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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
CURRENT MANAGEMENT OF STEMI
I GDE RURUS SURYAWANGILANG M. RAHMAN
Acute thrombosis induced bya ruptured or eroded
atherosclerotic coronaryplaque, with or without
concomitantvasoconstriction, causing a
sudden and critical reductionin blood flow
2Hamm CW et al. Eur Heart J 2011;32:2999 – 3054
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
DEFINITION
“ STEMI is a clinical syndrome characterized byischemic symptom which related to persistent ST
segment elevation in ECG ”
O’Gara et al: J Am Coll Cardiol. 2013 ; 29;:61(4)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Non-Traditional• Homocysteine• Lipoprotein (a)• C-Reactive Protein (CRP)
TraditionalModifiable• Dyslipidemia• Smoking• Hypertension• Diabetes Mellitus• Lack of physical ActivityNon Modifiable• Advanced age• Male Gender• Hereditary
CARDIOVASCULAR RISK FACTOR
PATHOGENESIS
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
PATHOGENESIS
Total Occlusion of Coronary Artery
Vulnerable Plaque Rupture
Thrombus Formation
Endothelial Dysfunction
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 20152015 ESC Guidelines NSTEMI
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
PATHOGENESIS
Myocardial Infarction
Biomarker Release
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
DIAGNOSIS
Typical chest pain persist >20min:• Pain, burning or weight sensation• Radiate to the neck, back or arm• Not relieved by rest or nitrate
Other Symptom:• Shortness of breath• Nausea• Diaphoresis• Palpitation
Usually normal,Sign of Complication;• Tachypnea,• Hypotension• Tachycardia-Bradycardia• Jugular veins distention• Gallop S3• Pulmonary Rales• Systolic Murmur
SYMPTOM SIGN
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
J-point + 0,04 Sec
Baseline
- ST-Elevation in minimaltwo contagious lead≥0,1mV
- In lead V2-V3 :≥0,2 mV in male ≥40 y.o≥0,25 mV in male<40 y.o≥0,15 mV in female
Target:≤10 minutes fromFirst Medical Contact
ESC Guidelines, 2012
DIAGNOSIS
ECG
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
DIAGNOSIS
Biomarker Specificity Onset Peak Duration
CK-MB Less 3-4 hrs 12-24 hrs 48-72 hrs
Troponin T Specific 3-12 hrs 12-24 hrs 8-21 days
Troponin I Specific 3-12 hrs 12-24 hrs 7-11 days
Biomarker
ACLS, 2012
CK-MB or Troponin
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
MANAGEMENT
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Onset ofsymptomsof STEMI
9-1-1EMS
Dispatch
EMS on-scene• Encourage 12-lead ECGs• Consider prehospital fibrinolytic ifcapable and EMS-to-needle within 30 min
EMSTriagePlan
Hospital fibrinolysis :Door-to-Needle within 30 min
Not PCIcapable
PCIcapableGoals†
Total ischemic time: Within 120 min*
EMS transportEMS onscene
P :Patient Dispatch
5 min aftersymptom onset
1 min Within8 min
Pre hospital Fibrinolytic EMS-to-Handle within 30 min
*Golden Hour = First 60 minutes
EMS transport:EMS-to-Balloon within 90 min
Patient self-transport:Hospital Door-to-Balloonwithin 90 min
Emergency Medical System
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
EMERGENCY ROOM
Indicated in patient with hypoxia (Sa02 <95%), dyspnea, and heart failure
• Morphine 4-8 mg i.v• Relieve pain and anxiety• Adverse reaction: Hypotension, respiratory depression, and vomiting
OXYGENATION
INTRAVENOUS OPIOID
ASPIRIN• Aspirin oral (chewable) or i.v should be given in STEMI• Loading dose 300-325 mg , maintenance dose 75-100 mg od
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
EMERGENCY ROOMP2Y12 RECEPTOR BLOCKER
• Ticagrelor & Prasugrel are preferable and recommended in patientswho planned for Primary PCI
• Loading dose Ticagrelor 180 mg or Prasugrel 60 mg• Loading dose Clopidogrel 600 mg (Primary PCI) or 300 mg (Fibrinolysis)
NITRATE
• Short acting nitrates (Nitroglyserin 0,4 mg or ISDN 5 mg S.L) is recommended• Should not be given in : RV infarction is suspected, hypotension, still in effect of
sildenafil/viagra, aorta stenosis, & HOCMBETA BLOCKERS
• Reduce myocardial oxygen demand and incident of lethal arrhythmia• Should not be given in: acute heart failure (Killip >2), significant AV Block,
hypotension (SBP<90mmHg) and bradycardia (<60bpm)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
REPERFUSION THERAPYSTRATEGY
VS
Primary PCI Fibrinolysis
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
ESC GUIDELINES,2012
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
• PCI is indicated for all STEMI patient in onset lessthan 12 hours
• Door to baloon time target is <90 minutes or <60minutes in new onset STEMI with large area at risk
• PCI procedure with balloon angioplasty+stent ismore recommended than balloon angioplasty alone
• Periprocedural antithrombotic therapy should begiven in Primary PCI
Primary-PCI Capable Centre
ESC Guidelines 2012; ACC/AHA Guidelines 2013
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
• Fibrinolysis is recommended for all patient with onset ≤12 hours if estimatingtime transfer to PCI capable centre >120 minutes, unless contraindicated
• In new onset STEMI (<2 hours) with large infarcted area and low bleedingrisk, Fibrinolysis is recommended if estimating time transfer to PCI capablecentre >90 minutes
• Fibrin specific agent (Alteplase, Reteplase, atau Tenecleptase) is morerecommended than nonspecific agent (Streptokinase)
• Periprocedural antithrombotic therapy should be given as well
Non Primary-PCI Capable Centre
ESC Guidelines 2012; ACC/AHA Guidelines 2013
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Coronary Artery Bypass Graft
Urgent CABG is indicated in patientswith STEMI and coronary anatomy
not amenable to PCI who haveongoing or recurrent ischemia,
cardiogenic shock, severe HF, orother high-risk features
CABG is recommended in patientswith STEMI at time of operative repair
of mechanical defects.[
“ The number of patients who require CABGIn acute phase of STEMI is relatively small ”
ACC/AHA Guidelines 2013
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
NON REPERFUSED STEMIPresent ≤12 hours onset Present >12 hours onset
Common Cause:• Spontaneus Reperfusion• Contraindicated to any reperfusion
therapy
Common Cause:• Late presenters• Resource limitation
Adjuvant Therapy Urgent PCIElective PCI
• Hemodinamically and/or Electrically unstable• Ongoing Ischemia in onset 12-24 hours
YES
NO
Viability & FunctionalAssestment
No ReperfusionTherapy
Cohen, et al 2012
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
CASE ILUSTRATION A 63 Years old gentleman with history of hypertension
and diabetic came to ER of primary hospital withprolonged typical chest pain with 2 hours onset
Vital sign: BP 150/90 mmHg, HR 95 bpm, RR 24, axillartemp 370C, with no abnormality in other physicalexamination
ECG Shows ST-segment elevation (V1-V6) at anteriorleads
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Question??
1. We have to confirm the diagnosis with serum marker
to establish the diagnosis.. (T/F)
2. At the moment your diagnosis is ?
a. Unstable Angina
b. Non STEMI
c. STEMI
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Management DUAL ANTIPLATELETS: Aspirin 300-325 mg plus ? Clopidogrel 600 mg loading then 75 mg od Ticagrelor 180 mg loading, then 90 bid mg Prasugrel 60 mg loading, then 10 mg od
NITRATE
BETA-BLOCKER
THROMBOLYTIC vs PPCI
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
b
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
SUMMARY• Acute emergency care is very important, the key point of
STEMI management is reperfusion therapy
• Determining the appropriate reperfusion therapy strategy ishighly depend on the clinical setting and resource availabilityin each medical center
• Time to perform reperfusion is the most important variableto get a better outcomes
• Guidelines of STEMI management can guide thepractitioners to perform a good acute emergency care andto choose the most appropriate reperfusion therapystrategy
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
LONGTERM MANAGEMENT
• To improve long term outcome and as a secondaryprevention of reccurent MI, hospitalization, and chronicheart failure
• Should be started at Pre-Hospital Discharge
• Long management including : Lifestyle management,Antiplatelet, Beta Blocker, RAAS Inhibitor, Statin, and Nitrate
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015