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Management Strategies for ACSACSFibrinolysisPrimary PCIST ElevationNo ST ElevationEarly InvasiveConservativeEarly ConservativeST ElevationFibrinolysisPrimary PCIFacilitated PCIClinical Classification of AMI: Expert ConsensusType ISpontaneous MI related to ischemia due to a primary coronary event such as a plaque erosion and/or rupture, fissuring, or dissectionType 2MI secondary to ischemia due to either O2 demand or decreased supply (coronary artery spasm, coronary embolism, anemia, HTN, hypotension, arrhythmia)Thygesen, K. et.al. Circulation 2007; 116: 2634 2653.Clinical Classification of AMI: Expert ConsensusType 3Sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggestive of myocardial ischemia, accompanied by presumably new ST elevation, or new LBBB, or evidence of fresh thrombus in a coronary a. by angiography and/or at autopsy, but death occurring before blood tests could be obtained, or at a time before the appearance of cardiac biomarkers in the blood.

Thygesen, K. et.al. Circulation 2007; 116: 2634 2653.Clinical Classification of AMI: Expert ConsensusType 4aMI associated with PCIType 4bMI associated with stent thrombosis as documented by angiography or at autopsyType 5MI associated with CABG

Thygesen, K. et.al. Circulation 2007; 116: 2634 2653.

Options for Transport of Patients With STEMI and Initial Reperfusion TreatmentEMS TransportOnset of symptoms of STEMI9-1-1EMSDispatchEMS on-sceneEncourage 12-lead ECGs.Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min.GOALSPCIcapableNot PCIcapableHospital fibrinolysis: Door-to-Needle within 30 min.EMS Triage PlanInter-HospitalTransferGolden Hour = first 60 min.Total ischemic time: within 120 min.Call 9-1-1Call fastPatientEMSPrehospital fibrinolysisEMS-to-needlewithin 30 min.EMS transportEMS-to-balloon within 90 min.Patient self-transport Hospital door-to-balloon within 90 min.Dispatch1 min.5 min.8 min.Symptom RecognitionCall to Medical SystemEDCath LabPreHospitalDelay in Initiation of Reperfusion Therapy

Increasing Loss of Myocytes

Treatment Delayed is Treatment Denied

Differential Diagnosis of Prolonged Chest PainAcute Cerebrovascular DiseaseAortic DissectionAcute Anxiety AttackEsophageal Rupture or SpasmGallbladder DiseasePancreatitisPeptic Ulcer DiseasePericarditisPneumothoraxPulmonary EmbolismSpinal or Chest Wall Disease

Electrocardiographic changesCauses of ST segment ElevationAcute myocardial infarctionBenign early repolarizationLeft bundle branch blockLeft ventricular hypertrophyVentricular aneursymCoronary vasospasmPericarditisBrugada SyndromeSubarachnoid hemorrhageMODIFICRILE ST-T CE SUGEREAZ ISC.MIOCARDIC: modificrile ischemice ale segmentului ST: segment ST orizontal sau descendent, cu sau fr inversia undei T; interval QT posibil prelungit; modificrile ischemice ale undei T:unde T bifazice, cu sau fr subdeniv. ST,unde T simetrice, nalte sau adnc inversate; pot fi prezente modificri reciproce ale undei T (ex. unde T pozitive i nalte n conducerile inf. cu unde T adnc inversate n conducerile ant.);exist i aspectul de pseudonormalizare a undelor T: undele T devin mai puin inversate sau pozitive n timpul ISM acute;se asociaz frecvent i undele U ce devin proeminente, tulburri de conducere (mai ales BRS, Hb.ant.sup.stg.), etc.;atenie! pot exista EKG de repaus normale la pacienii cu leziuni severe coronariene;

MODIFICRILE ST-T CE SUGEREAZ LEZ.MIOCARDIC:supradenivelarea acut a segmentului ST peste 1 mm. cu convexitatea n sus n conducerile ce reprezint aria infarctat,modificri evolutive de ST-T: undele T inversate nainte ca segmentul ST s se rentoarc la nivelul iniial,subdenivelare de segment ST n conducerile ce nu reprezint aria infarctat;atenie! leziunea acut de perete posterior asociaz: subdenivelare orizontal sau descendent de segment ST, unde T pozitive n V1 i/sau V2 , cu und R proeminent n aceleai conduceri;Dg.diferential: segmentul ST poate fi supradenivelat i n:pericardita acut, repolarizarea precoce,anevrism VS, HVS, bloc de ramur,hiperpotasemie, miocardite, CMPH apical,boli ale SNC, etc.

IMA inferior, BRD III, TPSV paroxistica, ST=T mixt

IM anteroseptal

IM anteroseptal (alta virsta)

IMA infero-lateral

PRINCIPALII MARKERI BIOCHIMICI AI NECROZEI MIOCARDICEmarkerapariia iniial (h)timpul mediu de vrfrentoarcerea la valoarea bazalfrecvena de determinare1. Mioglobina1-46-7 h24 hfrecvent, mai ales la 1-2 ore dup AP2. Troponina I3-1224 h5-10 zilecel puin o dat la 12 h dup AP3. Troponina T3-1212 h - 2 zile5-14 zilecel puin o dat la 12 ore dup AP4. CK-MB3-1224 h48-72 hde 3 ori la fiecare 8 h5. LDH1024-48 h10-14 zilecel puin o dat la 24 h dup AP012345678Cardiac troponin-no reperfusion Days After Onset of STEMIMultiples of the URLUpper reference limit125102050URL = 99th %tile of Reference Control Group100Cardiac troponin-reperfusion CKMB-no reperfusion CKMB-reperfusion Cardiac Biomarkers in STEMIAlpert et al. J Am Coll Cardiol 2000;36:959.Wu et al. Clin Chem 1999;45:1104.

ED Evaluation of Patients With STEMIAortic dissectionPulmonary embolusPerforating ulcerTension pneumothoraxEsophageal rupture with mediastinitisDifferential Diagnosis of STEMI: Life-Threatening

URGENELE CARDIACE PROPRIU-ZISE:a. Urgenele cardiace care amenin viaa: internarea de urgen n CCU:AC: FIA nsoit de tracturi de bypass, FLA, tahiaritmii ventriculare cu simptome ;Tulburri de conducere: bloc AV de gradul III cu hipoTA sau IC i/sau scpare ventricular;ISM:durere toracic anterioar puternic i prelungit nsoit de modificri EKG ischemice;IC:apariia unui nou suflu, apariia recent a febrei, evidenta cretere de volum a ascitei i/sau a hidrotoraxului;Cianoza:dispariia unui suflu continuu la bolnavul cu unt central sau unt Blalock-Taussig, infecie pulmonar acut;Cauze noncardiace:hemoptizie repetat, AIT i/sau convulsii repetate recente.b. Urgenele cardiace care nu amenin viaa:AC: FIA fr evidena tracturilor de bypass, EXV izolate, TV asimptomatic i nonsusinut;Tulburri de conducere: bloc AV de gradul III cu hemodinamic normal sau scpare nodal;ISM: durere toracic cronic i cu caracter nonischemic;Cianoz: cianoz cronic;Cauze noncardiace: atac de gut, colic biliar, etc..MONITORIZAREA BOLNAVULUI CRITIC: determin urmtoarele valori principaletensiunea arterial, frecvena cardiac, presiunea de umplere VS, debitul cardiac, rezistena vascular sistemic.

Gastroesophageal reflux (GERD) and spasmChest-wall painPleurisyPeptic ulcer diseasePanic attackCervical disc Neuropathic painBiliary or pancreatic painSomatization and psychogenic pain disorderED Evaluation of Patients With STEMIDifferential Diagnosis of STEMI: Other NoncardiacED Evaluation of Patients With STEMI

PericarditisAtypical anginaEarly repolarizationWolff-Parkinson-White S.Deeply inverted T-waves suggestive of a central nervous system lesion or apical hypertrophicLV hypertrophy with strainBrugada syndromeMyocarditisHyperkalemiaBundle-branch blocksVasospastic anginaHypertrophic cardiomyopathyDifferential Diagnosis of STEMI: Other Cardiovascular and Nonischemic

Sample Admitting Orders for the Patient With STEMI1. Condition: Serious2. Normal Saline or D5W intravenous to keep vein open3. Vital signs: Heart rate, blood pressure, respiratory rate4. Monitor: Continuous ECG monitoring for arrhythmia/ST-segment deviation5. Diet: NCEP ATP III Therapeutic Lifestyle Changes, low sodium diet

Sample Admitting Orders for the Patient With STEMI6. Activity: Bed rest with bedside commode, light activity when stable 7. Oxygen: 2 L/min when stable for 6 hrs, reassess need (i.e., O2 sat < 90%). Consider discontinuing if O2 saturation is > 90%.8. Medications: NTG, ASA, beta-blocker, ACE, ARB, pain meds, anxiolytics, daily stool softener9. Laboratory tests: cardiac biomarkers, CBC w/platelets, INR, aPTT, electrolytes, Mg2+, BUN, creatinine, glucose, serum lipids

Pharmacologic Management of AMIFirst 24 hAfter 24 hrsLong-termAspirinChew 325 mg75-162 qd75-162 mgReperfusiontherapyFibrinolytic or PCIMay repeat for recurrent occlusionHeparin or LMWHUse w/fibrinolytic48 hours w/fibrinolyticWarfarin (for LV thrombus)Beta blockersIV metoprolol (up to 15 mg)Titrate oral beta blockersContinue indefinitelyACE inhibitorsSmall initial doses orallyTitrate oral ACEIContinue indefinitelyNitroglycerinIV for 24-48 hrOnly for ongoing ischemiaSL prnStatinInitiateContinueContinue indefinitely

TT: CRITERII-ex. clinic: durere toracic sau echivalent dureros, consistente pentru IMA < 12 ore de la debutul simptomului/simptomelor asociate cu modificri EKG:-supradenivelarea segmentului ST = sau > de 1 mm. n 2 sau > conduceri vecine ale membrelor;-supradenivelarea segmentului ST = sau > de 2 mm. n 2 sau > conduceri vecine precordiale;-bloc de ramur nou constituit;-n caz de oc cardiogen: cateterizare i revascularizare de urgen, ---dac este posibil; TT de urgen, dac cateterizarea nu este posibil imediat.TT. BENEFICII-reducerea dimensiunii actualului IMA,-realizarea reperfuziei coronariene din zona infarctat (grad TIMI: 1,2,3),-ameliorarea funciei VS i prevenirea remodelrii lui,-prevenirea i reducerea complicaiilor timpurii i tardive,-reducerea reocluziei i a reinfarctizrii timpurii i tardive,-scderea mortalitii post-infarct, precoce i tardive.CI absolute:CI relative:-alterarea strii de contien,-sngerare intern activ, boal de coagulare cunoscut,-traumatism cerebral recent,-AVC hemoragic cunoscut n antecedente,intervenie chirurgical la nivelul mduvei spinrii i intracranian n ultimele 2 luni,-traumatism sau intervenie chirurgical n ultimele 2 sptmni, nsoite de sngerare n spaiu nchis,-TA > 200/120 mmHg.,-sarcin,-suspiciune de disecie de aort,-alergie anterioar la streptokinaz (nu este CI, dac se folosesc alte droguri trombolitice);-boala ulceroas peptic activ,-anamnez de AVC ischemic sau embolic n antecedente,-anticoagulante orale n uz cronic,-traumatisme majore sau intervenii chirurgicale > 2 sptmni i < 2 luni,-HTA cronic i necontrolat medicamentos, tratat sau netratat (TAD > 100 mmHg.),-cateterizare recent la nivelul venei subclavii sau jugulare interne.

ThrombolyticsAbsolute Contraindications

Previous hemorrhagic stroke at any time; or other strokes within one year

Known intracranial neoplasm

Active internal bleeding

Suspected aortic dissectionPrecautionsSevere uncontrolled HTN (BP>180/100mmHg)Current use of anticoagulants in therapeutic dose (INR 2-3)Recent trauma (within 2-4 weeks), including head trauma or traumatic or prolonged CPR or major surgery(