Early Management of  Suspected Myocardial Infarction DR Ihab Suliman MBBS(KHAR),ECFMG(USA)MRCP(UK), Board Certified nuclea...
Cardiac Risk Factors( CRF ) <ul><li>Family hx (1st degree relative < 55 yrs) </li></ul><ul><li>Smoking * </li></ul><ul><li...
19 years old female,single ,pharmacy student came with chest pain ,LDL 2.0(Never ignore chest pain)
19 years old female,single ,pharmacy student came with chest pain ,LDL 2.0,ECG done on discharge.
Clinical Presentation - Chest Pain <ul><li>Substernal </li></ul><ul><li>Visceral - vague burning, squeezing, tightness, he...
NOT  Suggestive of Cardiac Ischemia: <ul><li>Stabbing, knife-like pain </li></ul><ul><li>Radiation outside cervicothoracic...
Additional History <ul><li>Associated sx: </li></ul><ul><ul><li>SOB, N/V, diaphoresis </li></ul></ul><ul><li>PMH, meds </l...
 
Life-Threatening Causes of CP <ul><li>Cardiac ischemia </li></ul><ul><li>Esophageal rupture </li></ul><ul><li>Aortic disse...
A 26 year old woman presented 1 week post  delivery of her first baby. She has sharp L sided chest pain and she is short o...
Stabilizing Measures for ACS(STEMI) <ul><li>Aspirin 325 mg(saves lives) </li></ul><ul><li>IV: NS or RL KVO </li></ul><ul><...
Diagnostic Approach - EKG <ul><li>Base treatment on hx and clinical setting -  NOT  EKG findings! </li></ul><ul><li>initia...
 
 
Diagnostic Approach - CXR <ul><li>Primary value is to R/O pneumonia, PTX, wide mediastinum </li></ul><ul><li>May see cardi...
26 yr old  thin man with sudden onset of severe R sided  sharp chest pain ,tachypnoeic.
Initial Management: Pain Relief <ul><li>NTG  SL - 0.3-0.4 mg q5 min x 3 </li></ul><ul><li>NTG IV - start at 10-20 mcg/min,...
Initial Management - Anticoagulation <ul><li>Aspirin 325 mg PO </li></ul><ul><ul><li>GIVE TO ALL PTS UNLESS CONTRAINDICATE...
Reperfusion <ul><li>STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within ...
Thrombolytic Therapy <ul><li>PROMPT ADMINISTRATION IS MORE IMPORTANT THAN CHOICE OF AGENT(TPA,SK,TNK) </li></ul><ul><li>AD...
Indications for Thrombolytic Therapy <ul><li>Chest pain >30 min and <12 hrs duration </li></ul><ul><li>ST elevation >1 mm ...
Contraindications to Thrombolytic Therapy <ul><li>altered LOC </li></ul><ul><li>aortic dissection </li></ul><ul><li>CNS ma...
ACE Inhibitors <ul><li>Ace inhibitors should be started and continued indefinitely in all patients recovering from STEMI w...
Beta-Blockers <ul><li>Oral beta-blocker therapy should be initiated in the first 24 hours for patients who do not have the...
Aldosterone Blockade <ul><li>Use of aldosterone blockade in post-MI patients without significant renal dysfunction or hype...
Thienopyridines <ul><li>Clopidogrel (75mg daily) should be added to aspirin in patients with STEMI regardless of whether o...
New Recommendations in 2007 Update for Lipid Management <ul><li>A fasting lipid panel should be assessed in all patients a...
Pitfalls and Pearls <ul><li>Maintain high index of suspicion </li></ul><ul><li>Document risk factors in  every  CP patient...
Pitfalls and Pearls <ul><li>Normal EKG does not R/O AMI </li></ul><ul><li>Single CK-MB does not R/O AMI </li></ul><ul><li>...
QUIZZ <ul><li>QUIZZ </li></ul>
50 years old female with chronic renal failure,chest pain & dizziness she is hypertensive on lisinopril
26  Old army officer had flu last week,felt chest pain while driving his car,pain increased by deep breath,he has no histo...
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Early Treatment Of M Iassir

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Early Treatment Of M Iassir

  1. 1. Early Management of Suspected Myocardial Infarction DR Ihab Suliman MBBS(KHAR),ECFMG(USA)MRCP(UK), Board Certified nuclear cardiology(USA) Associate Consultant Adult Cardiology National Guard Hospital Member of the European Atherosclerosis Society. Member of the European Society of Cardiology. Member of the European working group on Nuclear Cardiology& Cardiac CT. Member of the European Association on Heart failure. Member of the American Society of Cardiovascular CT Member of the American Society of nuclear cardiology
  2. 2. Cardiac Risk Factors( CRF ) <ul><li>Family hx (1st degree relative < 55 yrs) </li></ul><ul><li>Smoking * </li></ul><ul><li>HTN * </li></ul><ul><li>Cholesterol * </li></ul><ul><li>DM * </li></ul><ul><li>Male gender </li></ul><ul><li>Obesity(Beating us) * </li></ul><ul><li>Document CRFs in Every CP Patient! </li></ul><ul><li> (* modifiable risks) </li></ul>
  3. 3. 19 years old female,single ,pharmacy student came with chest pain ,LDL 2.0(Never ignore chest pain)
  4. 4. 19 years old female,single ,pharmacy student came with chest pain ,LDL 2.0,ECG done on discharge.
  5. 5. Clinical Presentation - Chest Pain <ul><li>Substernal </li></ul><ul><li>Visceral - vague burning, squeezing, tightness, heaviness </li></ul><ul><li>Radiates to neck, jaw(very specific for cardiac pain), L shoulder/arm </li></ul><ul><li>Upper abdominal pain - think IMI </li></ul><ul><li>Atypical pain - coronary spasm, female, elderly, DM </li></ul>
  6. 6. NOT Suggestive of Cardiac Ischemia: <ul><li>Stabbing, knife-like pain </li></ul><ul><li>Radiation outside cervicothoracic segments </li></ul><ul><li>Very brief (< 5 sec) </li></ul><ul><li>Pleuritic </li></ul><ul><li>Reproduced by bending or palpation </li></ul><ul><li>Relieved by exertion </li></ul><ul><li>Prompt relief with NTG or O2 </li></ul>
  7. 7. Additional History <ul><li>Associated sx: </li></ul><ul><ul><li>SOB, N/V, diaphoresis </li></ul></ul><ul><li>PMH, meds </li></ul><ul><li>Recent (< 6 mos): </li></ul><ul><ul><li>trauma </li></ul></ul><ul><ul><li>surgery </li></ul></ul><ul><ul><li>bleeding </li></ul></ul>
  8. 9. Life-Threatening Causes of CP <ul><li>Cardiac ischemia </li></ul><ul><li>Esophageal rupture </li></ul><ul><li>Aortic dissection </li></ul><ul><li>Massive Pulmonary embolus </li></ul><ul><li>Tension Pneumothorax </li></ul>
  9. 10. A 26 year old woman presented 1 week post delivery of her first baby. She has sharp L sided chest pain and she is short of breath.
  10. 11. Stabilizing Measures for ACS(STEMI) <ul><li>Aspirin 325 mg(saves lives) </li></ul><ul><li>IV: NS or RL KVO </li></ul><ul><li>O 2 : 4-6 LPM via mask or N.C. </li></ul><ul><li>Monitor (V Fib) </li></ul><ul><li>Pulse ox </li></ul>
  11. 12. Diagnostic Approach - EKG <ul><li>Base treatment on hx and clinical setting - NOT EKG findings! </li></ul><ul><li>initial EKG may be normal in AMI </li></ul><ul><li>>1 mm ST elevation in 2 leads - acute transmural MI </li></ul><ul><ul><li>only seen in 40-50% at presentation </li></ul></ul>
  12. 15. Diagnostic Approach - CXR <ul><li>Primary value is to R/O pneumonia, PTX, wide mediastinum </li></ul><ul><li>May see cardiomegaly (with IHD, HTN, old MI) or CHF </li></ul>
  13. 16. 26 yr old thin man with sudden onset of severe R sided sharp chest pain ,tachypnoeic.
  14. 17. Initial Management: Pain Relief <ul><li>NTG SL - 0.3-0.4 mg q5 min x 3 </li></ul><ul><li>NTG IV - start at 10-20 mcg/min, titrate 5-10 mcg/min q 5-10 min </li></ul><ul><li>Safe w/o hemodynamic monitoring </li></ul><ul><li>Beware hypotension, bradycardia </li></ul>
  15. 18. Initial Management - Anticoagulation <ul><li>Aspirin 325 mg PO </li></ul><ul><ul><li>GIVE TO ALL PTS UNLESS CONTRAINDICATED! </li></ul></ul><ul><ul><li>reduces MI mortality, stroke </li></ul></ul><ul><li>Heparin IV </li></ul>
  16. 19. Reperfusion <ul><li>STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact. </li></ul><ul><li>Modified recommendation </li></ul><ul><li>STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center for intervention within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation, unless contraindicated. </li></ul><ul><li>Modified recommendation </li></ul>I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III
  17. 20. Thrombolytic Therapy <ul><li>PROMPT ADMINISTRATION IS MORE IMPORTANT THAN CHOICE OF AGENT(TPA,SK,TNK) </li></ul><ul><li>ADJUNCTIVE RX FURTHER REDUCES MORTALITY SEEN WITH THROMBOLYTICS ALONE </li></ul>
  18. 21. Indications for Thrombolytic Therapy <ul><li>Chest pain >30 min and <12 hrs duration </li></ul><ul><li>ST elevation >1 mm in two contiguous limb leads </li></ul><ul><li>ST elevation >2 mm in two contiguous chest leads </li></ul><ul><li>New LBBB(previous ECG) </li></ul>
  19. 22. Contraindications to Thrombolytic Therapy <ul><li>altered LOC </li></ul><ul><li>aortic dissection </li></ul><ul><li>CNS mass or bleed </li></ul><ul><li>active GI bleeding </li></ul><ul><li>spinal or cranial surgery w/in 2 mos. </li></ul><ul><li>SBP>200 mmHg, DBP>120 mmHg </li></ul><ul><li>major trauma or surgery w/in 2 wks </li></ul><ul><li>recent head injury </li></ul><ul><li>pregnancy </li></ul><ul><li>anticoagulation </li></ul><ul><li>bleeding disorder </li></ul><ul><li>traumatic CPR </li></ul><ul><li>drug allergy </li></ul><ul><li>(age) </li></ul>
  20. 23. ACE Inhibitors <ul><li>Ace inhibitors should be started and continued indefinitely in all patients recovering from STEMI with LVEF </ 40%, and for patients with preserved LVEF with hypertension, diabetes, or chronic kidney disease, unless contraindicated. </li></ul><ul><li>Modified recommendation </li></ul><ul><li>ACE inhibitors should be started and continued indefinitely in patients recovering from STEMI who are not lower risk unless contraindicated (low risk defined as those with normal LVEF in whom cardiovascular risk factors are well-controlled and revascularization has been performed). </li></ul><ul><li>New recommendation </li></ul><ul><li>Among lower risk patients recovering from STEMI, use of ACE inhibitors is reasonable. </li></ul><ul><li>New recommendation </li></ul>I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B
  21. 24. Beta-Blockers <ul><li>Oral beta-blocker therapy should be initiated in the first 24 hours for patients who do not have the following: </li></ul><ul><ul><li>Signs of heart failure </li></ul></ul><ul><ul><li>Evidence of low output state </li></ul></ul><ul><ul><li>Increased risk for cardiogenic shock </li></ul></ul><ul><ul><ul><li>Age >70 years </li></ul></ul></ul><ul><ul><ul><li>Systolic blood pressure <120 mm Hg </li></ul></ul></ul><ul><ul><ul><li>Sinus tachycardia (heart rate >110 or < 60 bpm) </li></ul></ul></ul><ul><ul><ul><li>Increased time since onset of symptoms of STEMI </li></ul></ul></ul><ul><ul><li>Relative contraindications to beta-blockade </li></ul></ul><ul><ul><ul><li>PR interval >0.24 seconds </li></ul></ul></ul><ul><ul><ul><li>second- or third-degree heart block </li></ul></ul></ul><ul><ul><ul><li>active asthma or reactive airway disease </li></ul></ul></ul><ul><ul><ul><li>Modified recommendation </li></ul></ul></ul>
  22. 25. Aldosterone Blockade <ul><li>Use of aldosterone blockade in post-MI patients without significant renal dysfunction or hyperkalemia is recommended in patients who: </li></ul><ul><li>are already receiving therapeutic doses of an ACE inhibitor and beta blocker </li></ul><ul><li>have a LVEF of less than or equal to 40% </li></ul><ul><li>have either diabetes or HF </li></ul><ul><li>Modified recommendation </li></ul>I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III
  23. 26. Thienopyridines <ul><li>Clopidogrel (75mg daily) should be added to aspirin in patients with STEMI regardless of whether or not reperfusion therapy is received. </li></ul><ul><li>New recommendation </li></ul><ul><li>Treatment with clopidogrel should continue for at least 14 days. </li></ul><ul><li>New recommendation </li></ul><ul><li>In patients taking clopidogrel in whom CABG is planned, the drug should be withheld for at least 5 days (preferably 7 days), unless the urgency for revascularization outweighs the risks of excess bleeding. </li></ul><ul><li>No change in recommendation </li></ul>I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III
  24. 27. New Recommendations in 2007 Update for Lipid Management <ul><li>A fasting lipid panel should be assessed in all patients and within 24 hours of hospitalization, and lipid-lowering medication should be initiated prior to discharge. </li></ul><ul><li>LDL-C should be <100mg/dL, and further reduction to <70mg/dL is reasonable. </li></ul><ul><li>If baseline LDL-C is 70 - 100 mg/dL, it is reasonable to treat to <70 mg/dL. </li></ul>I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B
  25. 28. Pitfalls and Pearls <ul><li>Maintain high index of suspicion </li></ul><ul><li>Document risk factors in every CP patient </li></ul><ul><li>Mentally rule out 5 life-threatening causes in every CP patient </li></ul><ul><li>Stabilize with IV/O 2 /monitor/pulse ox </li></ul>
  26. 29. Pitfalls and Pearls <ul><li>Normal EKG does not R/O AMI </li></ul><ul><li>Single CK-MB does not R/O AMI </li></ul><ul><li>ASA,B-blockers,Clopidogrel plus ACEI lower mortality & CHEAP </li></ul>
  27. 30. QUIZZ <ul><li>QUIZZ </li></ul>
  28. 31. 50 years old female with chronic renal failure,chest pain & dizziness she is hypertensive on lisinopril
  29. 32. 26 Old army officer had flu last week,felt chest pain while driving his car,pain increased by deep breath,he has no history of DM or HTN,nonsmoker,lipid profile LDL 2.0 MMMOL/ L

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