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Treatment of myocardial infarction

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Treatment of myocardial infarction

  1. 1. UNDER THE GUIDANCE OF : Dr. V.KRISHNA RAO PROF & HOD OF EMERGENCY MEDICINE CHAIRPERSON : Dr. B.R. SHIVAKUMAR PROF & HOD OF DEPT OF MEDICINE By, Dr. Mohammed Yaqub Intern (2011 batch) Intern
  2. 2. Prehospital chest pain evaluation and treatment  Prehospital EMS providers … 75 to 325 mg of aspirin (chewed) … non–enteric-coated formulations.  (goal is to quickly block thromboxane A2 formation in platelets)  Previously on NTG : take 1 tab S/L ; Not improving after 5 min Seek medical help
  3. 3. Fibrinolysis preferred  Early presentation (≤3hr from symptom onset and delay to invasive strategy)  Invasive strategy is not an option Catheterization laboratory occupied or not available Vascular access difficulties Lack of access to a skilled PCI laboratory  Delay to invasive strategy Prolonged transport (Door-to-balloon)–(door-to-needle) more than 1hr Medical contact-to-balloon or door-to-balloon more than 90 min
  4. 4. Invasive strategy preferred  Skilled PCI laboratory is available with surgical backup Medical contact-to-balloon or door-to-balloon less than 90min  High risk from STEMI Cardiogenic shock Killip class ≥ 3  Contraindications to fibrinolysis  Late presentation (> 3 hr)  Diagnosis of STEMI is in doubt
  5. 5. Initial recognition and management in ER 1. Airway, Breathing, Circulation (ABC) 2. Vital signs, general observation 3. Presence or absence of jugular venous distension 4. Pulmonary auscultation for rales 5. Cardiac auscultation for murmurs and gallops 6. Presence or absence of stroke
  6. 6. Laboratory Investigations (should be performed, but should not delay the implementation of reperfusion therapy.)  ECG  Serum biomarkers for cardiac damage  Complete blood count (CBC) with platelets  International normalized ratio (INR)  Activated partial thromboplastintime (aPTT)  Electrolytes and magnesium  Blood urea nitrogen (BUN),creatinine  Glucose  Complete Lipid Profile
  7. 7. Control of cardiac pain  Pain contribute to the heightened sympathetic activity  Typically accomplished with combination of nitrates, analgesics, oxygen and β-blockers  Oxygen Arterial oxygen desaturation (SaO2< 90%) Uncomplicated STEMI during the first 6 hours
  8. 8. Control of cardiac pain Nitroglycerin  Patients with ongoing ischemic discomfort s/l 0.4 mg every 5 minutes for a total of 3 doses  Intravenous NTG : 0.6 to 1.2 mg/hour ongoing ischemic discomfort that responds to nitrate therapy control of hypertension  Nitrates should not be administered to patients with: systolic pressure < 90 mm Hg or ≥ to 30 mm Hg below baseline severe bradycardia(< 50 bpm) tachycardia (> 100 bpm) suspected RV infarction. who have received a phosphodiesterase
  9. 9. Control of cardiac pain Analgesia  Morphine sulfate (2 to 4 mg intravenously) NSAIDS Increase risk of cardiovascular events so should be discontinued [A sub study analysis from the ExTRACTTIMI- 25trial showed increased risk of death, reinfarction, heart failure, or shock among patients on NSAID is within 7 days of enrollment].
  10. 10. Reperfusion therapy  The principal goal of fibrinolysis is prompt restoration of full IRA patency  Streptokinase , tPA(alteplase), TNK(tenecteplase), rPA(reteplase)  TNK and rPA-bolus fibrinolytics  Promote conversion of plasminogen to plasmin, which subsequently lyses fibrin thrombi
  11. 11. Contraindications and cautions for fibrinolysis in STEMI Absolute Contraindications:  Any prior intracranial hemorrhage  Known structural cerebral vascular lesion  Known malignant intracranial neoplasm  Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours  Suspected aortic dissection  Active bleeding or bleeding diathesis (excluding menses)  Significant closed-head or facial trauma within 3 months Note: Age restriction for fibrinolysis has been removed compared with prior guidelines.
  12. 12. Relative Contraindications:  Severe uncontrolled hypertension on presentation (SBP > 180 or DBP > 110)  Prior ischemic stroke >3 months  Traumatic or prolonged (> 10 mt.) CPR or major surgery (< 3 weeks)  Recent (< 2 to 4 weeks) internal bleeding  Noncompressible vascular punctures  For streptokinase/anistreplase: prior exposure (> 5 days ago) or prior allergic reaction to these agents  Pregnancy, Active peptic ulcer  Current use of anticoagulants
  13. 13. Choice of fibrinolytics  WP- 4 hr. t-PA is the preferred treatment  streptokinase t-PA equivalent choices -risk of death is low , and increased risk of ICH .  WP-4 to 12 hr . streptokinase and t-PA are equivalent options, but streptokinase is probably preferable to t- PA because of cost considerations
  14. 14. Assesment of reperfusion after fibrinolysis Noninvasive findings, s/o reperfusion include:  Relief of symptoms  Maintenance and restoration of hemodynamic and/or electrical instability  Reduction of ≥50 % of the initial STE pattern on follow-up ECG 60 to 90 minutes after initiation of therapy
  15. 15. Anticoagulant therapy  Prevention of DVT, pulmonary embolism, ventricular thrombus, cerebral embolization.  Establishing & maintaining patency of IRA.  Trials shown that more prolonged anticoagulant therapy is beneficial (duration of index hospita- lization) in patients receiving thrombolytic therapy
  16. 16.  IV Unfractionated Heparin  Selective Fibrinolytic –Bolus of 60 U/kg (maximum 4000 U) followed by an infusion of 12 U/kg/hr (maximum 1000 U)  Nonselective fibrinolytic agents-who are at high risk for systemic emboli (large or anterior MI, atrialfibrillation (AF), previous embolus, or known LV thrombus).  LMWH-30mg iv followed by 1mg/kg every 12hr
  17. 17. Antiplatelets  Aspirin should be given indefinitely to all STEMI pts. without a true aspirin allergy.  Patients undergoing PCI are also given aspirin loading  Patients not on aspirin therapy should be given non enteric aspirin 325 mg before PCI.  After PCI, use of aspirin should be continued indefinitely  Clopidogrel 300mg loading dose given orally.
  18. 18. Thienopyridines  Addition of P2Y12 inhibitor to aspirin warranted for most patients with STEMI  In patients for whom PCI is planned, clopidogrel should be started and continued.  Patients receiving a stent (BMS or DES) clopidogrel 75 mg daily or prasugrel 10 mg for at least 12 months;  If the risk of bleeding outweighs the anticipated benefit afforded by thienopyridine therapy, earlier discontinuation.  Continuation of thienopyridines beyond 15 months may be considered in patients undergoing DES placement
  19. 19.  Prior history of stroke and TIA for whom primary PCI is planned, prasugrel is not recommended  CABG planned ?... the drug should be withheld for at least 5 days in patients receiving clopidogrel and at least 7 days in patients receiving prasugrel.  Probably indicated in patients receiving fibrinolytic therapy who are unable to take aspirin because of hypersensitivity or GI intolerance
  20. 20. Glycoprotien IIb/IIIa inhibitors  It is reasonable to start abciximab as early as possible before primary PCI (with or without stenting) in patients with STEMI.  Tirofibanor eptifibatide may be considered before primary PCI (with or without stenting) in patients with STEMI.
  21. 21. ß-blockers  Relieve ischemic pain, reduce need for analgesics, reduce infarct size and life-threatening arrhythmias  Contra indications: o signs of heart failure o evidence of a low output state o increased risk for cardiogenic shock o other relative contraindications (PR interval > 0.24 S. 2ndor 3rddegree AV block, or reactive airway disease)
  22. 22.  Favorable effects with metoprolol , atenolol , carvedilol and timolol,  Beta blockers with intrinsic sympathomimetic activity probably should not be chosen.  Trial of esmolol in the presence of relative contraindications.
  23. 23. CCBs  Immediate-release preparation of nifedipine increased risk of in-hospital mortality  Verapamil & diltiazem can be given for relief of ongoing ischemia or slowing of a rapid ventricular response in AF in patients with contraindication to beta blockers.  INTERCEPT trial compared 300mg of diltiazem with placebo and Diltiazem did not reduce cardiac death, nonfatal reinfarction, during a 6-month follow-up
  24. 24. ACE Inhibitors  Improves MI by reducing myocardial remodelling  Recommended <24hrs in patient with acute MI with or without CHF  Captopril 12.5mg
  25. 25. Statins  Atorvastatin 40-80mg <24hrs in patients with ST elevation MI  Besides lowering cholesterol,beneficial affect are also related to direct affects on endothelial function,oxidative stress,inflammation,thrombosis as well as plaque stabilization.
  26. 26. Intensive glucose control in STEMI  It is reasonable to use an insulin based regimen to achieve and maintain glucose levels less than 180 mg/dl while avoiding hypoglycemia for patients with STEMI with either a complicated or uncomplicated course.
  27. 27. Balloon angioplasty
  28. 28. Coronary artery bypass graph (CABG)
  29. 29. ATHERECTOMY Rotational Atherectomy Directional Coronary Atherectomy Extraction Atherectomy
  30. 30. THANK YOU

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