ACLS MI

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Acute Coronary Syndromes:

STEMI

Joshua M. Kosowsky, MD

Brigham & Womens Hospital

Emergency Medicine Physician

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ACS Lecture Overview

Definition and pathophysiology

ACS case

Reperfusion therapy

Adjunctive medications

Shock & CHF

Right Ventricular Infarct

AHAACS Prevention Goals

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Acute Coronary Syndrome:

Definition & Pathophysiology

ACS = range of myocardial ischemic states:

Unstable angina Non-ST segment MI STEMI

Pathophysiology:

A

therosclerotic plaque disruption Intracoronary thrombus formation

BMJ 2003;326:1259-1261 (7 June), doi:10.1136/bmj.326.7401.1259

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Yeghiazarians et al., NEJM2000; 342: 101

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65 yo male with 1 hour

of left sided chest pain

Diaphoretic

H/o diabetes and

hyperlipidemia

T: 98.2 HR: 74

BP: 128/69 RR: 20

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How to treat ACS:

** iv and cardiac monitor **

MONA:

M- morphine

O- oxygen

N- nitratesA- aspirin

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Time is Muscle

Door

Data

Decision

Drug/Balloon

Goals:

Lytic therapy: 30 minutesPCI: 90 minutes

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ReperfusionReperfusionSTEMI patients presenting to a hospital with PCISTEMI patients presenting to a hospital with PCIcapability should be treated with primary PCIcapability should be treated with primary PCIwithin 90 minutes of first medical contact.within 90 minutes of first medical contact.

STEMI patients presenting to a hospital withoutSTEMI patients presenting to a hospital withoutPCI capability and who cannot be transferred to aPCI capability and who cannot be transferred to aPCI center for intervention within 90 minutes ofPCI center for intervention within 90 minutes of

first medical contact should be treated withfirst medical contact should be treated withfibrinolytic therapy within 30 minutes of hospitalfibrinolytic therapy within 30 minutes of hospitalpresentation, unless contraindicated.presentation, unless contraindicated.

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII


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Benefit of Thrombolytic Therapy

49

37

8

-14

35

2519 18

BBB Ant

STo

Inf

STo

ST Depr 0-1hr 2-3hr 4-6hr 7-12hr

-20

-10

0

10

20

30

40

50

ECG Findings Time to TreatmentLancet 343:311,1994

Lives Saved per Thousand Treated

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Fibrinolytic Therapy: Indications

ST elevation > 1 mm in 2 contiguous leads

or new or presumed new LBBB.

Signs and symptoms of MI.

Symptoms < 12 hours.

OK even if Q waves have appeared.

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Fibrinolytic Therapy:

Absolute Contraindications

Active internal bleeding

Suspected aortic dissection

Known intracranial neoplasm

Any hemorrhagic stroke ever of other stroke

within the past year.

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Fibrinolytic Therapy:

R

elative Contraindications Severe hypertension on presentation (BP>180/110)

History of chronic severe hypertension

History of priorC

VA

or other intracranial pathology Recent trauma (

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Fibrinolytic Therapy: Risk of

Intracerebral Hemorrhage Overall risk ~0.5%.

Higher risk with :

Age> 65

Weight 180/110

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Measuring Fibrinolytic Success:

No perfect indicators, but use:

Pain resolved?

Amount of ST elevation improved by >70%?

Start to worry if youre not seeing these by 45-60

minutes after the initiation of the lytic.

If no reperfusion, move to rescue angioplasty.

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Benefits relative to lytic therapy:

Successful in >90% of patients

More complete restoration of arterial patency

Less re-occlusion

Fewer strokes

Probably better outcomes in shock

Limitations: Time

Lack of widespread availability

Percutaneous Coronary Intervention

(PCI) inAcute MI

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Facilitated PCIFacilitated PCI

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII A planned reperfusion strategy using fullA planned reperfusion strategy using full--dosedose

fibrinolytic therapy followed by immediate PCI may befibrinolytic therapy followed by immediate PCI may be

harmful.harmful.

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Immediate or EmergencyImmediate or Emergency

Invasive Strategy and Rescue PCIInvasive Strategy and Rescue PCICoronary angiography with intent to perform PCI (orCoronary angiography with intent to perform PCI (oremergency CABG) is recommended for patients whoemergency CABG) is recommended for patients whohave received fibrinolytic therapy and have any of thehave received fibrinolytic therapy and have any of thefollowing:following:

Cardiogenic shock in patients less than 75 years whoCardiogenic shock in patients less than 75 years who

are suitable candidates for revascularization.are suitable candidates for revascularization.

Severe congestive heart failure and/or pulmonary edemaSevere congestive heart failure and/or pulmonary edema

(Killip class III).(Killip class III).

Hemodynamically compromising ventricular arrhythmias.Hemodynamically compromising ventricular arrhythmias.




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Coronary angiography with intent to perform rescue PCI isCoronary angiography with intent to perform rescue PCI isreasonable for patients in who fibrinolytic therapy has failedreasonable for patients in who fibrinolytic therapy has failed

STST--segment elevation

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Anticoagulants as Ancillary TherapyAnticoagulants as Ancillary Therapy

Patients undergoing reperfusion withPatients undergoing reperfusion withfibrinolytics should receive anticoagulantfibrinolytics should receive anticoagulanttherapy for a minimum of48 hours, andtherapy for a minimum of48 hours, and

preferably for the duration of the indexpreferably for the duration of the indexhospitalization, up to 8 days.hospitalization, up to 8 days.

Regimens other than UFH are recommendedRegimens other than UFH are recommended

if therapy is given for more than4

8 hoursif therapy is given for more than4

8 hoursbecause of risk of heparinbecause of risk of heparin--inducedinducedthrombocytopenia.thrombocytopenia.

Regimens with established efficacy include:Regimens with established efficacy include:

UFH, enoxaparin, fondaparinuxUFH, enoxaparin, fondaparinux



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Heparin

Recommended in:

Patients receiving fibrinolytics (not

SK/APSAC) All patients undergoing PCI.

Dosing:

60 unit/kg bolus then 12 units/kg/hr (max4000/1000)

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BetaBeta--BlockersBlockersOral betaOral beta--blocker therapy should be initiated inblocker therapy should be initiated inthe first 24 hours for patients who do not havethe first 24 hours for patients who do not havethe following:the following:

Signs of heart failureSigns of heart failureEvidence of low output stateEvidence of low output state

Increased risk for cardiogenic shockIncreased risk for cardiogenic shockAge >70 yearsAge >70 years

Systolic blood pressure 110 or < 60 bpm)

Increased time since onset of symptoms of STEMIIncreased time since onset of symptoms of STEMIRelative contraindications to betaRelative contraindications to beta--blockadeblockade

PR interval >0.24 secondsPR interval >0.24 seconds

secondsecond-- or thirdor third--degree heart blockdegree heart block

active asthma or reactive airway diseaseactive asthma or reactive airway disease


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BetaBeta--BlockersBlockersIt is reasonable to administer an IV betaIt is reasonable to administer an IV beta--blocker at the time of STEMI presentation toblocker at the time of STEMI presentation topatients who are hypertensive and who do notpatients who are hypertensive and who do nothave any of the following:have any of the following:

Signs of heart failureSigns of heart failure

Evidence of low output stateEvidence of low output state

Increased risk for cardiogenic shockIncreased risk for cardiogenic shock

Other relative contraindications to betaOther relative contraindications to beta--blockadeblockade

IV beta blockers should not be administered to patientsIV beta blockers should not be administered to patientswho have any of the following:who have any of the following:

Signs of heart failureSigns of heart failure

Evidence of low output stateEvidence of low output state

Increased risk of cardiogenic shockIncreased risk of cardiogenic shock

Other relative contraindications to betaOther relative contraindications to beta--blockadeblockade



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Treatment of Shock and CHF

For both, PCI is choice for reperfusion therapy.

CHF:

iv diuretics

nitrates for preload and afterload reduction (keep SBP>90)

consider dobutamine

Hypotension:

if SBP

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Right Ventricular Infarction

Presentation:

ST elevation inferiorly (II, III, AVF)

Hypotension (worse with preload reducing

agents: nitrates, morphine, diuretics)

Classic triad:

Jugular venous distention

Clear lungs

Hypotension

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RV Infarct 10-50% of inferior wall MIs (II,III,AVF)

have associated right ventricular infarct

Contractility of the right ventricle depends

on diastolic pressure and output can

decrease dramatically with decreased

preload (volume) Also increased loss ofAV synchrony

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ST elevation inferiorly in leads II, III, &AVF

ST elevation anteriorly in V1

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To do a right sided EKG

place pre-cordial leads(V1-V6) across the

right side of the chest

in a mirror image ofthe standard left-sided

leads (V1R-V6R)

Lead V4T is placed in the

right 5th intercostal space

at the mid-clavicular line

Standard EKG lead placement

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Key Treatment Points Give IVF to increase preload to treat

hypotension

Increased incidence ofAV block requiring

packing support

Increased in-hospital mortality to

aggressively pursue definitive treatment

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2007 Goals: Secondary Prevention2007 Goals: Secondary Prevention

Smoking:Smoking: Complete cessation, no exposureComplete cessation, no exposureto environmental tobacco smoke.to environmental tobacco smoke.

Blood Pressure Control:Blood Pressure Control:

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2007 Goals: Secondary Prevention2007 Goals: Secondary PreventionWeight Management:Weight Management:

Goals: BMI 18.5Goals: BMI 18.5 -- 24.9 kg/m2 and24.9 kg/m2 and

Waist circumference in men

ACLS MI

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