Professional Documents
Culture Documents
SYNDROME
Jose Socrates Dee Matuod Evardone
Cardiology RIC
Level II CDUH-IM
JULY 2015
CASE
Profile:
78F, Filipino
Hypertensive,
Non-DM,
Non-smoker,
Non-alcoholic beverage drinker
STEMI
1) NSTEMI-ACS
2) Unstable Angina
ACUTE CORONARY SYNDROME
Classic manifestation of ischemia is angina pectoris:
Pressure,
Tightness,
Squeezing,
Heaviness,
Burning
50% Stenosis:
there is a limitation of the ability to increase flow to
meet increased myocardial demand.
80% Stenosis:
myocardial ischemia at rest or with minimal stress
ACUTE CORONARY SYNDROME
Ischemic Heart Disease
Evaluation
of the
patient
with known
or
suspected
ischemic
heart
disease
Indications and Contraindications for Exercise
Electrocardiographic Testing in the Emergency Department
Requirements :
Two sets of cardiac enzymes at 4-hr intervals should be normal
ECG at the time of arrival and preexercise 12-lead ECG show no
significant abnormality
Absence of rest electrocardiographic abnormalities that would preclude
accurate assessment of the exercise ECG
From admission to the time that results are available from the second set
of cardiac enzymes: patient asymptomatic, lessening chest pain symptoms,
or persistent atypical symptoms
Absence of ischemic chest pain at the time of exercise testing
Contraindications
New or evolving electrocardiographic abnormalities on the rest tracing
Abnormal cardiac enzyme levels
Inability to perform exercise
Worsening or persistent ischemic chest pain symptoms from admission to the
time of exercise testing
Clinical risk profiling indicating that imminent coronary angiography is likely
C S
O Y
A
R N
C
O D
U
N R
T
A O
E
R M
Y E
ISCHEMIC HEART DISEASE
STABLE ISCHEMIC HEART DISEASE
Laboratory Tests:
1. Fasting lipid profile
MANAGEMENT
Lifestyle Modification and Treatment of Risk Factors
1) Healthy Diet
2) Physical Activity
3) Hypertension
4) Smoking
5) DM
6) Weight Management
7) Lipid Management
ISCHEMIC HEART DISEASE
MANAGEMENT
Pharmacologic Therapy to Improve Prognosis
Whether or not revascularization is being considered,
receive the following medications to improve prognosis,
thereby reducing the risk for MI and death:
1. Aspirin low-dose (80 to 160 mg/day)
2. Clopidogrel in case of aspirin intolerance (75 mg/day)
3. Statins irrespective of LDL-cholesterol levels
4. Beta blockers post-MI
5. ACEIs or ARBs (especially in patients with concomitant HF,
hypertension or diabetes)
Pharmacologic Therapy to Improve Prognosis
Pharmacologic Therapy to Improve Prognosis
Pharmacologic Therapy to Improve Prognosis
R
E
V
A
S
C
U
L
A
R
I
Z
A
T
I
O
N
Non-ST-Segment Elevation
Acute Coronary Syndrome
(Non-ST-Segment Elevation
Myocardial Infarction and
Unstable Angina)
NSTE-ACS
Pathophysiology:
1. imbalance between oxygen supply and oxygen
demand resulting from a partially occluding
thrombus forming on a disrupted
atherothrombotic coronary plaque or on
eroded coronary artery endothelium
2. dynamic obstruction
3. severe mechanical obstruction
4. increased myocardial oxygen demand
NSTE-ACS
NSTE-ACS
NSTE-ACS
DIAGNOSIS:
Clinical :
(1) it occurs at rest (or with minimal exertion),
lasting >10 minutes;
(2) it is of relatively recent onset (i.e., within the
prior 2 weeks); and/or
(3) it occurs with a crescendo pattern (i.e., distinctly
more severe, prolonged, or frequent than
previous episodes)
ANTI-ISCHEMIC ANTITHROMBOTIC
NSTE-ACS
Drugs Commonly Used in Intensive Medical Management of
Patients with UA and NSTEMI
NSTE-ACS
MEDICAL
TREATMENT
ANTI-ISCHEMIC ANTITHROMBOTIC
THERAPY THERAPY
antiplatelet drugs
anticoagulants.
NSTE-ACS
ORAL ANTIPLATELETS
Tirofiban 5 g/kg per min followed by infusion of 0.15 g/kg per min for 48
96 h
NSTE-ACS
HEPARINS
Unfractionated Bolus 70100 U/kg (maximum 5000 U) IV followed
heparin by infusion of 1215 U/kg per h (initial maximum
(UFH) 1000 U/h) titrated to ACT 250300 s
Enoxaparin 1 mg/kg SC every 12 h; the first dose may be preceded
by a 30-mg IV bolus; renal adjustment to
1 mg/kg once daily if creatine clearance <30 cc/min
Fondaparinux 2.5 mg SC qd
- PVA are generally younger and have fewer coronary risk factors
PROGNOSIS
1. Survival at 5 years is excellent (9095%)
2. Nonfatal MI occurs in up to 20% of patients by 5 years
3. There is a tendency for symptoms
4. and cardiac events to diminish over time
NSTE-ACS
CORONARY ANGIOGRAPHY
Revascularization by PCI
Drug/Medication Management
ANTI-ISCHEMIC ANTITHROMBOTIC
FIBRINOLYSIS
THERAPY THERAPY
Antiplatelet drugs
Anticoagulants
STEMI
MANAGEMENT IN THE EMERGENCY DEPARTMENT
the goals for the management of patients with suspected
STEMI include:
1. control of cardiac discomfort,
OXYGEN
O2 should be administered by nasal prongs or face mask (24 L/min) for
the first 612 h after infarction
STEMI
CONTROL OF DISCOMFORT
1) Sublingual nitroglycerin
Up to three doses of 0.4 mg should be administered at about 5-min intervals
2) Morphine
3) Intravenous beta blockers/ Oral Beta blockers
in the first 24 h for patients who do not
have any of the following:
(1) signs of heart failure,
(2) evidence of a low-output state,
(3) increased risk for cardiogenic shock, or
(4) other relative contraindications to beta blockade (PR interval greater than 0.24 seconds,
second- or third-degree heart block, active asthma, or reactive airway disease).
Fifteen minutes after the last intravenous dose, an oral
regimen is initiated of 50 mg every 6 h for 48 h, followed by 100
mg every 12 h
STEMI
STEMI
Initial ER Management
In-hospital Treatment