Emergency Cardiovacular Care (ECC)

Dr. Erwin Sukandi, SpPD, K-KV, FINASIM

Cardiology Division Internal Medicine Department

Cardiovascular Emergency
Acute

Coronary Syndrome Acute eart Fai!ure Acute Pericarditi" Cardiac #amponade In$ecti%e Endocarditi" Aortic Di""ection Dy"r&yt&mia Deep Vein #&rom'o"i"

ACUTE CORONARY SYNDROMES

De$ine acute coronary "yndrome" (ACS) *nder"tand t&e pat&op&y"io!o+y ,e capa'!e o$ ri"k "trati$ication Aware o$ medication" and "trate+ie" emp!oyed to mana+e ACS *"e 'a"ic princip!e" o$ EC- interpretation and in$arct !oca!i.ation App!y know!ed+e to ca"e "tudie"

LEARN N! O"#ECT $ES

Cardiovascular Disease
/0,122,222

American" &a%e one or more $orm" o$ &eart or '!ood %e""e! di"ea"e 324 o$ a!! deat&" are cardio%a"cu!ar di"ea"e

Cardiovascular Disease Acute Myocardia! In$arction

( eart Attack) - !eadin+ cau"e o$ deat& in *.S. 5.3 mi!!ion American" wi!! &a%e AMI6" t&i" year
7$ t&e"e 2.3 mi!!ion wi!! die8 032,222 wi!! die in $ir"t two &our"8
#emp!e Co!!e+e EMS Pro+ram 3

!oal o% ACS Managemen&'

REDUCE PATIENT SYMPTOMS REDUCE MORTALITY LIMIT MYOCARDIAL DAMAGE PRESERVE LV FUNCTION

TIME IS MUSCLE

ACUTE CORONARY SYNDROMES S&a(le Angina

Doe" not predict acute e%ent" Marker o$ e"ta'!i"&ed coronary artery di"ea"e (CAD)
Fi9ed !e"ion : partia!!y occ!uded %e""e! Mi"matc& in o9y+en "upp!y and demand

Precipitant";
< Exercise < Cold < Stress

Duration;
<

!" #$ to %& 'i()tes

=e!ie$;
< Rest < Nitro*l+ceri(e

ACUTE CORONARY SYNDROMES

Uns&a(le Angina

Clinical Presentation:

I.

New Onset Angina

< ,it-i( ./st #0% 'o(t-s < CCS III or IV

II. Crescendo Angina

< Pre1io)s st/2le /(*i(/ 3-ic- -/s 2eco'e 'ore

4re5)e(t6 se1ere6 .rolo(*ed6 e/sil+ i(d)ced or less res.o(si1e to (itro*l+ceri(e

III. Rest Angina

< A(*i(/ occ)rri(* /t rest /(d l/sti(* 'ore t-/( #$0%&

'i()tes

ACUTE CORONARY SYNDROMES

Uns&a(le Angina)NSTEM
*A:NS#EMI
Patent cu!prit artery, u!cerated p!a>ue and a""ociated

t&rom'u" Si+ni$icant ri"k o$ o$ t&rom'otic reocc!u"ion

*n"ta'!e An+ina ? ACS without a'norma! !e%e!" o$ "erum 'iomarker" $or myocardia! necro"i" 7Ti6Tt6C80M9: NS#EMI ? ACS with po"iti%e marker"

ACUTE CORONARY SYNDROMES

NSTEM

etero+eneou" popu!ation
Atypica! pre"entation Varia'!e a+e Medica! 'urden < rena! in"u$$iciency Percei%ed di$$icu!ty wit& interpretin+

'iomarker"

ACUTE CORONARY SYNDROMES

STEM

S#EMI
Comp!ete t&rom'otic occ!u"ion o$ a ma@or epicardia!

artery

Pre"entation;
C&aracteri"tic "ymptom" o$ cardiac i"c&emia
< More .rolo(*ed /(d se1ere s+'.to's < Little res.o(se to (itro*l+ceri(e

Speci$ic EK- c&an+e" on "eria! EK-" E!e%ation o$ "erum marker" $or cardiac in@ury
,;O de4i(itio( o4 AMI

Cardiovascular Disease Ris* +ac&ors

Ma@or

*ncontro!!a'!e

A+e Se9 =ace eredity

Cardiovascular Disease Ris* +ac&ors

Ma@or Contro!!a'!e
Smokin+ i+& ,P i+& '!ood c&o!e"tero! Dia'ete"

50

Cardiovascular Disease Ris* +ac&ors

Minor Contro!!a'!e
7'e"ity Aack o$ e9erci"e Stre"" Per"ona!ity

51

Cardiovascular Disease
Contro! ri"k $actor" - decrea"e Coronary Artery Di"ea"e and Acute Myocardia! In$arction

ACUTE CORONARY SYNDROMES

ETIOLOGY

Atherosclerotic plaque rupture *

inflammation thrombosis

Va"o"pa"m Di""ection Decrea"ed o9y+en de!i%ery 7e<*<

/(e'i/6-+.ote(sio(:

Increa"ed o9y+en con"umption 7e<*<

se.sis6 t-+rotoxicosis:

Coronary Ar&ery Disease

At&ero"c!ero"i" Narrowin+ o$ !umen < p!a>ue $ormation - re!ated to =i"k Factor" < re"u!t" in decrea"ed myocardia! per$u"ion Poor ti""ue per$u"ion cau"e"; ti""ue dama+e (i"c&emia) ti""ue deat& (in$arction)
5B

ACUTE CORONARY SYNDROMES

PATHOPHYSIOLOGY

at&eromatou" p!a>ue wit& a !ar+e, "o$t !ipid ric& core

en%e!oped eccentrica!!y wit&in t&e coronary intima contained on t&e !umina! "ur$ace 'y a t&in $i'rou" cap

core po""e""e" !ipid !aden monocyte" and macrop&a+e" t&at produce !ar+e amount" o$ tiss)e 4/ctor, a potent procoa+u!ant rupture occur" at t&e "&ou!der (t&e @unction o$ t&e p!a>ue and norma! endot&e!ium)

ACUTE CORONARY SYNDROMES

PATHOPHYSIOLOGY

e9po"ed ti""ue $actor comp!e9e" wit& $actor VIIa w&ic& in turn promote" +eneration o$ $actor Ca and t&e production o$ !ar+e amount" o$ t&rom'in circu!atin+ p!ate!et" are acti%ated 'y e9po"ure to co!!a+en, %on Di!!e'rand $actor, t&rom'in adeno"ine dip&o"p&ate, t&rom'o9ane AE and pro"tacyc!in", re!ea"ed 'y dama+ed endot&e!ium, contri'ute to p!ate!et acti%ation and induce %a"o"pa"m

ACUTE CORONARY SYNDROMES

PATHOPHYSIOLOGY

acti%ated p!ate!et" 'ind to one anot&er 'y cro""!inkin+ $i'rino+en to t&eir "ur$ace +!ycoprotein receptor" t&e acti%ation, ad&e"ion and a++re+ation o$ p!ate!et" and t&e acti%ation o$ t&e c!ottin+ ca"cade re"u!t" in an occ!u"i%e t&rom'u" t&rom'u" may partia!!y or $u!!y occ!ude a %e""e! !umen precipitatin+ myocardia! i"c&emia F:necro"i"

Diagnosis
Cardiac

C&e"t pain EC- c&a+e" Cardiac en.yme"

Sym,&oms -Angina .ec&oris

Pain Su'"terna! S>uee.in+:Cru"&in+: ea%ine"" May radiate to arm", "&ou!der",

@aw, upper 'ack, upper a'domen 'ack May 'e a""ociated wit& "&ortne"" o$ 'reat&, nau"ea, "weatin+
EE

Sym,&oms -Angina .ec&oris

Pain "e!dom !a"t" G 02 minute" Pain re!ie%ed 'y
=e"t Nitro+!ycerin

E0

Sym,&oms -Angina .ec&oris

-reat an9iety:Fear Fi9ation o$ t&e 'ody Pa!e, a"&en, or !i%id $ace Dy"pnea (S7,) may 'e a""ociated

E1

Sym,&oms -Angina .ec&oris

Nau"ea Diap&ore"i" ,P u"ua!!y up durin+ attack Dy"r&yt&mia may 'e pre"ent

Angina .ec&oris
Fo!!owin+

an an+ina attack t&ere i" no re"idua! dama+e to t&e myocardium

E/

+orms o% Angina .ec&oris

Sta'!e An+ina

7ccur" wit& e9erci"e Predicta'!e =e!ie%ed 'y re"t or Nitro+!ycerin

EB

+orms o% Angina .ec&oris

*n"ta'!e An+ina

More $re>uent:"e%ere Can occur durin+ re"t May indicate impendin+ MI =e>uire" immediate treatment and

tran"port to appropriate $aci!ity

EH

T/E ELECTROCARD O!RAM

5E

!ead EK-

< Cornerstone of initial evaluation < Within 10 minutes of presentation

Pre%iou" EK- tracin+"

< Compare

Seria! EK-"
< Essential

T/E ELECTROCARD O!RAM

1. S# "e+ment e!e%ation Emm 7% co(ti*)o)s le/ds:, new A,,,, true po"terior i"c&emia
STEMI

EMERGENT REPERFUSION . S# depre""ion G5mm, marked "ymmetrica! # wa%e in%er"ion" GE mm, dynamic S#-# c&an+e" wit& pain
UA!NSTEMI LI8ELY

MEDICAL MANAGEMENT =!0 URGENT IMAGING !. Non-dia+no"tic or norma! ECACS LESS LI8ELY

RIS8 STRATIFY

T/E ELECTROCARD O!RAM N+ARCT LOCAT ON

""# """# A$% $1 & $' I, aVA "# a$(# $)&$* I,aVA, V5-V/

; In$erior ; Antero"epta! ; i+& !atera! ; Aatera! ; E9ten"i%e

anterior $1&$ tall R# +, depression ; #rue po"terior

ELECTROCARD O!RAM

Cardiac en.yme Marker

Cardiac en.yme Marker Myo+!o'in C#nI C#n# CKM, #CK Initia! e!e%ation a$ter AMI 5-1&r 0-5E&r 0-5E&r 1-5E &r E-/ &r Mean time to peak e!e%ation" /-B&r 52-E1&r 5E-1H&r 52-E1&r 1.B&r(0-3) #ime to return to 'a"e!ine 5H-E1&r 0-52 day 3-51 day E-0day BE&r(32-I/)

NTER.RETAT ON O+ TRO.ON NS

Troponin I i+& "en"iti%ity and "peci$icity

Appear" wit&in * hours o$ in@ury =e>uire" up to 1' da-s $or c!earance
< Not )se4)l 3it- rei(4/rctio(

Spectrum
< ;i*-er t-e tro.o(i(6 t-e *re/ter t-e ris>

Fa!"e po"iti%e;
C F, pericarditi", myocarditi", contu"ion, cardiomyopat&y S&ock =ena! in"u$$iciency Pu!monary em'o!i

0 LL . SCORE
+.$.R",/ C(A++
" ""a ""b """ "$

($ %0NC,"ON "N A1"

No crack!e", no S0 Crack!e" J 32 4 !un+ $ie!d", no S0 Crack!e" J 32 4 !un+ $ie!d", S0 pre"ent Crack!e" G 32 4 !un+ $ie!d", pu!monary edema Cardio+enic S&ock

Managemen& o% Cardiac C1es& .ain

A!ENTS USED N ACUTE CORONARY SYNDROMES

23/ 23.N 3O2 PR.CA0,"ON+

T/E E$ DENCE
Level of Evidence Grading
De!! de"i+ned, randomi.ed, contro!!ed tria!" 7= meta-ana!y"e" in%o!%in+ !ar+e num'er o$ patient" Sma!!er radomi.ed tria!" 7= re%iew" o$ o'"er%ationa!, retro"pecti%e or nonrandomi.ed tria!" E9pert con"en"u", primary nonrandomi.ed 7= o'"er%ationa! data

A 4 C

T/E E$ DENCE
C!a"" I E%idence or +enera! a+reement t&at a "peci$ic procedure or treatmetn i" u"e$u! and e$$ecti%e Con$!ictin+ e%idence or di%er+ence o$ opinion a'out t&e uti!ity or e$$icacy o$ a procedure or treatment Dei+&t o$ e%idence or opinion i" in $a%our o$ uti!ity-e$$icacy *ti!ity-e$$icacy i" !e"" we!! e"ta'!i"&ed 'y e%idence or opinion E%idence or +enera! a+reement t&at a "peci$ic procedure or treatment i" neit&er u"e$u! n e$$ecti%e and may 'e &arm$u! C!a"" II

II a II ' C!a"" III

A!ENTS USED N ACUTE CORONAY SYNDROMES

OXYGEN

Ae%e! C e%idence

23/ Increa"e "upp!y to i"c&emic ti""ue 23.N Su"pect ACS 3O2 Start wit& na"a! cannu!a at 1A:min PR.CA0,"ON+ C7PD

A!ENTS USED N ACUTE CORONAY SYNDROMES

ASPIRIN
C!a"" I, Ae%e! A e%idence

23/
Morta!ity reduction ,!ock" "ynt&e"i" o$ thromboxane A
< In&i'it" p!ate!et a++re+ation < =e!a9e" arteria! tone

23.N
Su"pected ACS

3O2
5/2 m+ c&ewed "!ow!y, t&en H5-0E3 m+ dai!y or pr

CON,RA"N5"CA,"ON
#rue a!!er+y No -I tract 8

A!ENTS USED N ACUTE CORONAY SYNDROMES

UNFRACTIONATED HEPARIN

C!a"" I, Ae%e! A e%idence F ASA

23/
In&i'it" t&rom'in G ICa, Ca Pre%ent t&rom'u" $ormation o%er ruptured p!a>ue Pre%ent recurrence o$ t&rom'o"i" Pre%ent mura! t&rom'u"

23.N
*A:NS#EMI Dit& tPA Dit& P#CA:"ur+ica! re%a"cu!ari.ation

3O2
IV 'o!u" 7?& )(its!>* i1 to '/xi')' $&&& )(its:, t&en In$u"ion 7#&&& )(its!-r:

A!ENTS USED N ACUTE CORONAY

UNFRACTIONATED HEPARIN PR.CA0,"ON+

SYNDROMES

Acti%e '!eedin+ =ecent intracrania!, intra"pina!, eye

"ur+ery Se%ere &yperten"ion ,!eedin+ di"order"

A!ENTS USED N ACUTE CORONAY SYNDROMES

LOW MOLECULAR WEIGHT HEPARIN

E!g! Enoxaparin "Lovenox#$ %alteparin

C!a"" I, Ae%e! A e%idence F AS

23/
Antit&rom'otic, anti Ca Predicta'!e Do not re>uire coa+u!ation te"t monitorin+ Aower incidence o$ t&rom'ocytopenia No p!ate!et acti%ation ,ind" c!ot 'ound t&rom'in

23.N
Su"pected ACS

A!ENTS USED N ACUTE CORONAY SYNDROMES

LOW MOLECULAR WEIGHT HEPARIN

3O2
Su'cutaneou"!y

PR.CA0,"ON+
=ena! in"u$$iciency Dei+&t G 532 k+

A!ENTS USED N ACUTE CORONAY SYNDROMES

BETA-BLOCKERS (Bb
E!g! &etoprolol$ 'isoprolol$ Atenolol$ etc!

Ae%e! A e%idence

23/
Anti-arr&yt&mic Anti-i"c&emic Anti-&yperten"i%e Decrea"ed myocardia! rupture at one week in S#EMI

23.N
Dit&in 5E &our" o$ AMI ACS and e9ce"" "ympat&etic acti%ity

3O2
Intra%enou" 7ra!
7Meto.rolol:

A!ENTS USED N ACUTE CORONAY SYNDROMES

BETA-BLOCKERS (Bb CON,RA"N5"CA,"ON+

A4+O(0,.:
S&ock ,radycardia ypoten"ion Se%ere a"t&ma Acute C F:pu!monary edema

R.(A,"$.:
A"t&ma : "e%ere C7PD eart '!ock" Se%ere PVD IDDM E9treme a+e

A!ENTS USED N ACUTE CORONAY SYNDROMES

C!a"" I, Ae%e! A e%idence, i4 c/((ot t/>e ASA C!a"" I, Ae%e! , e%idence, ot-er3ise E!g! Clopidogrel "(lavix#$ )iclodipine

ADP ACTI!ATION INHIBITORS

23/
Irre%er"i'!e in&i'itor o$ ADP-receptor

mediated p!ate!et a++re+ation

23.N
S#EMI, ASA "en"iti%ity *A:NS#EMI i+& ri"k patient c&aracteri"tic"

A!ENTS USED N ACUTE CORONAY SYNDROMES

CLOPIDOGREL (P"#$i% 3O2

022m+ po !oad, t&en B3 m+ po >d

PR.CA0,"ON+
A!!er+y #&rom'ocytopenia i+& ri"k -I '!eed (CV "ur+ica! procedure anticipated)
< Sto. 'i(i')' $ d/+s .rior

A!ENTS USED N ACUTE CORONAY SYNDROMES

GPIIb&III# INHIBITORS

C!a"" I Ae%e! A e%idence i( ./tie(ts 3it- .l/((ed PCI i( #%0%@ -o)rs6 ASA /(d C!a"" IIa, Ae%e! A e%idence I( -i*- ris> ./tie(ts 3it-o)t .l/((ed PCI6 ASA /(d -

E!g! Eptifibatide "*ntegrelin#$ Abciximab )irofiban

23/

Competiti%e in&i'ition o$ $i'rino+en 'indin+ 'etween p!ate!et"

23.N

3O2

ACS, re$ractory "ymptom" *r+ent PCI Dit& ASA and *F F:- PCI ,o!u"; 5H2 mc+:k+ i% 7'/xi')' 3ei*-t #%&>*: In$u"ion; E mc+:k+:min 7half 3it- re(/l i(s)44icie(c+:

A!ENTS USED N ACUTE CORONAY SYNDROMES

EPTIFIBATIDE (In'()r("in

No e"ta'!i"&ed ro!e wit& t&rom'o!y"i" or AMD

PR.CA0,"ON+
Acti%e '!eedin+ wit&in 02 day" Stroke or &ead in@ury wit&in 02 day" ,!eedin+ diat&e"i" IN= GE.2 P!ate!et" J 522,222 Ma@or "ur+ery or trauma wit&in / week" *ncontro!!ed #N (S,P G E22, D,P G552) yper"en"iti%ity

A!ENTS USED N ACUTE CORONAY SYNDROMES

NITROGLYCERINE

Doe" not reduce morta!ity

Ae%e! C e%idence

23/
Decrea"e" i"c&emic pain
< Ve(odil/tio(!decre/sed .relo/d < Dil/tes coro(/r+ /rteries 7eli'i(/tes 1/sos./s': < I(cre/ses coro(/r+ coll/ter/l 4lo3

23.N
I"c&emic c&e"t pain For E1-1H &r a$ter AMI
< Rec)rre(t ./i( < ;+.erte(sio( < C;F

A!ENTS USED N ACUTE CORONAY SYNDROMES

NITROGLYCERINE

3O2
Su'!in+ua!
< #a'!et"; 2.0m+ > 3 minute" < Spray; 2.1 m+ > 3 minute"

IV In$u"ion < Start 52-E2 mc+:min < Increa"e 'y 3-52 mc+:min >3-52 minute"

PR.CA0,"ON+
A%oid &ypoten"ion .6treme caution wit& R$ infarction Interaction wit& "i!dena$i! (Via+ra)

A!ENTS USED N ACUTE CORONAY SYNDROMES

MORPHINE

23/
=educe i"c&emic pain =educe an9iety =educe e9ten"ion

Ae%e! C e%idence

< Red)ctio( o4 s+'./t-etic to(e /(d ox+*e( de'/(ds

23.N
7n+oin+ pain o$ in$arction Acute pu!monary edema S,P G I2 mm +

A!ENTS USED N ACUTE CORONAY SYNDROMES

MORPHINE

3O2
Sma!! increment" IV < # 0 A '* .r(6 to eli'i(/te ./i(

PR.CA0,"ON+
A!!er+y Nau"ea and %omitin+ ypoten"ion =e"piratory depre""ion

A!ENTS USED N ACUTE CORONAY SYNDROMES

ACE-INHIBITORS
..g. +amipril$ Enalapril$ Captopril Ae%e! A e%idence
7A(terior i(4/rct6 EF @&B:

23/
=educe

< Ae$t %entricu!ar dy"$unction and di!ation

=emode!in+ Decrea"e a$ter!oad and pre!oad =eduction in morta!ity

23.N
Dit&in E1 &our" AMI Su"pected or known CAD

A!ENTS USED N ACUTE CORONAY SYNDROMES

ACE-INHIBITORS

3O2
7ra!

PR.CA0,"ON+
Pre+nancy Symptomatic &ypoten"ion ,i!atera! rena! artery "teno"i" An+ioedema A!!er+y

MANA!EMENT NSTEM ACS

$ery /ig1 Ris*
PR.+.N,A,"ON

(*+,- ./ 0#1 AMI&Mor'#"i'1

,R.A,1.N,

Pro!on+ed:recurrent pain GEmm S# depre""ion Po"iti%e cardiac marker" G5mm tran"ient S# e!e%ation emodynamic in"ta'i!ity =e$ractory i"c&emia

ASA C!opido+re! eparin Epti$i'atide *r+ent coronary an+io+rap&y *r+ent re%a"cu!ari.ation

Can. K Cardio!. 5H(55), E22E

MANA!EMENT NSTEM ACS

/ig1 Ris*

(2-+,- ./ 0#1 AMI&Mor'#"i'1

PR.+.N,A,"ON
=e"t painG E2 minute" GEmm S# depre""ion Deep # wa%e in%er"ion (G3mm) GEmm # wa%e in%er"ion in G3 !ead" Po"iti%e cardiac marker"

,R.A,1.N,

ASA C!opido+re! eparin F:- Epti$i'atide

7i( co(s)lt/tio( 3it- c/rdiolo*+:

Ear!y coronary an+io+rap&y

Can. K Cardio!. 5H(55), E22E

MANA!EMENT NSTEM ACS

n&ermedia&e Ris*
PR.+.N,A,"ON

(.-2- ./ 0#1 AMI&Mor'#"i'1

,R.A,1.N,

=e"t pain New on"et or cre"cendo pain Non"peci$ic or norma! EKNorma! or 'order!ine po"iti%e cardiac marker" Increa"ed 'a"e!ine ri"k (DM, pre%iou" AMI,CA,-, recent PCI)

ASA F:-C!opido+re! eparin ES# or myocardia! per$u"ion "can Coronary an+io+rap&y

Can. K Cardio!. 5H(55), E22E

MANA!EMENT NSTEM ACS

Lo2 Ris*

(3.- ./ 0#1 AMI&Mor'#"i'1

PR.+.N,A,"ON
Sin+!e "&ort duration pain New on"et or cre"cendo pain Non"peci$ic:norma! EK- C E Norma! cardiac marker" C E No &i+& ri"k $eature"

,R.A,1.N,

ASA ES# wit&in 1H &our"

Can. K Cardio!. 5H(55), E22E

MANA!EMENT STEM ACS

0rgent

reperfusion:

%I,=IN7ALSIS PE=C*#ANE7*S C7=7NA=L

"N#E=VEN#I7N

A!ENTS USED N ACUTE CORONAY SYNDROMES

FIBRINOLYTICS
Ae%e! A e%idence

23/
P!a"mino+en acti%ator" De+rade t&e occ!u"i%e t&rom'u"

23.N
2",3"N !7 1"N0,.+ O% PR.+.N,A,"ON I"c&emic type c&e"t pain EK- compati'!e
< ST ele1/tio( C %'' i( %= co(ti*)o)s le/ds < (e3 L999 < tr)e .osterior i(4/rct

Pain J:? / &our" 7 #% -o)rs: No contraindication"

CONTRA ND CAT ONS TO T/ROM"OLYS S

CON,RA"N5"CA,"ON+
A4+O(0,.: L/c> o4 cle/r i(dic/tio(s Acti1e i(ter(/l 2leedi(* Rece(t tr/)'/6 '/Dor s)r*er+6 i(ter(/l 2leedi(*
73it-i( %3ee>s:

S)s.ected /ortic dissectio( Peric/rditis Pre1io)s -e'orr-/*ic stro>e Ot-er stro>es 3it-i( o(e +e/r 8(o3( i(tr/cr/(i/l (eo.l/s'

CONTRA ND CAT ONS TO T/ROM"OLYS S

R.(A,"$.:
Rece(t tr/)'/6 '/Dor s)r*er+6 i(ter(/l 2leedi(* 7%0@ 3ee>s: Se1ere )(co(trolled -+.erte(sio( 7C #E&!##& '';*: C)rre(t )se o4 /(tico/*)l/(ts 7INR C %0A: I(tr/cere2r/l ./t-olo*+ 7ot-er t-/( stro>e: 8(o3( 2leedi(* di/t-esis Acti1e .e.tic )lcer dise/se Pre*(/(c+ No(co'.ressi2le 1/sc)l/r .)(ct)res 8(o3( -+.erse(siti1it+ to /*e(t A*e C F$ +e/rs Prolo(*ed 7C #& 'i()tes: tr/)'/tic CPR

A!ENTS USED N ACUTE CORONAY SYNDROMES

FIBRINOLYTICS

3O2
,trepto-inase

- Deri%ed $rom 'eta-&emo!ytic Streptococcu" cu!ture" - Sma!!er in$arct", e!der!y, underwei+&t - 5.3 mi!!ion unit" o%er 5 &our )issue (lasminogen Activator t(A - Natura!!y occurrin+ en.yme - ,etter wit& !ar+e in$arct - i+&e"t incidence o$ IC - 53 m+ IV 'o!u" - 2.B3 m+:k+ o%er ne9t 02 min (32 m+) - 2.32 m+:k+ o%er ne9t /2 min (03 m+)

A!ENTS USED N ACUTE CORONAY SYNDROMES

FIBRINOLYTICS
)enecteplase ")./#
< Sin+!e 'o!u" < Dei+&t 'a"ed do"in+

+eteplase
< -enetica!!y modi$ied t-PA < Not wei+&t 'a"ed < #wo 'o!u"e" o$ 52 unit", 02 minute" apart

ACUTE CORONAY SYNDROMES

PERCUTANEOUS TRANSLUMUNAL ANGIOPLASTY

Ae%e! A:, e%idence

Emer+ent P#CA; Co(siderG

< 7n+oin+ "ymptom" o$ G5E &our duration < Contraindication" to t&rom'o!y"i" < Fai!ure o$ t&rom'o!ytic" < Cardio+enic "&ock and AMI < Pre%iou" CA,< MStutterin+ In$arctionN < Acce"" to !a'

ACUTE CORONARY SYNDROMES

(0))*.G *) ALL )1GE)2E+

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