoms of AF are acceptable. (Level of Evidence: C )

Electrical cardioversion
Synchronized mode, Initial energy 200 J Increments of 100 J until a maximum of 400 J Lower energies are required with biphasic waveforms Interval between 2 consecutive shocks should not be < 1 min.

Risk & Complication of electrical cardioversion

Embolism 1-7% : if no prophylactic anticoagulant before cardioversion Arrhythmia Hypokalemia Digitalis intoxication Myocardial Injury Transient ST elevation and small increased blood level of CK-MB. Probably not clinically significant

Prophylaxis of Thromboembolism before Cardioversion

Anticoagulate patients with AF lasting more than 48 h or of unknown duration, for at least 3 to 4 weeks before and after cardioversion (INR 2 to 3). Screening for the presence of thrombus in the LA or LAA by TEE is an alternative for routine preanticoagulation in candidates for cardioversion of AF.

Medical conversion Atrial fibrillation

Typical Doses of Drugs Used to Maintain Sinus Rhythm in Patients With Atrial Fibrillation

Anticoagulant
CHADS2 ( CHF , HT , age > 75 yrs , DM ,

stroke ) 2

no contraindication

keep INR

2-3

Vascular disease (prior MI, PAD, Aortic plaque )

ESC 2010

Regular Narrow QRSComplex Tachycardia

Paroxysmal Supraventricular Tachycardia (PSVT)

Rate ~150-250/min, Regular rhythm Abrupt onset & termination Not seen sinus P wave (usually not seen P wave or retrograde P wave) Usually narrow QRS complex

Paroxysmal Supraventricular Tachycardia (PSVT)

Rate ~150-250/min, Regular rhythm

Usually narrow QRS complex

Abrupt onset & termination Not seen sinus P wave (usually not seen P wave or retrograde P wave)

Management
Unstable VS : sedation+Cardioversion synchronized
biphasic 50-100 j , adenosine

Stable VS : Adenosine
6 mg rapidly iv if ineffective within 1-2 min give 12 mg Nausea,light-headedness,flushing Contraindication in asthma, second or third degree AV

block , sick sinus syndrome

Management
Diltiazem
0.25 mg/kg over 2 min, further 0.35 mg/kg after 15 min if

required Initial infusion 5-10 mg/hr , increased 5-15 mg/hr up to 24 hr, maintainance 120-360 mg oral daily

Verapamil
5-10 mg slowly iv (over 2-3 min) repeated 10 mg in 10-

15 min , oral maintainance 120-480 mg daily divided in 3-4 doses Contraindication in hypotension , bradycardia , wide complex tachycardia , VT

Regular

Narrow QRS

Irregular

Attempt vagal maneuvers Give adenosine 6 mg IV push. If no conversion give 12 mg IV push Convert?
Converts

Irregular Narrow-Complex Tachycardia AF/atrial flutter/MAT Consider expert consultation Control rate

Does not convert

If rhythm converts Probable reentry SVT

If rhythm does not convert Possible atrial flutter, atrial tachycardia, junctional tachycardia

Wide QRS-Complex Tachycardia

Approach to wide complex tachycardia

History of MI favor VT Age,rate and hemodynamic cannot differentiate Differential diagnosis of wide complex tachycardia 1) Ventricular tachycardia 2) SVT with aberrant conduction 3) SVT with preexisting bundle branch block 4) circus movement tachycardia in WPW

Clues for VT
AV dissociation Fusion beat Capture beat Axis : No mans land , LBBB with RAD QRS morphology Precordial concordance : negative specific more than positive

AV dissociation in VT

VA conduction are also seen

Positive concordance

VT No mans land

Management
Amiodarone
Oral loading dose 1200-1600 mg daily , maintainance

200-400 mg daily Intravenous loading 150 mg over 10 min then 360 mg over 6 hr then 560 mg over remaining 18 hr then 0.5 mg/min Contraindication in severe bradycardia , prolong QT

Ventricular Tachycardia (VT)

Regular rhythm (may be slightly irregular) Rate ~150-250/min Wide QRS complex

Polymorphic VT
Like VT but QRS complexes different in morphology Typical: QRS complexes spiral around the baseline, changing their axis and amplitude. Polymorphic VT + prolong QT interval = Torsades de pointes

Bradyarrhythmia

Bradyarrhythmia Sinus node dysfunction

Sinus arrest /pause Sinus exit block Sinus bradycardia Tachy-brady syndrome

AV block
1st degree AV block 2nd degree AV block
2nd degree AV block type I 2nd degree AV block type II 2nd degree AV block 2:1 Advanced 2nddegree AV block

3nd degree AV block

Escape Rhythms
Escape beats= rescuing beats originating outside the sinus node AV Node (junctional rhythm): 40 to 60 beats/minute , narrow QRS Ventricles: 30 to 40 beats/minute , wide QRS

Sinus bradycardia Sinus rhythm Rate<60/min

Sinus Arrest and SA Exit Block

Tachy-brady syndrome

Junctional rhythm

Junctional rhythm
Rate 40-60/min Most often not seen P wave (Occasional retrograde P wave) Narrow QRS complex

Idioventricular rhythm
Rate 30-40 /min Wide QRS complex

AV Block
First degree AV block Second degree AV block Type I (Wenchkebach) Type II 2:1 second degree AV block Advanced second degree AV block Third degree AV block

1st DEGREE AV BLOCK

PR interval >0.2 sec All beats are conducted through to the ventricle

2nd DEGREE AV BLOCK: Mobitz type I (Wenckebach)

Progressive prolongation of the PR interval until a QRS is dropped

2nd DEGREE AV BLOCK: Mobitz type II

QRS complexes are dropped at regular intervals without prolongation of the PR interval

2nd DEGREE AV BLOCK 2:1

2 sinus P wave: 1 QRS complex Constant PR interval (Impossible to tell whether it is Mobitz I or II)

High grade AV block (Advanced AV block)

3:1 AV block Constant PR interval

Third degree AV block

No beats are conducted through to the ventricles. AV dissociation: atrium and ventricles are driven by independent pacemakers

Bradycardia Algorithm

Bradycardias slow (rate < 60 bpm) relatively slow Primary CAB survey

NO

Serious signs or symptoms ? Due to Bradycardia ?

YES

Type II second-degree AV block Third-degree AV block NO YES

Intervention sequences Atropine 0.5-1 mg Transcutaneous pacing Dopamine 5-20 ug/kg/min Epinephrine 2-10 ug/min Isoproterenol 2-10ug/kg

Observe

Prepare for transvenous pacer If symptoms develop, transcutaneous pacing ----> transvenous pacing placed

Search for & treat possible contributing factors

5H
Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypoglycemia Hypothermia

5T
Toxins Tamponade (cardiac) Tension pneumothorax Thrombosis (coronary or pulmonary) Trauma (hypovolemia, increased ICP)

Transcutaneous Pacing

Pacing Control

Pacing Control

Method
1. 2.
3.

4. 5. 6.

Attach electrode. Turn on pacemaker at desire rate. In bradyasystolic arrest, set initial output to maximum; once capture has been confirmed, output until threshold determined. In conscious patient, start with minimum output and until threshold is achieved. Set output at 10-20% above capture threshold. Give sedative & analgesia as needed.

Capture
Definition:Cardiac depolarization and resultant contraction caused by pacemaker stimulus

Acute coronary syndrome

References
Guideline UA/NSTEMI ACC/AHA 2007 Guideline STEMI ACC/AHA 2007 , 2009

Pathophysiology of ACS
Example of atherosclerosis disease progression
Lipid pool Macrophages Stress, tensile, internal Shear forces, external

Large fissure

Occlusive thrombus (STEMI)

Small fissure
Mural thrombus (unstable angina/ NSTEMI)

Fissure

Atherosclerotic plaque

Plaque disruption

Thrombus

Fuster V et al NEJM 1992;326:310318 Davies MJ et al Circulation 1990;82(Suppl II):II38, II46

Spectrum of Acute Coronary Syndrome

Ischemic Discomfort at Rest
No ST Elevation ST Elevation

0.2 mV in V1-3 0.1 mV in other lead >2 contiguous leads

Unstable Angina

Non ST Elevation MI

Q-wave MI

Braunwald E et al. J Am Coll Cardiol 2000;36:9701062.

Diagnosis
Clinical presentation ECG finding Cardiac Biomarker

Clinical presentation
Angina
Retrosternal chest pain, burning, heaviness Radiating to neck,jaw,epigastrium,shoulder ,Lt arm Precipitated by exercise,cold weather,emotional stress Duration < 2-10 min

Rest or unstable angina

Same as angina , more severe Typical <20 min

Acute myocardial infarction

Same as angina , more severe Sudden onset, often with shortness of breathing,weakness, nausea , vomitting Usually lasting 30 min or longer

Pericarditis
Sharp, pleuritic pain Aggravated by changes in positions, variable in duration, pericardial friction rub Braunwald s Heart disease ,textbook of cardiovascular medicine eight edition

ED Evaluation of Patients With STEMI

Differential Diagnosis of STEMI: Life-Threatening
Aortic dissection
Pulmonary embolus Perforating ulcer

Tension pneumothorax
Boerhaave syndrome (esophageal rupture with

mediastinitis)

ED Evaluation of Patients With STEMI

Differential Diagnosis of STEMI: Other Noncardiac
Gastroesophageal reflux (GERD) and spasm Cervical disc or neuropathic pain

Chest-wall pain
Pleurisy Peptic ulcer disease

Biliary or pancreatic pain

Somatization and psychogenic pain disorder

Panic attack

ECG finding
ST Elevation
> 0.2 mV in leads V1-3 > 0.1 mV in other leads Elevation in at least 2 contiguous leads

Comparison of EKG Changes Associated with Acute Pericarditis, Myocardial Infarction and Early Repolarization
ECG Finding
ST-segment shape Q waves Reciprocal STsegment changes Location of STsegment elevation ST/T ratio in lead V6 Loss of R-wave voltage PR-segment depression

Acute Pericarditis
Concave upward Absent Absent

Myocardial Infarction
Convex upward Present Present

Early Repolarization
Concave upward Absent Absent

Limb and precordial leads >0.25 Absent Present

Area of involved artery N/A Present Absent

Precordial leads

<0.25 Absent Absent

Marriott Practical Electrcaediography 10th edition

Early repolarization

LVH

LBBB

pericarditis

Hyper K

ASMI

Brugada

Acute Inferior wall MI

Acute Anterior wall MI

Wall
Septal Anterior Anteroseptal Extensive anterior Lateral High lateral Anterolateral Inferior RV infarct posterior

ST elevation
V1-V2 V3-V4 V1-V4 V1-V6 V6, I, AVL I, AVL V3-V6, AVL II, III, AVF V3R-V4R Tall R in V1

Corelation of Wall and coronary vessel

Progression of Nonreperfused Qwave AMI

Biochemical Cardiac Markers

ESC/ACCF/AHA/WHF Expert Consensus Document, JACC Vol. 50, No. 22, 2007 :217395

Management
General management
Oxygenation Analgesia NTG Blood sugar control

Specific management
Reperfusion Antiplatelets Anticoagulant Betablocker ACEI/ARB Aldosterone blockade Statin

Analgesia
Morphine remains Class I for STEMI although may increase adverse events in UA/NSTEMI NSAID medications increase mortality, reinfarction, and heart failure in proportion to degree of COX-2 selectivity
Discontinue on admission for STEMI Do not initiate during acute phase of management
ACC/AHA guideline for STEMI 2007

Oxygen
I IIa IIb III

Supplemental oxygen should be administered to patients with arterial oxygen desaturation (SaO2 < 90%).

I IIa IIb III

It is reasonable to administer supplemental oxygen to all patients with uncomplicated STEMI during the first 6 hours.
ACC/AHA guideline for STEMI 2007

Nitroglycerin
I IIa IIb III

Patients with ongoing ischemic discomfort should receive sublingual NTG (0.4 mg) every 5 minutes for a total of 3 doses, after which an assessment should be made about the need for intravenous NTG.

I IIa IIb III

Intravenous NTG is indicated for relief of ongoing ischemic discomfort that responds to nitrate therapy, control of hypertension, or management of pulmonary congestion.
ACC/AHA guideline for STEMI 2007

Nitroglycerin Contraindications
Nitrates should not be administered when:
systolic pressure < 90 mm Hg or to 30 mm Hg below baseline severe bradycardia (< 50 bpm) tachycardia (> 100 bpm) or suspected RV infarction.

Nitrates should not be administered to patients who have received a phosphodiesterase inhibitor for erectile dysfunction within the last 24 hours (48 hours for tadalafil).

Specific management

Reperfusion Options for STEMI Patients

Reperfusion Options for STEMI Patients Select Reperfusion Treatment.

If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.
Fibrinolysis generally preferred Early presentation ( 3 hours from symptom onset and delay to invasive strategy) Invasive strategy not an option Cath lab occupied or not available Vascular access difficulties No access to skilled PCI lab Delay to invasive strategy Prolonged transport Door-to-balloon more than 90 minutes > 1 hour vs fibrinolysis (fibrin-specific agent) now
ACC/AHA guideline for STEMI 2007

Reperfusion Options for STEMI Patients Select Reperfusion Treatment.

If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy. Invasive strategy generally preferred Skilled PCI lab available with surgical backup Door-to-balloon < 90 minutes High Risk from STEMI Cardiogenic shock, Killip class 3 Contraindications to fibrinolysis, including increased risk of bleeding and ICH

Late presentation > 3 hours from symptom onset

Diagnosis of STEMI is in doubt
ACC/AHA guideline for STEMI 2007

Primary PCI
I IIa IIb III

STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 min of first medical contact as a systems goal. STEMI patients presenting to a hospital without PCI capability, and who cannot be transferred to a PCI center and undergo PCI within 90 min of first medical contact, should be treated with fibrinolytic therapy within 30 min of hospital presentation as a systems goal, unless fibrinolytic therapy is contraindicated.
ACC/AHA guideline for STEMI 2007

I IIa IIb III

Application of PCI for STEMI

STEMI
Thrombolysis
Primary PCI Facilitated PCI Success Failure

Routine immediate or urgent PCI

Routine Deferred CAG + PCI

Selective CAG + PCI only for High-risk pts

Rescue PCI

Curr Probl Cardiol, January 2003

Rescue and Late PCI

Assessment of Reperfusion
I IIa IIb III

It is reasonable to monitor the pattern of ST elevation, cardiac rhythm and clinical symptoms over the 60 to 180 minutes after initiation of fibrinolytic therapy. Noninvasive findings suggestive of reperfusion include: Relief of symptoms Maintenance and restoration of hemodynamic and/or electrical instability

Reduction of 50% of the initial ST-segment elevation pattern on follow-up ECG 60 to 90 minutes after initiation of therapy.
ACC/AHA guideline 2007

Rescue PCI
PCI in no reperfusion after fibrinolytic therapy Failed reperfusion

ongoing chest pain resolution of ST elevation < 50 % Early peak of cardiac enzyme Benefit ( Meta-analysis in 2007) Mortality rate 10.4% to 7.3 % ( RR 0.69, 95% CI 0.46-1.05 ; p=0.09) Reinfarction 10.7% to 6.1 % ( RR 0.58, 95% CI 0.35-0.97 ; p=0.04) Heart failure 17.8% to 12.7 % ( RR0.73,95% CI 0.54-1.00 ; p=0.05)

Thrombolytic Therapy
Indications ? Contraindications ? Which drug ? How fast to be given ? Conjunctive antithrombotics ?

Indication for fribinolysis Therapy In STEMI

ST segment elevation > 0.2 mV in leads V1-3 > 0.1 mV in other leads Elevation in at least 2 continuous leads or new LBBB

Duration < 12 hr (class I) 12-24 hr with ongoing pain ( class IIa)

No contraindications

Mortality prediction of STEMI

TIMI Risk Score for STEMI
Historical Age 65-74 75 DM/HTN or angina Exam SBP < 100 HR >100 Killip II-IV Weight < 67 kg Presentation Anterior STE or LBBB Time to rx > 4 hrs 2 points 3 points 1 point 3 points 2 points 2 points 1 point 1 point 1 point Risk Score Odds of death by 30D*

0 1 2 3 4 5 6 7 8 >8

0.1 0.3 0.4 0.7 1.2 2.2 3.0 4.8 5.8 8.8

(0.1-0.2)
(0.2-0.3) (0.3-0.5)

(0.6-0.9)
(1.0-1.5) (1.9-2.6) (2.5-3.6) (3.8-6.1) (4.2-7.8) (6.3-12)

Risk Score = Total

(0 -14)

*referenced to average mortality (95% confidence intervals)

Thrombolytic Therapy
Indications ? Contraindications ? Which drug ? How fast to be given ? Conjunctive antithrombotics ?

Absolute Contraindications for Thrombolytic Rx

Any prior ICH Known structural cerebral vascular lesion Malignant intracranial neoplasm Ischemic stroke within 3 months Suspected aortic dissection Active bleeding diathesis (excluding menses) Significant closed-head or facial trauma within 3 months

Relative Contraindications for Thrombolytic Rx

Chronic severe poorly controlled HTN Severe uncontrolled HTN on presentation SBP>180, DBP>110 Prior ischemic stroke > 3 months, intracranial pathology Traumatic or prolonged >10 min CPR or major surgery within 3 weeks Recent within 2-4 weeks internal bleeding Noncompressible vascular puncture SK, anistreplase: prior exposure > 5 days ago or prior allergic reaction Pregnancy Active peptic ulcer Current use of anticoagulation

Risks for ICH After Thrombolysis

Age > 65 Weight < 70 kg Female Hypertension Use of tPA

Thrombolytic Therapy
Indications ? Contraindications ? Which drug ? How fast to be given ? Conjunctive antithrombotics ?

Thrombolytic Agents
First generation Streptokinase* Urokinase Staphylokinase Second generation APSAC Alteplase* Saruplase Third generation Reteplase* (r-PA) Lanoteplase* (n-PA) TNK-PA Staphylokinase

Thrombolytic Agents in Clinical Practice

SK 1.5 mu IV > 1 hr Accelerated tPA 15 mg IV bolus 50 mg (0.75 mg/kg) IV in 30 min 35 mg (0.5 mg/kg) IV in 60 min

Comparison
Streptokinase
Dose Bolus Admin. Antigenic Allergic React Systemic Fibrinogen Depletion ~90-min patency rates (%) TIMI grade 3 flow, % 1.5 MU over 30-60 min No Yes Yes Marked 50 32

Alteplase
Up to 100mg in 90 min (wt-based) No No No Mild 75 54

Reteplase

Tenecteplase

10U x 2 30-50mg each over 2 min based on weight Yes Yes No No No No Moderate Minimal 75? 60 75 63

Antiplatelets
Aspirin Thienopyridines Glycoprotein IIb/IIIa receptor antagonist

Aspirin
Reduce mortality Reduce coronary reocclusion Reduce recurrent ischemic events

Aspirin
Aspirin should be chewed by patients who

have not taken aspirin before presentation

with STEMI. The initial dose should be 162 mg to 325 mg

Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with nonenteric-coated formulations.
ACC/AHA guideline for STEMI 2007

Complementary Mode of Action between

Clopidogrel and ASA
Clopidogrel is an advanced ADP receptor antagonist and inhibits platelet aggregation by antagonizing the effects of ADP

COX, cyclooxygenase; ADP, adenosine diphosphate; TxA2, thromboxane A2

Schafer AI Am J Med 1996;101:199209

ST-Elevation MI: Clopidogrel Trials

COMMIT / CCS-2
46,000 patients Mortality, D / MI / CVA AMI < 24 hrs Age up to 100 ~ 50% lytic No loading dose China Non-invasive strategy 3,500 Patients Infarct artery patency AMI < 12 hrs Age < 75 100% fibrinolytic Loading dose Europe / N. America Invasive strategy

Thienopyridines
I IIa IIb III

Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. Treatment with clopidogrel should continue for at least 14 days.

I IIa IIb III

ACC/AHA guideline for STEMI 2007

Thienopyridines
I IIa IIb III

In patients < 75 years who receive fibrinolytic therapy or who do not receive reperfusion therapy, it is reasonable to administer an oral clopidogrel loading dose of 300 mg. (No data are available to guide decision making regarding an oral loading dose in patients 75 years of age.) Long-term maintenance therapy (e.g., 1 year) with clopidogrel (75 mg per day orally) can be useful in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy.
ACC/AHA guideline for STEMI 2007

I IIa IIb III

ACC/AHA guideline for STEMI 2009

Anticoagulant

Anticoagulant
Reduce reocclusion Reduce reinfarction Reduce recurrent ischemia

Fondaparinux

Heparin

LMWH
Bivalirudin

Anticoagulants
I IIa IIb III

I IIa IIb III

Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 hours (Level of Evidence: C) and preferably for the duration of the index hospitalization, up to 8 days (regimens other than unfractionated heparin [UFH] are recommended if anticoagulant therapy is given for more than 48 hours because of the risk of heparin-induced thrombocytopenia with prolonged UFH treatment). (Level of Evidence: A) Anticoagulant regimens with established efficacy include: UFH (LOE: C) ACC/AHA guideline STEMI 2007 Enoxaparin (LOE:A) Fondaparinux (LOE:B)

ACC/AHA guideline STEMI 2007

Beta-Blockers

Beta-Blockers
Reduce reinfarct size Reduce reinfarction Reduce life threatening ventricular tachyarrhythmias

Beta-Blockers
I IIa IIb III

Oral beta-blocker therapy should be initiated in the first 24 hours for patients who do not have any of the following: 1) signs of heart failure, 2) evidence of a low output state, 3) increased risk* for cardiogenic shock, or 4) other relative contraindications to beta blockade (PR interval > 0.24 sec, 2nd- or 3rd-degree heart block, active asthma, or reactive airway disease). presentation to STEMI patients who are hypertensive and who do not have any of the following: 1) signs of heart failure, 2) evidence of a low output state, 3) increased risk* for cardiogenic shock, or 4) other relative contraindications to beta blockade (PR interval > 0.24 sec, 2nd- or 3rd-degree heart block, active asthma, or reactive airway disease).
ACC/AHA guideline STEMI 2007

I IIa IIb III It is reasonable to administer an IV beta blocker at the time of

Inhibition of the ReninAngiotensin Aldosterone System

Inhibition of the Renin-AngiotensinAldosterone System

ACEI/ARB
Reduce mortality

Aldosterone blockade
Reduce mortality Reduce hospitalization

ACE/ARB: Within 24 Hours

I IIa IIb III

An ACE inhibitor should be administered orally within the first 24 hours of STEMI to the following patients without hypotension or known class of contraindications: Anterior infarction Pulmonary congestion

LVEF < 0.40

I IIa IIb III

An ARB should be given to ACE-intolerant patients with either clinical or radiological signs of HF or LVEF < 0.40.

ACC/AHA guideline STEMI 2007

Aldosterone blockade

I IIa IIb III

Use of aldosterone blockade in post-STEMI patients without significant renal dysfunction or hyperkalemia is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor and beta blocker, have an LVEF of 40% and have either diabetes or HF.

ACC/AHA guideline STEMI 2007

Statins
Lipid effects
1. Inhibition of cholesterol synthesis 2. Decrease LDL-C 3. Increase HDL-C 4. DecreaseTG

Non-lipid effects

1. Regression of atherosclerosis 2. Plaque stabilization 3. Endothelial function 4. Vasomotor activity 5. Angiogenesis 6. Anti-inflammation 7. Oxidative processes 8. Anti-thrombotic

Cardiol Rev 1999;16(Suppl.):1-6.

Roles of statins in ACS

Improve endothelial function Repair ruptured atherosclerotic plaques

Improve plaque stabilization

Reduce thrombus formation on rupture plaques

Prefer high dose atrovastation 80 mg/day

(MIRACL, PROVE-IT)

Cardiol Rev 1999;16(Suppl.):1-6.

ST elevation ASA, clopidogrel,Beta-blocker,statin

< 12 hours Eligible for thrombolytic Rx
D to N time <30 min

> 12 hours Not candidate for reperfusion Rx No

Thrombolytic Rx contraindicated
D to balloon time 90+30 min

Persistent symptoms
Yes Consider reperfusion Rx

SK If failed SK, rescue (salvage) PTCA

Cardiac cath with primary PTCA

Medical Rx: ACEI, Nitrates

Summary of Pharmacologic Rx: Ischemia

1st 24 h During Hosp Hosp DC + Long Term

Aspirin Clopidogrel Fibrinolytic

162-325 mg
Loading+maintainance

75-162 mg/d p.o. 75-162 mg/d p.o. lifelong 75 mg/d p.o 75 mg/d p.o 2 wk-1 yr, stent

tPA,TNK, rPA, SK
As dose recommended Oral daily
As dose recommended

UFH/LMWH/ fondaparinux Beta-blocker

Oral daily

Oral daily

JACC 2004;44: 671,Circulation 2004;110: 588

Summary of Pharmacologic Rx: LVD, Sec. Prev

1st 24 h Anterior MI, Pulm Cong., EF < 40 ACEI intol., HF, EF < 40 During Hosp Hosp DC + Long Term Oral Daily Indefinitely

ACEI ARB Aldo Blocker

Oral Daily

Statin

Oral daily

No renal dysf, Same as K+ < 5.0 mEq/L during On ACEI, Hosp. HF or DM Oral daily Indefinitely,
LDL <70-100

JACC 2004;44:671 , Circ 2004;110:588

Fast Track MI


checklist


Non invasive procedure Non ST elevation ST Elevation SK

(SK)

SK

Invasive procedure

ICU / CCU

 ............................................................................................................ HN. . . .. . 1. 2. 3. 4. , 5. 20 6. 7. 8. 9. 10. 11. 12. 13. 14. Vital Sign BP_________mmHg, P_________/, R_________/ 15. 16. ER [ 1, 3 5, 8 10, 15 16 (14) SBP 180, SBP < 100, P 100, P 40, R 24, R 6] ECG GP


checklist ER Activate fast track MI

 Acute STEMI (Fast Track) *Onset .............../....................( ER) .............../....................( ER) ECG 12 Lead .............../....................( ER) / / ECG .............../....................()

............................................... HN. . ..................................................

ASA gr V 1 .............../....................( ER) Clopidogrel 4 ( > 75 ) .............../....................( ER) Troponin T .............../....................( ER) .............../....................() ............................................... Admit .............../....................() .............../....................( ER ) ........................................................./....................( Ward) Ward .............../....................( Ward) Ward .........../..........( Ward) ........................... Killip.. * Streptokinase .............../....................( Ward) (Symptom , ECG) Streptokinase 90 .............../....................( Ward) (Major bleeding) ( ) ( ) ........................................................................ ................................................................................ ( ) ( ) ( ) ( ) ............................................. Door to Needle time hr ..min .................................................................................................................................................. ................................................................................................................................................................................................

Fast track MI


checklist ER Activate fast track MI yes Admit ER fast track MI Admit ward fast track MI ECG STEMI ECG no ECG ECG

Caremap standing order D/C

 Acute ST Elevation MI Fast Track

 / (Streptokinase)


Non invasive procedure Non ST elevation ST Elevation SK

(SK) SK

Invasive procedure

ICU / CCU




Contraindication of thrombolytic Acute anterior wall MI killip >III Cardiogenic shock Rescue PCI

 STEMI

 STEMI


1. Acute STEMI 30 2. Acute STEMI 3. Acute STEMI killip classification 4. Major bleeding


1. Acute STEMI 2. Acute STEMI 30 3. Door to EKG time 10 4. Door to Diagnosis time 20

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