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100%
90%
80%
70%
60%
% of Patients
50%
n = 195
40%
30%
20%
10%
0%
<50%
50-70%
>70%
Symptoms of Heart
Attack
Chest discomfort
Jaw or arm discomfort
Shortness of breath
Cold sweat
Upset stomach
Fatigue
Over 25% of patients have no chest discomfort
Heart is not heavily innervated and pain is
typically not severe
ECG Criteria
Chest x-raycardiomegaly
Markedly elevated
cardiac enzymes
Elevated BUN
Hemodynamic Criteria
Complications
VSD/PMD-rupture
Myocardial rupture
Killip classification
Hemodynamic classification
Mechanical complications
Continuing Medical Implementation
...bridging the care gap
Clinical Signs of LV
Dysfunction
Hypotension
Pulsus alternans
Reduced volume
carotid
LV apical
enlargement/displace
ment
Sustained apex - to
S2
Soft S1
Paradoxically split S2
S3 gallop
(not S4 = impaired
LV compliance)
Mitral regurgitation
Pulmonary congestion
rales
% patients
Mortality (%)
30-50
33
15-20
15
40
IV Cardiogenic shock
10
80-100
I No CHF
Figure 6
2 points
3 points
1 point
3 points
2 points
2 points
1 point
Presentation
Anterior STE or LBBB
Time to rx > 4 hrs
1 point
1 point
(0 -14)
(FRONT)
Risk Score
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)
Acute Mortality
Reduction
Prognosis Post MI
Mortality in the first year post MI
averages 10%
Subsequently mortality 5% per year
85% of deaths due to CAD
50%
of these sudden
50% within first 3 months
33% within the first three weeks
Continuing Medical Implementation
...bridging the care gap
Pre-CCU
CCU
-Block
Medications
(Plavix) 600 mg
Alternative-Prasugrel (Effient) 60 mg
Clopidogrel
11
11.0
10
9.3
Ticagrelor
8
7
6
5
4
3
2
1
0
No. at risk
Ticagrelor 4,201
Clopidogrel 4,229
2
3,887
3,892
4
3,834
3,823
6
Months
3,732
3,730
8
3,011
3,022
10
2,297
2,333
11
12
1,891
1,868
Beta-Blockers
TREATMENT:
EXCLUSION:
Effects of Metoprolol
COMMIT (N = 45,852)
Totality of Evidence (N = 5
Death
13%
P=0.0006
30% relative
increase in
*cardiogenic
shock
ReMI
22%
P=0.0002
VF
15%
P=0.002
*Risk factors for cardiogenic shock :heart failure, age > 70 , systolic blood
pressure < 120, sinus tachycardia > 110 or heart rate < 60, increased time
since onset of STEMI symptoms
Lancet. 2005;366:1622.
Beta-Blockers
Recommendations - Class Ia
(B)
**
Beta-Blockers
Recommendations - Class IIa
(B)
Beta-Blockers
Recommendations - Class III
(A)
IV beta blockers SHOULD NOT be administered
*Risk factors for cardiogenic shock :heart failure, age > 70 , systolic blood
pressure < 120, sinus tachycardia > 110 or heart rate < 60, increased time
since onset of STEMI symptoms
Placebo
Cumulative Incidence (%)
15
17.4%
14.8%
Atorvastatin
10
Time to first occurrence of:
Death (any cause)
Nonfatal MI
Resuscitated cardiac arrest
Worsening angina with new
objective evidence and urgent
rehospitalization
0
0
12
16
Reperfusion
Time is Muscle
Brief Review of
Thrombolytic Trials
GISSI-1: Streptokinase 18% reduction in mortality at 21 d
GUSTO-1: tPA. 15% reduction in 30-day mortality compared
to Streptokinase
GUSTO-3: Reteplase had no benefit over tPA but is easier to
use (double bolus)
ASSENT: TNKase is similar to tPA but with less non-cerebral
bleeding and better mortality with symptoms>4 hrs: Single
bolus, fibrin selective, resistance to PAI-1
*Overall risk of ICH is 0.7%; Strokes occurred in 1.4%
Anticoagulants
Patients undergoing reperfusion with
efficacy include:
UFH (LOE: C)
Enoxaparin (LOE:A)
Fondaparinux (LOE:B)
PCI
N=7739
Fibrinolysis
P<.0001
P<.0001
P=.0002
P=.0003
P<.0001
P=.032
P=.0004
Death
Death,
no shock
data
ReMI
Rec.
Total
Ischemia Stroke
P<.0001
Hem.
Stroke
Major
Bleed
Death
MI
CVA
*Patients with cardiogenic shock or severe heart failure initially seen at a nonPCI-capable hospital should be transferred for cardiac
catheterization and revascularization as soon as possible, irrespective of time delay from MI onsetClass I, LOE: B). Angiography and
revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.
Reperfusion at a NonPCI-Capable
Hospital
Transfer of Patients
With STEMI to a PCICapable Hospital for
Coronary Angiography
After Fibrinolytic
Therapy
Rescue PCI
If evidence of
cardiogenic shock,
severe heart failure
hemodynamically compromising
ventricular arrhythmias.
SACMC Standards
EMS SENDS EKG TO ER MD FROM
FIELD
Scene
SACMC
SACMC average DBT 54 min
Five years of DBT < 90 min
Helicopter
Transfer
Ground/Air Transfer:
Enhance First
Responders
transportation
Early activation of Air
Onsite Helipad:
Availability of Transport