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Cme Acs 2. Stemi (Izzah)
Cme Acs 2. Stemi (Izzah)
Cme Acs 2. Stemi (Izzah)
Outline
Introduction Clinical diagnosis Investigation Management Case discussion
Introduction
Myocardial infarction due to acute
Atherosclerotic plaque rupture, fissuring or ulceration with superimposed thrombosis and coronary vasospasm.
ECG changes - diagnosis of STEMI: New onset ST-segment elevation Presumed new LBBB
1. Clinical history
or pressing in nature, lasting more than 30 minutes, may radiate to the jaw or down the left upper limb, may occur at rest or with activity Associated with
vomiting, lightheadedness and syncope, dyspnea with/without chest pain-> diabetics, elderly and female
Hx of prev IHD, PCI, CABG, risk factors, hx
of CVA
2. ECG changes
ST elevation
Q wave
T inversion
Pathological Q wave
ECG patterns
Investigation
Serial ECG Chest x ray Blood ix FBC Cardiac enzyme Renal profile, electroytes PT/INR Arterial blood gas Lipid profile FBS, haemoglobin A1c Urgent echocardiogram
Management of STEMI
Early management of STEMI is directed at: Pain relief Establishing early reperfusion
Treatment
Thrombolysis Treatment
If given within 1 hour, abort the infarction and reduce mortality by up to 50% If SBP < 90 mmHg, should receive inotropic support prior to treatment Should be given ONLY for STEMI
Streptokinase most widely used agent not fibrin specific and is less efficacious than fibrin selective agents Antigenic IV Streptokinase 1.5 mega Units in 100ml NS over 1 hour
Alteplase fibrin specific achieves better reperfusion at 90min as compared to streptokinase higher rate of reocclusionneed heparin
Tenecteplase, Reteplase Second generation fibrin specific agents as efficacious as alteplase slightly lower bleeding risk as compared to alteplase easier to administersingle/double bolus Heparin needed
Indicator of successful reperfusion 1) Resolution of chest pain 2) Return of ST elevation to isoline or decrease by 50% (within 6090mins) 3) Early peaking CK/CK-MB levels 4) Restoration of hemodynamic and electrical stability
Failed Fibrinolysis persistent chest pain, ST elevation and hemodynamic instability Mx = rescue PCI
17
dilatation) Door-to-needle time (time from hospital arrival to administration of fibrinolytic therapy)
Very late (>12hours) Both PCI and thrombolysis is not suitable for asymptomatic and hemodynamically stable pt If not stable-> primary PCI is preferred
Large infarcts Anterior infarcts Cardiogenic shock Elderly patients Post revascularization (post CABG and post PCI) Post infarct angina
3) Contraindications of thrombolysis
Absolute contraindications
Risk of intracranial hemorrhage History of intracranial hemorrhage History of ischemic stroke <3months Structural cerebral lesion (aneurysm, AVM) Intracranial tumour Risk of bleeding Suspected aortic dissection Significant head trauma < 3/12 Active bleeding (except menses)
Relative contraindication
Risk of intracranial hemorrhage Blood pressure >180/110 mmHg Hx of severe, chronic uncontrolled hypertension History of ischemic stroke >3 months Risk of bleeding Recent major surgery < 3 weeks On anti coagulant treatment (INR > 2) Recent internal bleed within 4 weeks Active peptic ulcer
Secondary prevention
Stop smoking Diet control Regular Exercise Control of Hypertension Good Glycemic control Antiplatelet Agents Aspirin 150 mg od (lifelong) and clopidogrel
75 mg od ( dual antiplt at least 1 month) - blockers lifelong if no contraindication ACE Inhibitors and ARB Lipid-lowering therapy- statin Oral Anticoagulant (warfarin) persistent AF, LV thrombus (give for 3- 6 months) Cardiac rehabilitation
Complications of STEMI
Arrhythmias
Tachy or bradyarrhythmias Asymptomatic to cardiogenic shock Free wall rupture, ventricular septal rupture, papillary muscle rupture Inferior MI triad of hypotension, clear lung fields and elevated jugular venous pressure ST elevation in right precordial leads (V4R) Not for diuretics/nitrates, Mx: iv fluid, inotrope Chest pain post STEMI reinfarction, ischemia, pericarditis, Dresslers syndrome DVT
Mechanical complications
Others
CASE DISCUSSION
HOPI
Mr K, 40 year old malay male, chronic smoker with
u/l DM - default treatment for 1 year Presented with: Chest pain at 11pm last night occurred at rest initially centrally located but later radiated to bilateral chest and back - pressing in nature - lasted 20 minutes pain score 7/10 a/w: SOB, profuse sweating, palpitations, nausea and vomiting - vomited x 2 at kk
In KK Lanchang
In KK, BP 98/72, HR 76 Dxt 18.2 Pt was given iv ranitidine 25mg s/l gtn 1/1 t aspirin 300mg crushed ECG noted st
elevation at lead 1, avl, v2-v5, reciprocal changes st depression at lead 111, avf
In ED
Pain score 4/10 O/E: conscious, alert, not pale, not tacypneic, not tachycardic,
good pulse volume, crt < 2 sec BP 137/67, HR 100 bpm, Spo2 98%, afebrile Lungs clear, equal a/e, cvs drnm p/a soft, non tender No pedal edema
ECG: Ventricular bigeminy, st elevation at 1, v2, v5 Bedside Echo in ED: hypokinesia at anterior, septal and
lateral wall
ECG in ED
Diagnosis: 1. Acute anterolateral MI killip 1 2. Uncontrolled DM tro DKA and HHS Mx in ED: iv streptokinase 1.5 megaunit in 100 cc NS in 1 hour t clopidogrel 300mg given Nasal prong 3l/min Ivi insulin sliding scale, hourly dxt Iv maxolon 10 mg stat Condom catheter
Management in CCU
Daily ecg and ce ecg and ce stat upon chest pain cont insulin sliding scale strict dxt and vs monitoring kiv for PCI if increasing in chest pain/ ecg new evolving changes start ACS treatment and other medication: t aspirin 150mg od t plavix 75mg od s/c fondaparinux 2.5mg od t simvastatin 40mg on s/l gtn 1/1 prn t perindopril 4mg od t bisoprolol 1.25mg od t alprazolam 0.5mg on syr lactulose 15mls prn
Progression in ward
Blood ix normal, treat as MI and uncontrolled DM T/O of CCU to general ward on 3rd day Echo done inpatient, EF: 45%, RMWA present Patient remain stable in ward, no chest pain CK reducing in trend: 118 > 6376 > 1327 > 298 > 105 Seen by dietitian, physiotherapist Completed s/c fonda for 5/7, discharged well Memo to kk for dxt monitoring, rpt RP in 2 weeks For stop smoking clinic Tca hosp Serdang for further management
Discharge medication:
Tab pantoprazole 40mg od T metformin 1g bd T plavix 75 mg od Tab aspirin 150mg od S/l gtn 1/1 prn Tab bisoprolol 2.5mg od T.Isordil 10mg tds T.Perindopril 4mg od
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