Holistic in Risk factors and Cardiovascular Management Warong Lapanun MD. Cardiology division Bhumibol Adulyadej Hospital ...
 
 
Atherosclerosis
Cross-section through the wall of a healthy artery with intact endothelium, intima and smooth muscle bundles (SEM)
Artery demonstrating endothelial erosion (SEM)
 
Intimal thickening Extralipid pool Fibrous scar
Atheromatous plaque
Plaque Rupture
Coronary occlusion Plaque rupture Occlusive thrombus
Most Myocardial Infarctions Are Caused by Low-Grade Stenoses <ul><ul><li>Pooled data from 4 studies: Ambrose et al, 1988; ...
Features of a Ruptured  Atherosclerotic Plaque <ul><li>Eccentric, lipid-rich </li></ul><ul><li>Fragile fibrous cap </li></...
Plaque rupture triggers <ul><li>Emotional stress </li></ul><ul><li>Physical activity </li></ul><ul><li>Vasospasm </li></ul...
Vulnerable Versus Stable  Atherosclerotic Plaques Libby P.  Circulation.  1995;91:2844-2850. Vulnerable Plaque <ul><li>Thi...
Coronary Remodeling (Adapted from Glagov et al.) Normal vessel Minimal CAD Progression Compensatory expansion maintains co...
Atherosclerosis:  A Progressive Process Disease progression PHASE I: Initiation  PHASE II: Progression  PHASE III: Complic...
IVUS=intravascular ultrasound Nissen S, Yock P.  Circulation 2001 ; 103: 604–616 Angiogram IVUS Little evidence of disease...
Correlation of CT angiography of the coronary arteries with intravascular ultrasound illustrates the ability of MDCT to de...
 
Estimated 10-Year CHD Risk in  55-Year-Old Adults According to Levels of Various Risk Factors :   Framingham Heart Study  ...
CHD Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y Cumulative Hazard (%) Yes No 866 288...
The INTERHEART Study Metabolic risk factors and their influence on the  occurrence of AMI <ul><li>Feb. 1999 to Mar 2003, 1...
The INTERHEART Study Population Attributable Risk (cumulated men& women) <ul><li>Smoking   DM Abdo Obesity Abn Lipids </li...
INTERHEART: Risk of AMI Associated With Risk Factors <ul><li>Risk Factor Control(%)  Case AMI(%) OR ( adj.for age,sex, smo...
 
Discharge Dx
Gender
 
 
Risk factors
Prevalence of RF according to gender
Relationship Between Changes in LDL-C and HDL-C Levels and CHD Risk Third Report of the NCEP Expert Panel. NIH Publication...
CHD Outcomes in Clinical Trials of  LDL Cholesterol-Lowering Therapy   Mean   CHD  CHD    No.   No.   Person-  cholesterol...
Relation Between LDL-Cholesterol Reduction And Risk Of Cardiovascular Events % LDL-C Reduction 10 0 20 40 70 % Reduction I...
Vessel Wall And Endothelial Cell Membrane Changes With Atherogenesis Reproduced from Mason et al.  Circulation .  2004;109...
Role Of Statins In ACS:  Non-Lipid Effects  ( Pleiotropic effects) ADP = adenosine diphosphate; CD40-L = CD40 ligand; IFN ...
Clinical Events Correlate Directly With On-Treatment LDL-Cholesterol Levels P = placebo; S = statin. Reproduced from O'Kee...
ASCOT-LLA: Nonfatal MI And Fatal CAD Primary End Point Adapted from Sever et al.  Lancet .  2003;361:1149, with permission...
Effects of Lipid-Lowering Therapy on CHD Events in Statin Trials 25 20 15 10 5 0 Patients with CHD event (%) 90 110 130 15...
PROVE IT-TIMI 22: A Major Cardiovascular Event Or Death From Any Cause   Primary End Point Adapted from Cannon et al.  N E...
PROVE IT-TIMI 22: Effect Of Different Statin Regimens On LDL Cholesterol And CRP <ul><li>Biological Statin Response Regime...
PROVE IT-TIMI 22: A Major Cardiovascular Event Or Death From Any Cause At Different Censoring Times Reproduced from Cannon...
NCEP-ATP III National Cholesterol Education Program  Adult Treatment Panel III
Evolution of Lipid Management Guidelines ATP I (1988) ATP II (1993) ATP III (2001) Diet; low-dose, nonstatin monotherapy H...
Update to ATP III: Risk Categories, LDL-C Goals Implications of Recent Clinical Trials for the National Cholesterol Educat...
Am J Cardiol. 2004;93: 154-8
 
 
 
 
 
 
 
 
 
 
 
 
HDL LDL TG Total chol
 
 
 
 
 
 
 
 
 
 
 
 
Cardiac Emergency
Cardiac Emergency <ul><li>Acute coronary syndrome </li></ul><ul><li>Arrhythmia </li></ul><ul><li>Hypertensive emergency </...
<ul><li>P :  P recipitating , Position  </li></ul><ul><li>Q : Quality and Quantity </li></ul><ul><li>R : Region, Radiate, ...
<ul><li>Acute myocardial infarction </li></ul><ul><li>Acute aortic dissection </li></ul><ul><li>Acute pulmonary embolism <...
Characteristics of Typical and Atypical angina pectoris (1) <ul><li>Typical </li></ul><ul><ul><li>Substernal </li></ul></u...
Angina chest pain
DDx of AMI  <ul><li>Aortic dissection </li></ul><ul><li>Acute pericarditis </li></ul><ul><li>Acute pulmonary embolism </li...
Atypical symptoms <ul><li>Elderly </li></ul><ul><li>Women </li></ul><ul><li>Diabetes </li></ul><ul><li>Post operation </li...
AMI  Definition •  Chest pain • ECG •  Troponin  positive
STEMI  Blood flow Chest discomfort PMVT, VF Sudden Death M. Ischemia Heart failure Cardiogenic shock Elevated +CK,Trop-T M...
Wave Front Theory LAD occlusion
False +ve Troponin <ul><li>Cardioversion </li></ul><ul><li>Pulmonary embolism </li></ul><ul><li>Tachycardia </li></ul><ul>...
TIMI Risk Score for STEMI ( Total points 0-14 ) <ul><li>Historical Points   </li></ul><ul><li>Age  >  75   3 </li></ul><ul...
Acute antero-lateral MI
Time From Onset of Symptoms Select a reperfusion strategy <12 hours >12 hours <ul><li>How is “onset of symptoms”define d ?...
Select a Reperfusion Strategy <ul><li>Thrombolytic Rx selected: </li></ul><ul><li>( no contraindication) </li></ul><ul><li...
Extensive antero-lateral ischemia
Effect of thrombolytic on mortality according to admission ECG Live save per thousand FTT Collaborative group: Lancet 1994...
Applicability and Efficacy of  Lysis vs PCI 0% 50% 100% 100% 50% 0% Fribrinolysis Primary angioplsty Availability Availabi...
Total ischemic time A B C ER Rx <30min (lytic) <90 min (PCI) CP reperfuse microvascular epicardial
การคัดกรอง
<ul><li>Fast Track MI   </li></ul><ul><li>EKG  ด่วนแพทย์ดูใน  10  นาที </li></ul><ul><li>   ST elevation  ตาม   staff car...
30-day mortality (%) Relationship between 30-day mortality and Door to Balloon time( N=522 ) Berger et al. Circulation 199...
PCI vs Fibrinolysis with fibrin-specific agents
Fribrinolysis is generally preferred if <ul><li>Early presentation  <  3 hr from symptom onset and delay to invasive strat...
Invasive Strategy is  generally preferred if <ul><li>Skilled PCI lab available with surgical backup </li></ul><ul><ul><li>...
Assessment of Reperfusion Option for Patients with   STEMI <ul><li>Step 1: Assess Time and Risk </li></ul><ul><ul><li>Time...
Absolute Contraindication for thrombolytic Rx <ul><li>A: Aortic dissection </li></ul><ul><li>B: Bleeding  ( active in 2-4 ...
 
60 yo man, smoker, 1hr severe CP, BP 100/60
58 yo lady, DM HT, syncope, sweating, CP 2/10, BP 80/60
V4R
 
68 yo man, 3 hrs 8/10 CP, BP 100/60
 
Algorithm for ECG identification  of  the IRA in Anterior MI STE in V 1 , V 2  and V 3 STE in V1 (>2.5 mm)  and AVL or RBB...
A 63 yo lady, 3 hrs 7/10 CP Given Metalalyse + Clexane , continuing chest pain,  VF x II in cath lab
 
 
 
AMI in LBBB <ul><li>Q wave : not be used </li></ul><ul><li>Indicator : Primary ST change </li></ul><ul><ul><li>ST deviatio...
ST  elevation without infarction <ul><li>LVH </li></ul><ul><li>LBBB </li></ul><ul><li>Benign early repolarization </li></u...
ED :55 yo man, 3 hrs Lt. CP 5/10, less with sits forward
GP: 34 yo athlete, anterior CP 3/10, pt. of tenderness Fish hook
60-yo man severe headache and collapsed
 
 
 
Conditions Associated with TDP <ul><li>E’lyte abnormality </li></ul><ul><ul><li>K + ,  Mg ++ ,  Ca  ++ </li></ul></ul><ul>...
Tachycardia with pulse <ul><li>Stable or unstable </li></ul><ul><li>Unstable ( rate usually >150/min) </li></ul><ul><ul><l...
Cardioversion <ul><li>AF : 100,200,300,360 J </li></ul><ul><li>Stable MMVT:100,200,300,360 J </li></ul><ul><li>SVT or A fl...
Stable tachycardia Narrow QRS <ul><li>SVT </li></ul><ul><li>Vagal ma. </li></ul><ul><li>Adenosine </li></ul><ul><li>6/12/1...
SVT after Rx with Adenosine 6mg IV
AF with WPW: How to Rx?  Unstable : Cardioversion 100 J Stable : Amiodarone 150 mg IV
34-yo lady, gen. edema 3 mo.
 
 
Cardiac tamponade
Pericardiocentesis
 
Hemopericardium
23-y-old man with fever 7 day and chest pain
Pericardial fluid
Hypertensive crisis <ul><li>Definition </li></ul><ul><ul><li>Severe elevation in BP ( >220/120 mmHg) </li></ul></ul><ul><u...
Wong, T. Y. et al. N Engl J Med 2004;351:2310-2317 Examples of Mild Hypertensive Retinopathy AV nicking Focal narrowing AV...
Accelerated-malignant HT <ul><li>Fundoscopic changes </li></ul><ul><ul><li>Retinal hemorrhages </li></ul></ul><ul><ul><li>...
HT and autoregulation of CBF <ul><li>CBF : cerebral perfusion pressure ( CPP) </li></ul><ul><li>  CPP= MAP - ICP </li></ul...
Cerebral Autoregulation Mean arterial pressure (mmHg) Cerebral blood flow  (ml/100 gm per min ) 50 100 150 200 150 100 50 ...
Goal of Rx in HT emergency <ul><li>Reduce mean arterial BP no > 25%  </li></ul><ul><ul><li>Within  minutes to 1 hours </li...
Pitfalls in the Rx  <ul><li>Excessive falls in BP should be avoided </li></ul><ul><ul><li>ischemia : Renal, cerebral, card...
Acute ischemic stroke and BP  <ul><li>SBP>220 mmHg  or DBP 120-140 mmHg </li></ul><ul><ul><li>Caution reduction of BP 10%-...
Acute aortic dissection <ul><li>Suspected diagnosis </li></ul><ul><ul><li>   BP to the lowest tolerate level in 15-30 min...
Approach to HT  crisis BP  > 220/120 mmHg Headache No neurosign No target organ damage Urgency Identify the cause and Rx t...
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Emergency Cardiology

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  • Emergency Cardiology

    1. 1. Holistic in Risk factors and Cardiovascular Management Warong Lapanun MD. Cardiology division Bhumibol Adulyadej Hospital Emergency Medicine Lunch Symposium: 2/9/07
    2. 4. Atherosclerosis
    3. 5. Cross-section through the wall of a healthy artery with intact endothelium, intima and smooth muscle bundles (SEM)
    4. 6. Artery demonstrating endothelial erosion (SEM)
    5. 8. Intimal thickening Extralipid pool Fibrous scar
    6. 9. Atheromatous plaque
    7. 10. Plaque Rupture
    8. 11. Coronary occlusion Plaque rupture Occlusive thrombus
    9. 12. Most Myocardial Infarctions Are Caused by Low-Grade Stenoses <ul><ul><li>Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992. (Adapted from Falk et al.) </li></ul></ul><ul><ul><li>Falk E et al, Circulation , 1995. </li></ul></ul>
    10. 13. Features of a Ruptured Atherosclerotic Plaque <ul><li>Eccentric, lipid-rich </li></ul><ul><li>Fragile fibrous cap </li></ul><ul><li>Prior luminal obstruction < 50% </li></ul><ul><li>Visible rupture and thrombus </li></ul>Constantinides P. Am J Cardiol. 1990;66:37G-40G.
    11. 14. Plaque rupture triggers <ul><li>Emotional stress </li></ul><ul><li>Physical activity </li></ul><ul><li>Vasospasm </li></ul><ul><li>Cathecholamines </li></ul>
    12. 15. Vulnerable Versus Stable Atherosclerotic Plaques Libby P. Circulation. 1995;91:2844-2850. Vulnerable Plaque <ul><li>Thin fibrous cap </li></ul><ul><li>Inflammatory cell infiltrates: </li></ul><ul><li>proteolytic activity </li></ul><ul><li>Lipid-rich plaque </li></ul>Lumen Lipid Core Fibrous Cap <ul><li>Thick fibrous cap </li></ul><ul><li>Smooth muscle cells: more extracellular matrix </li></ul><ul><li>Lipid-poor plaque </li></ul>Stable Plaque Lumen Lipid Core Fibrous Cap
    13. 16. Coronary Remodeling (Adapted from Glagov et al.) Normal vessel Minimal CAD Progression Compensatory expansion maintains constant lumen Expansion overcome: lumen narrows Severe CAD Moderate CAD Glagov et al, N Engl J Med , 1987.
    14. 17. Atherosclerosis: A Progressive Process Disease progression PHASE I: Initiation PHASE II: Progression PHASE III: Complication Normal Fatty Streak Fibrous Plaque Occlusive Atherosclerotic Plaque Plaque Rupture/ Fissure & Thrombosis MI Stroke Critical Leg Ischemia Coronary Death Unstable Angina Libby P. Circulation. 2001;104:365-372.
    15. 18. IVUS=intravascular ultrasound Nissen S, Yock P. Circulation 2001 ; 103: 604–616 Angiogram IVUS Little evidence of disease Atheroma No evidence of disease The IVUS technique can detect angiographically ‘silent’ atheroma
    16. 19. Correlation of CT angiography of the coronary arteries with intravascular ultrasound illustrates the ability of MDCT to demonstrate calcified and non-calcified coronary plaques (Becker et al., Eur J Radiol 2000) Non-calcified, soft, lipid-rich plaque in left anterior descending artery (arrow) . The plaque was confirmed by intravascular ultrasound (Kopp et al., Radiology 2004)
    17. 21. Estimated 10-Year CHD Risk in 55-Year-Old Adults According to Levels of Various Risk Factors : Framingham Heart Study A B C D Blood Pressure (mm Hg) 120/80 140/90 140/90 140/90 Total Cholesterol (mg/dL) 200 240 240 240 HDL Cholesterol (mg/dL) 50 50 40 40 Diabetes No No Yes Yes Cigarettes No No No Yes Source: Circulation 1998;97:1837-1847.
    18. 22. CHD Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y Cumulative Hazard (%) Yes No 866 288 852 279 834 234 292 100 The Kuopio Ischaemic Heart Disease Risk Factor Study Unadjusted Kaplan-Meier Curve No. at Risk Metabolic Syndrome Yes Metabolic Syndrome: 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 2.43 (1.64-3.61) Follow-up, Y 866 288 852 279 834 234 292 100 CVD Mortality All Cause Mortality Lakka H-M, et al. JAMA . 2002;288:2709-2716. No 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.55 (1.96-6.43) Follow-up, Y 866 288 852 279 834 234 292 100
    19. 23. The INTERHEART Study Metabolic risk factors and their influence on the occurrence of AMI <ul><li>Feb. 1999 to Mar 2003, 15,000 cases of AMI were compared with 15,000 controls in 52 countries </li></ul><ul><li>The prevalence of modifiable RF, calculation of the population attributable risk (PAR) </li></ul><ul><li>Frequency of RF in total pop. – Frequency of RF in those without MI </li></ul><ul><li>Frequency of RF in total pop. </li></ul>Yusuf S et al. Lancet 2004, 364;937-962
    20. 24. The INTERHEART Study Population Attributable Risk (cumulated men& women) <ul><li>Smoking DM Abdo Obesity Abn Lipids </li></ul><ul><li> PAR in% </li></ul><ul><li>Western Europe 29.3 15.0 63.4 44.6 </li></ul><ul><li>Central Eastern Eu 30.2 9.1 28.0 35.0 </li></ul><ul><li>Middle East 45.5 15.5 25.9 70.5 </li></ul><ul><li>Africa 38.9 16.7 58.4 74.1 </li></ul><ul><li>South Asia 37.4 11.8 37.7 58.7 </li></ul><ul><li>South East Asia+ Japan 36.7 21.0 58.0 67.7 </li></ul><ul><li>Australia+NZ 44.8 7.2 61.3 43.4 </li></ul><ul><li>South America 38.3 17.7 45.5 47.6 </li></ul><ul><li>North America 26.1 13.0 59.5 50.5 </li></ul><ul><li>All 52 countries 36.4 12.3 33.7 64.1 </li></ul>Yusuf S et al. Lancet 2004, 364;937-962
    21. 25. INTERHEART: Risk of AMI Associated With Risk Factors <ul><li>Risk Factor Control(%) Case AMI(%) OR ( adj.for age,sex, smoking) </li></ul><ul><li>Lipid(ApoB/ApoA-1) 20.0 33.5 3.87 </li></ul><ul><li>Current smoking 26.8 45.2 2.95 </li></ul><ul><li>DM 7.5 18.4 3.08 </li></ul><ul><li>HT 21.9 39.0 2.48 </li></ul><ul><li>Abdo. Obesity 33.3 46.3 2.22 </li></ul><ul><li>Psychosocial 2.51 </li></ul><ul><li>Veg.& Fruit daily 42.4 35.8 0.70 </li></ul><ul><li>Exercise 19.3 14.3 0.72 </li></ul><ul><li>Alcohol intake 24.5 24.0 0.79 </li></ul>Yusuf S et al. Lancet 2004, 364;937-962
    22. 27. Discharge Dx
    23. 28. Gender
    24. 31. Risk factors
    25. 32. Prevalence of RF according to gender
    26. 33. Relationship Between Changes in LDL-C and HDL-C Levels and CHD Risk Third Report of the NCEP Expert Panel. NIH Publication No. 01-3670 2001. http://hin.nhlbi.nih.gov/ncep_slds/menu.htm 1% decrease in LDL-C reduces CHD risk by 1% 1% increase in HDL-C reduces CHD risk by 3%
    27. 34. CHD Outcomes in Clinical Trials of LDL Cholesterol-Lowering Therapy Mean CHD CHD No. No. Person- cholesterol Incidence Mortality Intervention trials treated years reduction (%) (% change) (% change) Surgery 1 421 4,084 22 -43 -30 Sequestrants 3 1,992 14,491 9 -21 -32 Diet 6 1,200 6,356 11 -24 -21 Statins 12 17,405 89,123 20 -30 -29 Source: This table is adapted from the meta-analysis of Gordon, 2000.
    28. 35. Relation Between LDL-Cholesterol Reduction And Risk Of Cardiovascular Events % LDL-C Reduction 10 0 20 40 70 % Reduction In Risk Of Nonfatal MI Or CHD Pravastatin LRC-CPPT WOSCOPS CARE POSCH 4S (Simvastatin) 13 26 35 60 % LDL-C Reduction 10 0 20 40 70 % Reduction In Risk Of Nonfatal MI Or CHD (4.5 y) LRC-CPPT ( P >.05) WOSCOPS CARE POSCH ( P >.05) 4S (Simvastatin) 13 26 35 60 * <ul><li>When outcomes at 4.5 y are considered, beneficial effects of statins occurred more rapidly </li></ul><ul><li>These effects may not be entirely cholesterol dependent; *difference possibly due to pleiotropic effects </li></ul>Reproduced from Liao and Laufs. Annu Rev Pharmacol Toxicol . 2005;45:89, with permission from Annual Reviews . www.annualreviews.org. Liao. Am J Cardiol . 2005;96(suppl):24F.
    29. 36. Vessel Wall And Endothelial Cell Membrane Changes With Atherogenesis Reproduced from Mason et al. Circulation . 2004;109(suppl II):II-34, with permission. Mason et al. Am J Cardiol . 2005;96(suppl):11F.
    30. 37. Role Of Statins In ACS: Non-Lipid Effects ( Pleiotropic effects) ADP = adenosine diphosphate; CD40-L = CD40 ligand; IFN = interferon; IL = interleukin; vWF = von Willebrand factor. Reproduced from Ray and Cannon. J Thromb Thrombolysis . 2004;18:89, with permission. Cannon and Ray. Am J Cardiol . 2005;96:54F.
    31. 38. Clinical Events Correlate Directly With On-Treatment LDL-Cholesterol Levels P = placebo; S = statin. Reproduced from O'Keefe et al. J Am Coll Cardiol . 2004;43:2142, with permission. CHD Events (%) 10 9 8 7 6 5 4 3 2 1 0 -1 55 75 95 115 135 155 175 195 LDL Cholesterol (mg/dL) y = 0.0599x - 3.3952 R 2 = 0.9305 P =.0019 AFCAPS-S WOSCOPS-S ASCOT-S ASCOT-P AFCAPS-P WOSCOPS-P Primary prevention: 4-5 yr duration
    32. 39. ASCOT-LLA: Nonfatal MI And Fatal CAD Primary End Point Adapted from Sever et al. Lancet . 2003;361:1149, with permission. Sever et al. Am J Cardiol . 2005;96(suppl):39F. 2 0 1 4 3 Years 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Cumulative Incidence (%) Placebo Atorvastatin 10 mg Number of Events 36% Reduction HR = 0.64 (0.50-0.83) P =.0005 Number of Events 154 100 N=10,305
    33. 40. Effects of Lipid-Lowering Therapy on CHD Events in Statin Trials 25 20 15 10 5 0 Patients with CHD event (%) 90 110 130 150 170 190 210 S = statin-treated P = placebo-treated *Extrapolated to 5 y 4S - P CARE - P LIPID - P 4S - S WOSCOPS - S WOSCOPS - P AFCAPS - P AFCAPS - S LIPID - S CARE - S Primary prevention Simvastatin Pravastatin Lovastatin Modified from Kastelein JJP. Atherosclerosis. 1999;143(suppl 1): S17-S21. HPS - S HPS - P Atorvastatin ASCOT - S * ASCOT - P * Secondary prevention LDL-C (mg/dL)
    34. 41. PROVE IT-TIMI 22: A Major Cardiovascular Event Or Death From Any Cause Primary End Point Adapted from Cannon et al. N Engl J Med . 2004;350:1495, with permission. Ray and Cannon. Am J Cardiol . 2005;96(suppl):54F. 15 0 10 30 25 5 20 Months Of Follow-Up 0 3 9 15 21 6 12 18 24 27 30 Death Or Major Cardiovascular Event (%) Pravastatin 40 mg Atorvastatin 80 mg P =.005 Overall P =.03 n= 4,162 with CHD
    35. 42. PROVE IT-TIMI 22: Effect Of Different Statin Regimens On LDL Cholesterol And CRP <ul><li>Biological Statin Response Regimen Baseline 30 Days 4 Months </li></ul>LDL mg/dL (mean) Pravastatin 40 mg 106 88 97 Atorvastatin 80 mg 106 60 67 P value NS <.001 <.001 CRP mg/L (median) Pravastatin 40 mg 11.9 2.3 2.1 Atorvastatin 80 mg 12.2 1.6 1.3 P value NS <.001 <.001 Cannon et al. N Engl J Med . 2004;350:1495. Ridker et al. N Engl J Med . 2005;352:20. Reproduced from Ray and Cannon. Am J Cardiol . 2005;96(suppl):54F, with permission.
    36. 43. PROVE IT-TIMI 22: A Major Cardiovascular Event Or Death From Any Cause At Different Censoring Times Reproduced from Cannon et al. N Engl J Med . 2004;350:1495, with permission. Ray and Cannon. Am J Cardiol . 2005;96(suppl):54F. Censoring Time Hazard Ratio (95% CI) Risk Reduction (%) Event Rate (%) Atorvastatin Pravastatin 30 days 90 days 180 days End of follow-up 17 1.9 2.2 18 6.3 7.7 14 12.2 14.1 16 22.4 26.3 0.50 0.75 1.0 High-Dose Atorvastatin Better Standard-Dose Pravastatin Better 1.50 1.25
    37. 44. NCEP-ATP III National Cholesterol Education Program Adult Treatment Panel III
    38. 45. Evolution of Lipid Management Guidelines ATP I (1988) ATP II (1993) ATP III (2001) Diet; low-dose, nonstatin monotherapy High-dose statin, combination therapy Low- to moderate-dose statin monotherapy Increasing aggressiveness of cholesterol-lowering therapy The National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP)
    39. 46. Update to ATP III: Risk Categories, LDL-C Goals Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines: Circulation . 2004;110:227-239. <160 <130 <130 <100 (optional <70) LDL-C Goal (mg/dL) > 160 > 130 > 130 > 100 Initial TLC (mg/dl) > 130 (optional 100-129) Moderately high risk: 2+ risk factors (10-year risk 10-20%) > 190 (optional 160-189) Lower risk: 0–1 risk factor >160 Moderate risk: 2+ risk factors (10-year risk  10%) > 100 (optional <100) High risk: CHD or CHD risk equivalents (10-year risk >20%) Consider drug (mg/dl) Risk Category
    40. 47. Am J Cardiol. 2004;93: 154-8
    41. 60. HDL LDL TG Total chol
    42. 73. Cardiac Emergency
    43. 74. Cardiac Emergency <ul><li>Acute coronary syndrome </li></ul><ul><li>Arrhythmia </li></ul><ul><li>Hypertensive emergency </li></ul><ul><li>Aortic dissection </li></ul><ul><li>Cardiac tamponade </li></ul>
    44. 75. <ul><li>P : P recipitating , Position </li></ul><ul><li>Q : Quality and Quantity </li></ul><ul><li>R : Region, Radiate, Refer </li></ul><ul><li>S : Symptom associated </li></ul><ul><li>T : Timing , Terminating </li></ul>Taking Hx of obscure pain
    45. 76. <ul><li>Acute myocardial infarction </li></ul><ul><li>Acute aortic dissection </li></ul><ul><li>Acute pulmonary embolism </li></ul><ul><li>Tension pneumothorax </li></ul>Killer chest pain
    46. 77. Characteristics of Typical and Atypical angina pectoris (1) <ul><li>Typical </li></ul><ul><ul><li>Substernal </li></ul></ul><ul><ul><li>Burning, heavy, or squeezing feeling </li></ul></ul><ul><ul><li>Precipitated by exertion or emotion </li></ul></ul><ul><ul><li>Promptly relieved by rest of NTG </li></ul></ul>
    47. 78. Angina chest pain
    48. 79. DDx of AMI <ul><li>Aortic dissection </li></ul><ul><li>Acute pericarditis </li></ul><ul><li>Acute pulmonary embolism </li></ul><ul><li>Intercostal neuralgia </li></ul><ul><li>Costochondritis </li></ul><ul><li>Abdominal visceral disorders </li></ul><ul><ul><li>PU, Pancreatitis, biliary colic </li></ul></ul>
    49. 80. Atypical symptoms <ul><li>Elderly </li></ul><ul><li>Women </li></ul><ul><li>Diabetes </li></ul><ul><li>Post operation </li></ul>Angina equivalent
    50. 81. AMI Definition • Chest pain • ECG • Troponin positive
    51. 82. STEMI Blood flow Chest discomfort PMVT, VF Sudden Death M. Ischemia Heart failure Cardiogenic shock Elevated +CK,Trop-T M.stunning Consequences after acute coronary artery occlusion NSTEMI ,UA Cardiovascular Research & Prevention Center, Bhumibol Adulyadej hospital
    52. 83. Wave Front Theory LAD occlusion
    53. 84. False +ve Troponin <ul><li>Cardioversion </li></ul><ul><li>Pulmonary embolism </li></ul><ul><li>Tachycardia </li></ul><ul><li>Decompensated heart failure </li></ul><ul><li>Sepsis </li></ul>
    54. 85. TIMI Risk Score for STEMI ( Total points 0-14 ) <ul><li>Historical Points </li></ul><ul><li>Age > 75 3 </li></ul><ul><li>65-74 2 </li></ul><ul><li>DM or HT or 1 </li></ul><ul><li>Angina </li></ul><ul><li>Exam. </li></ul><ul><li>SBP<100 3 </li></ul><ul><li>HR >100 2 </li></ul><ul><li>Killip II-IV 2 </li></ul><ul><li>Wt< 67kg( 150 lb) 1 </li></ul><ul><li>Presentation </li></ul><ul><li>Ant. STE or LBBB 1 </li></ul><ul><li>Time to Rx > 4 hr 1 </li></ul>Risk Score 30-d MR(%) 0 0.8 1 1.6 2 2.2 3 4.4 4 7.3 5 12 6 16 7 23 8 27 >8 36 Morrow et al. Circulaion 2000
    55. 86. Acute antero-lateral MI
    56. 87. Time From Onset of Symptoms Select a reperfusion strategy <12 hours >12 hours <ul><li>How is “onset of symptoms”define d ? </li></ul><ul><li>Why the division between <12 and > 12 hours? </li></ul>
    57. 88. Select a Reperfusion Strategy <ul><li>Thrombolytic Rx selected: </li></ul><ul><li>( no contraindication) </li></ul><ul><li>Front-loaded alteplase or </li></ul><ul><li>Streptokinase or </li></ul><ul><li>Reteplase </li></ul><ul><li>Goal: Door-to-drug<30 min </li></ul><ul><li>Primary PTCA selected: Goal </li></ul><ul><li>Door-to- Balloon < 90 min </li></ul>Contraindication to thrombolyticRX Or Eqivalent alternative
    58. 89. Extensive antero-lateral ischemia
    59. 90. Effect of thrombolytic on mortality according to admission ECG Live save per thousand FTT Collaborative group: Lancet 1994; 343
    60. 91. Applicability and Efficacy of Lysis vs PCI 0% 50% 100% 100% 50% 0% Fribrinolysis Primary angioplsty Availability Availability 10% <50% Treated > 90% TIMI 3 > 90% Treated Reocclusion Stroke 54% TIMI 3 5% 0.1% 10% Reocclusion 1% Stroke 25% Reocclusion
    61. 92. Total ischemic time A B C ER Rx <30min (lytic) <90 min (PCI) CP reperfuse microvascular epicardial
    62. 93. การคัดกรอง
    63. 94. <ul><li>Fast Track MI </li></ul><ul><li>EKG ด่วนแพทย์ดูใน 10 นาที </li></ul><ul><li> ST elevation ตาม staff cardio ทันที </li></ul><ul><li>No ST elevation ………………. MD. </li></ul>
    64. 95. 30-day mortality (%) Relationship between 30-day mortality and Door to Balloon time( N=522 ) Berger et al. Circulation 1999;100:14-20 P=0.001
    65. 96. PCI vs Fibrinolysis with fibrin-specific agents
    66. 97. Fribrinolysis is generally preferred if <ul><li>Early presentation < 3 hr from symptom onset and delay to invasive strategy </li></ul><ul><li>Invasive strategy is not an option </li></ul><ul><ul><li>Cath-lab occupied/not available </li></ul></ul><ul><ul><li>Vascular access difficulties </li></ul></ul><ul><ul><li>Lack of access to a skilled PCI lab </li></ul></ul><ul><li>Delay to invasive strategy </li></ul><ul><ul><li>Prolonged transport </li></ul></ul><ul><ul><li>(D-to-B) - (D-to-N) > 1 hr </li></ul></ul><ul><ul><li>Contact-to-B or D-to-B > 90 min </li></ul></ul>
    67. 98. Invasive Strategy is generally preferred if <ul><li>Skilled PCI lab available with surgical backup </li></ul><ul><ul><li>(D-to-B) - (D-to-N) < 1 hr </li></ul></ul><ul><ul><li>Contact-to-B or D-to-B < 90 min </li></ul></ul><ul><li>Contraindications to fribrinolysis including increased risk of bleeding of ICH </li></ul><ul><li>Late presentation </li></ul><ul><ul><li>The symptom onset was >3 hr ago </li></ul></ul>
    68. 99. Assessment of Reperfusion Option for Patients with STEMI <ul><li>Step 1: Assess Time and Risk </li></ul><ul><ul><li>Time since onset of symptoms </li></ul></ul><ul><ul><li>Risk of STEMI </li></ul></ul><ul><ul><li>Risk of fibrinolysis </li></ul></ul><ul><ul><li>Time required for transport to a skilled PCI lab </li></ul></ul><ul><li>Step 2 : Determine of Fibrinolysis or an Invasive Strategy is preferred </li></ul><ul><ul><li>If presentation in < 3 hr and there is no delay to an invasive strategy, there is no preference for either strategy </li></ul></ul>
    69. 100. Absolute Contraindication for thrombolytic Rx <ul><li>A: Aortic dissection </li></ul><ul><li>B: Bleeding ( active in 2-4 wk or bleeding diathesis) </li></ul><ul><li>C: Cranial : </li></ul><ul><li>Any prior ICH, </li></ul><ul><li>3 mo of ischemic stroke or closed head trauma, </li></ul><ul><li>Intracranial neoplasm </li></ul><ul><li>D: Drug allergy </li></ul>
    70. 102. 60 yo man, smoker, 1hr severe CP, BP 100/60
    71. 103. 58 yo lady, DM HT, syncope, sweating, CP 2/10, BP 80/60
    72. 104. V4R
    73. 106. 68 yo man, 3 hrs 8/10 CP, BP 100/60
    74. 108. Algorithm for ECG identification of the IRA in Anterior MI STE in V 1 , V 2 and V 3 STE in V1 (>2.5 mm) and AVL or RBBB with Q wave or both ST depression (<1 mm) in II, III, and AVF STE in II, III, and AVF Wrap around
    75. 109. A 63 yo lady, 3 hrs 7/10 CP Given Metalalyse + Clexane , continuing chest pain, VF x II in cath lab
    76. 113. AMI in LBBB <ul><li>Q wave : not be used </li></ul><ul><li>Indicator : Primary ST change </li></ul><ul><ul><li>ST deviation in the same( concordant) direction as the major QRS vector </li></ul></ul><ul><li>Concordant ST changes </li></ul><ul><ul><li>elevation > 1 mm concordant with QRS </li></ul></ul><ul><ul><li>ST depression > 1 mm in leads V1, V2, or V3 </li></ul></ul><ul><li>Extremely discordant </li></ul><ul><ul><li>ST elevation > 5 mm discordant with QRS </li></ul></ul>
    77. 114. ST elevation without infarction <ul><li>LVH </li></ul><ul><li>LBBB </li></ul><ul><li>Benign early repolarization </li></ul><ul><li>Brugada’s syndrome </li></ul><ul><li>LV aneurysm </li></ul><ul><li>Acute pericarditis </li></ul><ul><li>Myocarditis </li></ul><ul><li>Ventricular pace rhythm </li></ul>
    78. 115. ED :55 yo man, 3 hrs Lt. CP 5/10, less with sits forward
    79. 116. GP: 34 yo athlete, anterior CP 3/10, pt. of tenderness Fish hook
    80. 117. 60-yo man severe headache and collapsed
    81. 121. Conditions Associated with TDP <ul><li>E’lyte abnormality </li></ul><ul><ul><li>K + , Mg ++ , Ca ++ </li></ul></ul><ul><li>Drug-related </li></ul><ul><ul><li>Antiarrhythmic </li></ul></ul><ul><ul><ul><li>IA, IC, III </li></ul></ul></ul><ul><ul><li>Psychotropic agents </li></ul></ul><ul><ul><li>Organophosphate </li></ul></ul><ul><li>Liquid protein diet </li></ul><ul><li>Cardiac disease </li></ul><ul><ul><li>IHD, myocarditis </li></ul></ul><ul><ul><li>Bradycardia </li></ul></ul><ul><li>CNS disease </li></ul><ul><ul><li>Intracranial lesion </li></ul></ul><ul><ul><li>SAH </li></ul></ul><ul><li>Congenital LQTS </li></ul>
    82. 122. Tachycardia with pulse <ul><li>Stable or unstable </li></ul><ul><li>Unstable ( rate usually >150/min) </li></ul><ul><ul><li>Altered mental status </li></ul></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Signs of shock </li></ul></ul><ul><li>If Unstable  Cardioversion </li></ul>
    83. 123. Cardioversion <ul><li>AF : 100,200,300,360 J </li></ul><ul><li>Stable MMVT:100,200,300,360 J </li></ul><ul><li>SVT or A flutter:50,100,200,300,360 J </li></ul><ul><li>PMVT: Rx as VF </li></ul>Synchronized mode?
    84. 124. Stable tachycardia Narrow QRS <ul><li>SVT </li></ul><ul><li>Vagal ma. </li></ul><ul><li>Adenosine </li></ul><ul><li>6/12/12 mg IV </li></ul>Regular Irregular Regular Irregular Wide QRS <ul><li>AF, Aflutter, MAT: Diltriazem, B-blocker </li></ul><ul><li>MMVT </li></ul><ul><li>Amiodarone 150 mg iv in 10 min repeat as needed </li></ul><ul><li>Cardioversion </li></ul><ul><li>AF with WPW : Amiodarone 150 mg iv </li></ul><ul><li>TDP: MgSO 4 1-2 g iv </li></ul>Treat possible contributing factors: 6H-5T
    85. 125. SVT after Rx with Adenosine 6mg IV
    86. 126. AF with WPW: How to Rx? Unstable : Cardioversion 100 J Stable : Amiodarone 150 mg IV
    87. 127. 34-yo lady, gen. edema 3 mo.
    88. 130. Cardiac tamponade
    89. 131. Pericardiocentesis
    90. 133. Hemopericardium
    91. 134. 23-y-old man with fever 7 day and chest pain
    92. 135. Pericardial fluid
    93. 136. Hypertensive crisis <ul><li>Definition </li></ul><ul><ul><li>Severe elevation in BP ( >220/120 mmHg) </li></ul></ul><ul><ul><li>Sub classified into emergency and urgency </li></ul></ul><ul><li>Hypertensive emergency </li></ul><ul><ul><li>Require an immediate reduction in BP ( 1 hr ) </li></ul></ul><ul><ul><li>Rx IV therapy and in ICU </li></ul></ul><ul><li>Hypertensive urgency </li></ul><ul><ul><li>No evidence of progressive end-organ injury </li></ul></ul><ul><ul><li>Require only gradual reduction in BP in 24-48 hr </li></ul></ul>
    94. 137. Wong, T. Y. et al. N Engl J Med 2004;351:2310-2317 Examples of Mild Hypertensive Retinopathy AV nicking Focal narrowing AV nicking Copper wiring
    95. 138. Accelerated-malignant HT <ul><li>Fundoscopic changes </li></ul><ul><ul><li>Retinal hemorrhages </li></ul></ul><ul><ul><li>Exudates </li></ul></ul><ul><ul><li>Papilledema </li></ul></ul>
    96. 139. HT and autoregulation of CBF <ul><li>CBF : cerebral perfusion pressure ( CPP) </li></ul><ul><li> CPP= MAP - ICP </li></ul><ul><li>MAP = DBP + 1/3 Pulse pressure </li></ul>
    97. 140. Cerebral Autoregulation Mean arterial pressure (mmHg) Cerebral blood flow (ml/100 gm per min ) 50 100 150 200 150 100 50 0 Normotensive Hypertensive Strandgaard S,et al; Br Med J 1:507, 1973
    98. 141. Goal of Rx in HT emergency <ul><li>Reduce mean arterial BP no > 25% </li></ul><ul><ul><li>Within minutes to 1 hours </li></ul></ul>Toward 160/110 mmHg within 2- 6 hours Toward normal BP in 24- 48 hours JNC VII. JAMA 2003;289:2560-2572
    99. 142. Pitfalls in the Rx <ul><li>Excessive falls in BP should be avoided </li></ul><ul><ul><li>ischemia : Renal, cerebral, cardiac </li></ul></ul><ul><ul><li>SL/ short acting Nifedipine: not recommended </li></ul></ul><ul><li>Three exceptions </li></ul><ul><ul><li>Ischemic stroke </li></ul></ul><ul><ul><li>Aortic dissection  SBP should < 100 mmHg (+/-) </li></ul></ul><ul><ul><li>Lower BP for thrombolytic Rx ( Stroke ) </li></ul></ul>
    100. 143. Acute ischemic stroke and BP <ul><li>SBP>220 mmHg or DBP 120-140 mmHg </li></ul><ul><ul><li>Caution reduction of BP 10%-15% </li></ul></ul><ul><ul><li>Carefully monitoring Neuro signs /BP </li></ul></ul><ul><li>DBP> 140 mmHg </li></ul><ul><ul><li>IV infusion of Na nitroprusside </li></ul></ul><ul><ul><li>Reduce BP 10%-15% </li></ul></ul><ul><li>Lytic Rx within first 3 hrs </li></ul><ul><ul><li>>185/110 mmHg : contraindication </li></ul></ul><ul><ul><li>BP > 180/105 mmHg : iv anti HT </li></ul></ul>American Stroke Association. Stroke 2003;34
    101. 144. Acute aortic dissection <ul><li>Suspected diagnosis </li></ul><ul><ul><li> BP to the lowest tolerate level in 15-30 min </li></ul></ul><ul><li>Initial Rx : IV NaNTP and IV Beta-blocker </li></ul><ul><li>Contraindication : hydralazine, nifedipine </li></ul><ul><ul><li>Stimulation of sympathetic activity </li></ul></ul><ul><ul><li>Increase shear stress on the aortic wall </li></ul></ul>
    102. 145. Approach to HT crisis BP > 220/120 mmHg Headache No neurosign No target organ damage Urgency Identify the cause and Rx the cause ( panic, anxiety) Otherwise use oral anti HTagent Neurosign( encep., stroke) Retinopathy gr III, IV severe chest pain ( IHD, dissecting aneu) Pulmonary edema Cathecholamine excess ARF Emergency IV therapy Recheck in 6-24 hr
    103. 146. Question
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