Suryono

6th Surabaya Cardiology Update

Surabaya, Saturday 12th September 2015

How To Manage The Complication of

ACS Patients

Complications in Acute Coronary Syndromes

ACS complication includes :

1. Conduction diturbances

2. Hemodynamic disturbances

3. Mechanical complication

1. Conduction Disturbances

Sinus Bradycardia

Sinus Tachycardia

Atrial Fibrillation

Ventricular Arrhythmias

Heart Block

Sinus Bradycardia

Occurs in 15-25% of AMI, usually inferior wall or RV

Usually transient and resolves within 24 hours

Caused by increased vagal tone, SA node ischaemia,

drugs (BB), reperfusion after fibrinolysis

Treatment :

1. Atropine

2. Temporary pacing

Sinus Tachycardia

Occurs in 30-40% of AMI

Persistent tachycardia more common with larger

MI and anterior MI

Associated with higher morbidity and mortality

Treatment :

Beta Blocker

Atrial Fibrillation

Incidence 5-18%

Usually associated with comorbidities : heart failure,

kidney diseases, hypertension, diabetes, pulmonary

diseases

Treatment :

1. Rate control with BB

2. Amiodarone

Ventricular arrhythmias in STEMI (all

locations) :Non Sustained VT (<30 seconds) :

No treatment unless frequent and symptomatic :

BB, Amiodarone, Procainamide

Sustained MonomorphicVT (>30 seconds)

with hemodynamic symptom :

Usually transient, Due to ischaemia in first 48

hours of AMI

Cardioversion, Amiodarone, Procainamide,

Lidocaine

,

VF :

Usually occurs in 48-72 hours after MI

The persence of ST elevation is the most powerful predictor of

VF

Other predictors : early repolarization, hypokalemia,

hypotension, higher troponins, severe LV dysfunction

Associated with higher in-hospital mortality

Treatment : Defibrillate, Amiodarone, Reperfusion

ICD have been shown to reduce mortality in

post MI pts with EF ≤ 30%

Heart Block of MI

Inferior Wall MI :

1st degree and Weckenbach occur in the AV node and usually due

to RCA occlusion. Usually resolves within 5-7 days. Usually it

requires no treatment.

Anterior Wall MI :

More serious block that occurs below the AV node with wide

QRS

Second Degree type 2 and Third Degree more common

High mortality rate : 80%

Tx : Temporary pacing

2. Hemodynamic Disturbances :Cardiogenic Shock

Causes :

Extensive LV infarction

Mechanical complication

Mortality rate : 80-90%

The larger the infarct the more pump failure occurs

Management of Cardiogenic Shock

(ACC/AHA Guidelines) :

Emergency revascularization with either PCI or CABG

for cardiogenic shock due to pump failure after STEMI

(Class Ib)

Immediate transfer to a PCI-capable facility with one-

site cardiac surgical back up is indicated for patients

with STEMI and CS

Fibrinolytic therapy for patients without

contraindication and when revascularization is not

feasible

Usual medical treatment of STEMI except Beta

Blocker

Inotropic and vassopressor support

IABP (Class IIa)

Especially for RVMI : volume load & avoid diuretic to

keep PWP optimal (usually around 18 mmHg)

Right Ventricular Infarction :

40% incidence with inferior MI :

- Most often proximal RCA occlusion

- Higher mortality when RV infarcted

Pathophysiology of RVMI :

Decreased right ventricular compliance

Reduced RV filling

Decreased RV stroke volume

Decreased LV filling Periferal hypoperfusion : hypotension,

tachycardia

Right Ventricular Infarction :

Diagnosis : clinical triad of Hypotension, Elevated JVP,

Clear lung fields (decreased PWP)

Get right side chest lead (V4R –V6R) with all inferior wall MI

Treatment :

Fluid to increase LV filling

Avoid preload reduction (Nitrat, diuretic)

Inotropes (Dobutamine, Dopamine)

Maintain atrial kick (Cardioversion of AF may be needed)

Temporary pacing if bradycardia

3. Mechanical Complication :

Papillary Muscle Rupture Acute Mitral

Regurgitation

Ventricular Septal Rupture

Ventricular Free Wall Rupture

Cardiac Tamponade

Ventricular Aneurysm

Thromboembolism

Acute Right to Left Shunt Through Foramen

Ovale

Papillary Muscle Rupture Life threathening

It causes Acute Mitral regurgitation

More common in inferior MI

Occurs 2-7 days after MI

Present with : hypotension, acute dyspneu, heart failure

pulmonary edema, new systolic murmur

Diagnosis by : Cardiac echo (TEE or TTE)

Management :

Afterload reduction : Nitroprusside, IABP

Diuretics

Emergent surgery for mitral valve repair (if no papillary muscle

necroses) or replacement

Ventricular Septal Rupture

Occurs equally in anterior and inferior MI :

- Anterior MI : rupture usually in apical septum

- Inferior MI : usually at the base of the heart

- Usually occurs within 3-5 days after MI (sometimes

in first 24 hours)

Risk factor :

- “Wrap around” LAD (ST elevation in anterior and

inferior leads)

- Large infarct

- RV infarction

Present with :

1. Sudden onset of hypotension

2. Biventricular failure (mostly right sided due to left to right shunt)

3. New harsh holosystolic murmur

Diagnosed by :

1. Doppler echo

2. Right heart cath showing left to right shunt through septum

Management :

Afterload reduction (Nitroprusside, IABP)

Diuretics

Inotropes (if cardiogenic shock +)

Surgery repair : Surgery is urgent if shock present but can be delayed

for weeks untill infarct heals if patient stable enough

LV Free Wall Rupture Present in up to 26% of patient who died with AMI

Occurs within 5 days in 50% cases and within 2 weeks in 90%

cases

Risk factors for rupture :

Fibrinolytic therapy (higher incidence than PCI)

No history of angina or previous MI (less collateral circulation)

ST elevation or Q waves on initial ECG

Large infarcts, higher biomarkers

Anterior MI

Age > 70

Female

Complete rupture or Incomplete / subacute rupture

Diagnosed by : echocardiogram, pericardiocentesis if fluid

present, emergency surgery if fluid is blood

Management :

Fluids, Inotropes, Vassopressor

IABP

Surgical repair

Ventricular Aneurysm

Occurs in 8-15% of MI

Diagnose :

oOften prolonged ST elevation following anterior wall

MI

oCardiac enlargement and dyskinetic area on echo

o 3rd and 4th heart sounds, systolic murmur and mitral

regurgitation

Complication with LV aneurysm :

o Heart failure – bulging of aneurysm during systole steals parts of

stroke volume so CO and volume load

o Ventricular arrythmias

o Thromboembolism

o Ventricular rupture

Management :

Afterload reduction (usually with ACEI)

Anti ischaemic medication for angina

Anticoagulation

Surgical aneurismectomy

Thromboembolism

Mural thrombi at the site of infarction (especially

large anterior MI)

In atria during atrial fibrillation

Treatment :

ANTICOAGULANT

Cardiac Tamponade

Occur due to rupture at the site of infarction

Present with : hypotension, JVD, muffled heart sound

Treatment :

Pericardiocentesis

Surgery if blood in pericardium

Acute Right to Left Shunt Through Patent

Foramen Ovale

Rare complication

Presents : Patients with RVMI shown with hypotension, clear

lung fields, and decreased blood saturation (cyanotic)

Diagnosed by : TEE

Management :

Principle : to optimize the right ventricular function to minimize

shunting

Surgical intervention is required, includes :

1. Coronary artery bypass grafting

2. Closure of atrial septal defect

THANKS FOR ATTENTION