Maf!

il#eml"nl fflrsl 1 Houri)

{I). An.11,&Nw:
• Ad,oqujt,• an.itg,...~ L' ~ l fur:
Rehv111g pam &: distre,.;
Dl!Crea.sang adl\'ttrg,c (sympathetk') drift whidl. In tum rmi.m:
• Vascular resistance, BP, and inam 511.e
• Suscephbilil) lo wntricular Mrhythmias
A#!f\lS.
• lntra,'ffl0\15 opiate (IV morphine sulphite 5- 10 mg) pluE
• Anll<ffl1etle (TV met, ,dopramide 10 mg)
• A,'Old lnlratm!!oCUlar l'OUle (clinical effect IS d.-layed due 10 poor
sl.elew m~le perfusion)
{ii). i\nti-TlrG I al!c D Ali
• 4ntifl4kk1Jhrc!N♦i
a.,rnn;
Aspirin (300 mg) sil-p or.u cbe (within 12 hours)
Followed by asptnn (75mg) 1ndNtn1tel)

Clopidogrel:
• liOO mg single dose (.,.,thin 12 houn) follo-,j by l:iO mgdai1y for
1 week and 75 mg daih thereafter
• CJoridogrel ~ ,\.,;ptnn 15 81:TTE.R than asptnn alonr D I ~ dw
n.-.k of death. Ml and strolle
Tocagrelor.
• mg X (Wlre, f<Jl)o..-e,j byCJO mg twieedaily.
(8()
• It L~ more rapid (-30 min). - polffll than dopidogiel.
• It 15 nx,re effecti,oe than dopidogtel DI n!dudng va,adar death. Ml.
and stroke
• Tom L' ~'O ownll ma,<•r bi-ting rilk OOffllMRd with
dopidogfl'I
• Side-dfocts d)"'pro.'8 (fflll!lt COIIUIIOII). ~ nm\. ildm.g.
Pr.lliugrel
• It is rn.nnlv indiathed In patk'IIIS undergoing I'(] for ACS.
• 60 mg x Ol1Cl' at l'O Ihm 10 mg Q0 (oner cWly).
• Side-.>ffects bk-..--dmg nrJ..
• An>1dtnf',)ht.'llt! > 7S}'tWS(riskofhemorrhagicstrokr)
 I""'"' 5 C\nOIOlO<.Y

Gl\rop,ptl'in Ub. Illa Inhibitors (GPO;

Too;..,., ag\.'lllS .uc abciximab. eptifibahde, and tirofiban.
lh.~ agent~ 1nhib11 platelet aggregation & thrombus fo. nwlklL
These a~-nts decn>ase death & Ml when added to aspirin+ clnpiJog.el m
p.illenl~ undergoing PCI
Till'\' Jr(' Sl\'ell as winfu_'iKln" 2- 24 hours post·PCI
Tht•n.• is :-,;o 0-EAR BE\EFIT for starting thr5e aser,ts pnm to PCl
• Anll-"A1f111.u1on Tiwam;
It n.'Ju..-\.>s the risk of thromboembolic romphcatiam (stroke)
It al.._, redua.>s the progn.'SS1lm of thrombus, and re-Infarction, but does
not lo1,,w mortality
It should be <'.Ontinul'J for 8 days or until discharge, or coronary
n.•vi15CUl.anutJon.
It 1' adue\'ed u.,;u-,g l'ld-..or of:
• l!nfract1or..-d Heparin:
• Monitor with aPn' (should be 15-2 i.. oo.mol)
• Dosage: 60 U/kg IV bol\1$, then 12 UJlrWhour for 48 hows (or
until cmd of PCI).
• Eooxapann:
• It is low-molecular weight heparin {1.MWH)
• Dosage: I m&'kgtwicedally xSC(smi,111 w)(far2-8
days).
• Fondap,mmD.-
• It t \ 1 b1 wit lh best safety lllld effit.K)'
profile
• Dosage: 2.5 mg QD (once daly) x SC (for 2- 8 days)
• Bivalirudin:
• lt IS dizect tluo.nbi11 ~
• Dosage: 0.75 m&'kg tvbolus at 1hr time cl PCl. dm 1 75
mg/k&'hlur.

Nitrates d~n.•a..,.., rnortabty.

• Dilate con,nary artenes (increa.,;e bkxxl supply)
• \'enodildtion ( ~ preload. and thus demand)
Doiiage:
• Sublingu.11 gl\·,"'l'rvl tnnitrate ~ - 500 IJ8) as first-aid in su1peded
.\CS.
~ ... - M lOtU\I.

• lntra\'enou~ glvceni tnnitrate (0.6 I 2 mg/ht.,ur)

Contrn,ndtCJtums
• I h povol~nu3
• 5} mptmnallt' R\ uifaniion
• Rrt.Hllod,Pr.ii

Be !,lockers hdVt bfci1 h decre th mortJltt

Bet,1 blockt'rs hould th p of Ion I rm ma nlC'l\,'l,I\C£
th .rp
\!t.'Chan,,m & l:M.>ncfits alread~ d1"--usscd aliO\"l'.
Contrnindk;it1rni,
• Mtxlt.,rah.'•lo•<;t•vere heart fatlurc (pulnvm.1ry sde111a
• Bradvc.ud1,1 (ht.-.11-t r.ite < 65 lipm)
• 11) pntt111S1on lsvst11lic Bl' < HIS mm!~)
• S.., L'f(' hroncho,;pJ,m
{I\}. Reofrlu'-100 lllerapy:
• Reperfus1on n,...rap) invoh, u-ing ellhc!r:
Perrutanenu, Coron.iry lnt._>nenhon (('( I) L)R
Thromliolv·-1, (f1hrinolys1s1
• Role of Repertus1u1111wrap} 111 U \ & NSITMI
lkperh.1s1on tlwrapy i, ot :--O liSI ,md am e,.('11 b,., h,11mlul·
• f'CJ 1, nut dl,'<.twc lit...:.tusc the tnlan1-re111l'tl artery , not
Ol"Clud&i 111 60-65~u C.L-.e:.
• lhn,mbolvsi.s 1s nc,t efte(f1,._. 1'ecausc th, n,.,n 1,,1.luJ,ng thromb
.,re
pl I -nch
• Roi, ofR,pt'rfw;lun llit:r,1p\· in STEt\0
Ra.,x7fu.,ion tlwrapy ts ot pnme unport,mce 111 n:stonng the ,nr< 11.11)
art, ry p,lt,'11(} .
• I'Cl i, d(<.'ctive be,,,usc the ,nfarct-relJte<l ,1rt, n is occlud,d.
• fh,..,mbolv,is is ellectl\t' lx'Clluse the ocduJins l111<,mb1 w
rb n ch
V. Long.Term Post-ACS Management::
• Life ~tyle modtficahon, (.ure.id1· dt-.cu.,sed).
• Medications:
Aspirin& Oopidogrel:
• Ou.al .inti•plalelcl «aspirin+ dopldogrcll ,-hould be gh~n lor JI
least 3 months.
• Dual anti-platelet therapy &r PO
• Al least for 30 ~fay~ in pJtiL'11L~ who n.-reivl' a b.m:~llll.'t.11
slenl
• At least for 12 month.-. in patient<; who rcccivc a drug~luting
stcnt.
Bt!ta-bluckr.
Nittate,,
Stalln.S:
• Serum cholesterol ~ht,uld be mea...un.'IJ within 24 hours of
presentation
• Thi'> is bt.><:Ju..">c ~rum chnk-.tenll r.ilb transuintly in the iir.;t 3
mont1-t. po'> t•:'1,11.

( ~..,,. s, CutOIOUMa
• lrrespecti\e of serum chnJL.,,kl'lll ro11Ct•ntrat10n, all pahenb should
recci\:C Stlbn therap1 post-ACS.
• Stating therapy e.g. Alorva-.t.Jtin 80 mg d..iily.
Target LDL < 100 mg/dL.
• Target HDL>40mg/dL
• T,lrget trigly,-erides < 150 mgldL
ACE-lnlub11ors:
or
• Initial.- wuh1n hour; ho,pitaliz.ation if there are no
contramdic.ihons.
• Best mort:alit)' l:t.!nrn I i-, "'-'t."fl in p.ili.mb "ilh aa.,te tvll and l \'
wstolic d\'Sfunction (EF · l.<\' ).
• It ~hould ~ part or maintenan.:e thenpy due 10 follo",ng
advantaS1,>s.
• lmpm\e,, ,urvival
• Counteract \-entricular rernodding
• PreH•nl the onset orhean failure
• R.t.>duc" n,l. or recurrent :-..n
o implantable Cardiac D..>fibnllator (ICD):
• ll 1, hdpful in pre\ent suddt!n c.1rd1..ic death in patients with acute
tv!I and l V ~y.. tolic dysfunction (EF S 30%)
 ,..,,,. 5: C,RDIQllK,t

l'llana@!iirill i)f Audf" M:

! (('!11(JO\'Tl3nu...illv t:nst.lbl immediate ek-ctn.:al c.udio1m;ion lo sinus
rhythm.
lkmoch n.,rru(ally Stnbk--
s:JJ]' 1; Bale Control
• TJrgetra1e6()-IOOlipm 11th!: ratet too rapid
• Agents:
• f;l-blockers (preferred agents)
• Caloum mmnel blocl.:ers ( erap.umf. dilh l'ITI)
• Digoxm
SJFP 2; Rh> thm Control
• AF <48 hOW'5 k Im,; nskof stroke using CHAOS-VAS - (!il-r
bdo1• 1
• lntm1't!'ll0us heparin tollov,l'd b) cardio1ers1on
• Electncal cardioverston is preferred over pharmacol<>gic
cardlOl l 'l'SIOn.
• EIL-ct=I c.irdlo~, ona~ c.tlk>d DC ulfdi01'\!l"SIOI\.
• Ph.irrn.1rologic card101, on .:an be ,1 '"" b1 parenteral
f,ccarrudl' proc.-un.unld,.• nd amlodarone
• AF >48 hours&. high ri,k of 5troke using OfAOS-VASscore 11ft
below)
• If AF is> 48 hour.; then we can follow any one ol HE
followmg two options.
Qiztion-1;
• Anllroagul.ite ror 3 "'--cl.s. th.'n perform cm1iovl!nlon.
• Anhroagulate for 4 "'-'1.-ks after perfonnq: cardiovenion.
• Antiroagulate with Warfann.
• Targt?t INR IS 2-3.
Qi,tion - 2:
• To al'Oid waiting 3 weeks for anticoegulation obtain ir--
,~,pt,.,~-..J cchocardiogram (TEE) to look for left aria)
tlvombus
• If left .atrium thrombu& as present then follow option- I, Le.
antJroagulatlOI\ (3 weeks) - cardioYl'ISion - .,,......,,ladm
(4 weeks)
• II left atriui.i, tl uo.nbus is absent then dimctl) pafuun
cardlCIVl.'l'SIOII without anticoagulation for 3 VA"ef 9
 Treatment of SVJ
• Tn.'JtlilL'fll ls not al\\'ll)S ne,,...-;.1ry.
• Acut,• <'pi..•o<ll' m htmudyn.imiG1lly WlStable patit.'111 IX. nil \
• Acuk, pisode m hemcidvnamicallv st.iblc p.t!K.'llt
Be.t m,tlal sh-p i,, \.i I rr nc kilrotid 'll!;.s.lI:c V •
1mmcrs1c,11)
If \'agal maneL1v~ fail thm drug ol ch.11Cl· is(\ d ;,i l' 3 -12 mg)
If adenosinc 1sn·1 l!ffocti\'l' then.
• IV t,,. t.i blocker.; metoprolol)
• IV .:aloum channel blocJ..cl"i (clllh.iz m, \!!rapamil)
• RL-current :,VI ;
uthvtcr ablJtion-thr most effective therapy.
Alt.-rrl..111\1:' options - pmpilylaxis \\1th bcl.:t I ~ C.CB, c r flL-unmdi!
It•~ .am 1c.1I i'm1•11:.enC\1
1',1a nst.1 or 1i tm
• lmmcds unl,\'ll('Mllll1.cd rdio\'er,;ion d b
• Follo"t hll!tt-uu.alin Cu,1101PUllmofl,ll'\' ~
Sti'p - 1;
• Start CPR (as per basic life support (BLS) guidelines)
• Give oxygen & attach defibrillator & monitor,
• Identify the rhythm (1.e. VF) on thr morutor.
Stl-p-2:
• Ddii foUowedb)· CPRfor2mlnules 5cydes)
• Obtain IV access
Stt>p-3:
• ~ rhytlvn (after 2 minules), whether shockable (VP, VI) or
non-shocbble (asystole, PEA)
• Ji shodal,le rhythm- I 2'-¾ltod: followed by (]'R for2
minutes (5 cycles)
• If non-shockable- immediately resume CPR wlllu.4 gMi:w Ihde
• Start epinephrine (I mg boh.111, then every 3 -5 m'-r I ~
• ~der intubation
Sti'p-4:
• Assess rhythm after 2 mnates. whether tlmlu1"1e ~ Vl)orllOll-
shockable (asystole. PEA)
• :r shod:able mythm- dPliv,i,r shod- fall.> 1edbyCPRforl
minutes (5 cycles)
• If non-shocbble-inmi:dialely IBll.lmCPR without ........
• Start IV amiodarcft (1" dole• 300q, 2"1 dme lst q, gl.Wn
after 3 - 5 mins)
If cardioversion is falls • repeat from step-2(1.e. delhe thcdr, W11$lby
CPR)
If cardioversion is suansful:
• MaintainconlinUDUSinfusionoftheamiodm- ;1Jf :: f a • ,
• Mainstayuf dum-. lherapy-inqAaaab'-cfell•PI I 4
 , ....... Ii: C\IOIOl05\

~~:!:!·>:e:#ar "ladr,caadla M}:

• It L' de/med as~ 3 consecuthe premature, entricular rontractJons (PVG), nt a
ratt- of k.>l"wn 100 and 250 bpm.
• :'\on-su,t.Ulll'U VT 1s a,ymptomahr, while sustained VT (> 30 seconds) can lead
tu p.llpllallnns hypot~1nn. ,\'flC'OJX', .ind pu1,...Je,.,re;,
• Ca:r,;er:
o Coronary ~rtf.'ry di-ease \\1lh pnor ~11- most common cause
o Cardiomyopalhits
o Prolt,~t.>d Qf S)ndrom.,
o Drug 10,ic1ty
• ECG:
o \.\'ide ,111d blurre QRS completes.
o In monomorplul \ T al ORS compll'XL" aw idlmtkaL
o ln polymorpruc VJ, the QRS lOmpk'XCS are difforent.

rut it-;s VT
• Ex. cth the same reps a: r \ !lltncular fibnllahon \
above
CJ>R
nstable \\1th pul
Hemod\T&.111110111\
• Svnchrorua-d IX GU'daover, - I ce.
• Follow wuh I\ m odarore \Ihm
Hemod,-rum1u1lly Stab c
• Drugs - JV .\mi0d.lm111: r. rrocama.m I\ S.:,tJlol
• It drugs fail. thcnsvnchrom unwu\'i!f'i n