Professional Documents
Culture Documents
ACS;STEMI/NSTEMI; Pathophysiology
Coronary plaque fissuring & rupture Platelet aggregation & activation Activation of coagulation cascade Generation of Thrombin Formation of thrombus Vasospasm Complete occlusion of coronary vessel In absence of collaterals lead to STEMI Partial obstruction--------NSTEMI
Differential Diagnosis
History ECG within 5 minutes of presentation MONA(Previous guidelines) Establishment of eligibility criteria for reperfusion therapy
ST-segment elevation of >1mm in at least two contiguous leads New or presumably new onset LBBB. No contraindication to fibrinolytic therapy. Window period.
Admit in CCU. MONA; Morphine, Oxygen, NG, Aspirin. I/V line. History & Examination ( Rapid ). ECG; Thrombolytic??? Blood chemistry, Cardiac Enzymes. CXR ( Portable ).
ACS; Examination
Not helpful in diagnosis of AMI but it is helpful in
excluding other D/D Heamodynamic status of patient with MI Mechanical complication of MI Evidence of risk factors Evidence of other co-existing disease Risk stratification
Mortality 5% 13.6%
I II
No evid; of HF
85%
III
IV
Pulm; edema
Card; shock
1%
1%
32.2%
57.8%
ACS; Antiplatelates
ACS; Management
Anti-coagulant therapy heparin, low molecular weight heparin (LMWH), warfarin, hirudin, hirulog
Thrombolytics are not indicated lytic agents may stimulate the thrombogenic process and result in paradoxical aggravation of ischemia and myocardial infarction
ACS; Management
Beta Blockers
ACS; Management
a
ACEI
ACS; Management
Nitrates
ACS; Management
Statins
ACS; Management
General care
Diet Bowel Sleep Mobilization DM management if diabetic
UA/NSTEMI; CABG/PCI
Age
Co morbidities Severity of CAD Prior revascularization procedures Technical feasibility Durability of percutaneous revascularization
LMD 3-VD 2-VD with proximal LAD, LVD or ischemia on stress testing.
UA/NSTEMI
DESPITE OPTIMUM MEDICAL TREATMENT PATIENTS ARE AT RISK OF;
RECURRENT ANGINA MI DEATH
UA/NSTEMI;
EARLY DETERMINATION OF CORONARY
ANATOMY MAY IDENTIFY THE PATIENTS THAT WOULD BE MOST APPROPRIATELY TREATED WITH PCI OR SURGICAL REVASCULARIZATION, THEREFORE REDUCING COSTS, HOSPITAL ADMISSIONS AND LENGTH OF STAY
USA/NSTEMI: TREATMENT
THE ULTIMATE GOAL OF TREATMENT IS :
RESTORATION OF MYOCARDIAL
REPERFUSION: STEMI
RESTORATION OF BLOOD FLOW
Targets
Fibrinolytic: Door to needle time <30 minutes
reaction Pregnancy Active peptic ulcer Current use of anticoagulants: Higher the INR, higher the risk of bleeding
PCI
PCI
PCI
THANKYOU