Acute Coronary Syndromes

MI MI 1 1

Objectives
Identify patients with acute coronary syndromes

Outline acute management of unstable angina, non-Q wave and Q-wave myocardial infarction
Identify patients who are candidates for revascularization interventions Recognize high-risk patients and early complications of myocardial infarction

MI MI 2 2

Acute Coronary Syndromes

Overlapping clinical conditions Unstable angina Non-Q-wave myocardial infarction (MI) Q-wave (ST-segment elevation) myocardial infarction Variable degrees of coronary artery occlusion Process of inflammation, platelet activation/ aggregation, thrombus formation, microembolization
MI MI 3 3

Chest Pain Algorithm

Patient with chest pain

History, physical examination, ECG, chest radiograph MI with ST-segment elevation present? Yes To MI algorithm No Unstable angina present No Consider alternative evaluation
MI 4

Unstable Angina and Non-QWave Myocardial Infarction

Evaluation and management similar Preliminary diagnosis Clinical symptoms Risk factors Electrocardiogram Cardiac enzymes Assess short-term risks
MI 5

Chest Pain Algorithm

Unstable angina present Admit, monitor ECG, O2 Aspirin Sublingual or spray nitroglycerin Intravenous nitroglycerin Heparin (unfractionated, low molecular weight) -blocker GP IIb/IIIa inhibitor (high-risk patients) Symptoms relieved? Yes Elective evaluation No (next slide)

MI 6

Chest Pain Algorithm

Symptoms relieved? No Adjust dose of nitroglycerin, -blocker Consider calcium channel blocker Symptoms relieved? Yes Elective evaluation No Emergency consultation/transfer
MI 7

Cautions
Nitroglycerin Avoid decrease in blood pressure 10% Adjust unfractionated heparin infusion -blocker contraindications Heart rate < 60 beats/min Moderate-severe heart failure Atrioventricular block > first degree Systolic blood pressure < 100 mm Hg Peripheral hypoperfusion Bronchospastic disease
MI 8

Q-Wave (ST-segment elevation) Myocardial Infarction

Occlusion of coronary artery by thrombus Progression of necrosis with time Diagnosis Clinical symptoms Electrocardiogram Cardiac enzymes
MI 9

Q-Wave (ST-segment elevation) Myocardial Infarction

Admit, O2 Aspirin Sublingual, spray and/or iv nitroglycerin Morphine Heparin (unfractionated, low molecular weight) -blocker

Candidate for thrombolytic?

No

MI 10

Emergency consultation/transfer for primary PTCA

Definite Indications for Thrombolytic Therapy

Consistent Clinical Syndrome Chest pain, new arrhythmia, unexplained hypotension or pulmonary edema Diagnostic ECG ST elevation 1 mm in 2 contiguous leads or new left bundle-branch block Less than 12 hours since onset of pain
MI 11

Relative Indications for Thrombolytic Therapy

Consistent Clinical Syndrome
Chest pain, new arrhythmia, unexplained hypotension or pulmonary edema Nondiagnostic ECG Left bundle-branch block of unknown duration
MI 12

Absolute Contraindications for Thrombolytic Therapy

History of hemorrhagic stroke Stroke or CVA within 1 year Allergy to the agent Surgery or trauma in past 2 wks Known intracranial neoplasm Suspected aortic dissection Active internal bleeding (except menstruation)

MI 13

Relative Contraindications for Thrombolytic Therapy

Severe uncontrolled hypertension (>180/110 mm Hg) History of chronic severe hypertension CVA or intracerebral pathology > 1 yr ago Current anticoagulant use Recent trauma (within 2-4 weeks) Allergy or prior exposure to streptokinase
MI 14

Relative Contraindications for Thrombolytic Therapy

Active peptic ulcer disease Significant hepatic dysfunction Recent (2-4 weeks) internal bleeding

Bleeding diathesis
Noncompressible arterial or central venous puncture

Pregnancy
MI 15

Q-Wave (ST-segment elevation) Myocardial Infarction

Candidate for thrombolytic? No Emergency consultation/transfer Yes for primary PTCA Thrombolytic agent given Complications of MI Yes Emergency consultation/transfer No Elective evaluation
MI 16

Continuing Therapy
Heparin infusion after thrombolysis (except after streptokinase) Aspirin daily Nitroglycerin for 24- 48 hours

-blocker unless contraindicated Angiotensin-converting enzyme (ACE) inhibitor within first 24 hours Cardiology consultation and/or transfer
MI 17

Complications of Myocardial Infarction

Heart failure: Systolic BP >100 mm Hg Vasodilators Nitroglycerin Nitroprusside Inotropes Dobutamine Milrinone Loop diuretics
MI 18

Complications of Myocardial Infarction

Heart failure: Systolic BP < 90 mm Hg
Vasopressors initially Norepinephrine

Dopamine
Inotropes when BP stable Consider PTCA or intra-aortic balloon pump Cardiology consultation
MI 19

Complications of Myocardial Infarction

Recurrent ischemia or infarction Follow unstable angina algorithm

Cardiology consultation
Consider repeat thrombolysis with non-streptokinase agent

Angioplasty or bypass
MI 20

Complications of Myocardial Infarction

Arrhythmias Prophylactic drugs not recommended Follow ACLS guidelines

MI 21

Perioperative Myocardial Infarction

Peak occurrence on third postoperative day
May be painless or other pain may obscure diagnosis

New or worsening arrhythmias

Pulmonary edema Thrombolysis may be contraindicated Consider primary PTCA
MI 22

Key Points

MI 23