AMBULATORY

MANAGEMENT OF
MYOCARDIAL INFARCTION
AT FIRST HOUR

Presenter – Dr. Gaurav Singh

Moderator – Dr. Savita Kapila
 What is Ambulatory care/management

• Ambulatory care or outpatient care is medical care provided on an

outpatient basis, including diagnosis, observation, consultation,
treatment, intervention, and rehabilitation services.

• This care can include advanced medical technology and procedures

even when provided outside of hospitals.
 Where is it important?
• If you are working in an OPD(cardiac/non-cardiac center).
E.g., OPD without in-patient facility,
OPD in Non-PCI hospital,
OPD in PCI hospital,
Inside Ambulance on way to a PCI facility(PRE-HOSPITAL FIBRINOLYSIS)

• Working in a non-cardiac facility in remote places such as PHC/CHC.

E.g., while driving from one city to another/long-distance tour, a person
started having chest pain and presented in a nearby Primary Health Centre.
 PRESENTATION
The patient will present in OPD/ER with complaints of chest pain/angina
(most common presentation) or

Angina equivalent symptoms which include –

1. Shoulder or jaw pain

2. Nausea
3. Vomiting
4. Diaphoresis/sweating
(seen especially in women/elderly/diabetics)
 MANAGEMENT
CLINICAL EVALUATION – (TO BE DONE WITHIN 30 MINUTES)

1. Initial Assessment
2. History
3. Physical Examination
4. Electrocardiography
5. Biomarkers
6. Chest Radiography (not conclusive for diagnosis of MI)

IMMEDIATE MANAGEMENT (NEXT 30 MINUTES)

DECISION-MAKING AS PER PROTOCOLS/AVAILABILITY OF SERVICES FOR

REPERFUSION THERAPY (NEXT 30-60MINUTES)
CLINICAL EVALUATION
 INITIAL ASSESSMENT

• Clinical Stability – does the patient need immediate treatment for

impending or actual circulatory or respiratory collapse

• Immediate prognosis – the risk of a life-threatening condition such as

ACS/PE/Arrhythmia or aortic dissection
 History
• Chest pain – Nature of pain is most important

Diffuse/substernal/squeezing pain – characteristic of MI

Sharp/stabbing pain; exacerbated by resp./coughing – pleuritic

• Duration of pain is second most important as it suggests diagnosis and guides the
treatment (early vs late presenters)

• Previous chest pain episodes - nature/severity/whether similar or not

• Any co-morbidities
• Previous H/O Myocardial infarction
• H/O Cocaine use in young patients
• Recent use of PDE-V inhibitors
 Physical Examination
• If or once the patient is stable, first is to identify potential precipitating causes of
myocardial ischemia(uncontrolled BP), e/o hemodynamic complications(CCF,
new MR, hypotension)

• For patients whose clinical findings don’t suggest myocardial ischemia, search for

Non-coronary but potential life-threatening cause of chest pain – aortic

dissection, pulmonary embolism f/b

Other cardiac conditions like pericarditis

Non-cardiac conditions – esophageal discomfort/GERD

 ELECTROCARDIOGRAPHY – < 10min, 15-30min serial ECG
The joint European Society of Cardiology, American College of Cardiology Foundation, the American
Heart Association, and the World Heart Federation (ESC/ACCF/AHA/WHF) committee for the
definition of MI established specific ECG criteria for the diagnosis of -
NSTEMI :
1. New horizontal or downsloping ST-depression ≥0.5 mm in two contiguous leads
and/or
2. T inversion >1 mm in two contiguous leads with prominent R wave or R/S ratio >1.

STEMI:
3. New ST-segment elevation at the J-point in two contiguous leads with the cut-points: ≥1mm (0.1
mV) in all leads other than leads V2-V3;
4. For leads V2-V3:
≥1.5 mm in women regardless of age,
≥2.5 mm in men <40 years,
≥2 mm in men ≥40 years.
 BIOMARKERS
Obtain blood for cardiac biomarkers (troponin preferred over CPK-MB)
Cardiac troponin T (cTnT) is preferred over cardiac troponin I (cTnI) at
presentation and then 3-6hr after symptom onset.
Non specific Troponin can be done if cardiac troponin assay is not available
Now-a-days, high sensitivity cardiac Troponin assays are available which can
detect troponins in blood as low as <1pg/ml

• Other tests include –

 CBC with platelet count
 Serum electrolytes,
 coagulation profile for patients taking anticoagulants (PT-INR, aPTT).
 BUN, creatinine, blood glucose, and serum lipid profile.
 CHEST
RADIOGRAPHY
• All patients with chest pain should get a chest X-ray done.

• It is usually nondiagnostic in patients with ACS but can show pulmonary edema
secondary to ischemia-induced diastolic or systolic dysfunction.

• It is more useful for diagnosing other disorders. e.g., it may show a widened
mediastinum or aortic knob in patients with aortic dissection.

• It generally has normal findings in PE but can show atelectasis, an elevated

hemidiaphragm, a pleural effusion or Westermark sign. (focal peripheral
hyperlucency secondary to oligemia resulting in a collapsed appearance of
vessels distal to the occlusion

• It can also reveal pneumonia or pneumothorax.

 Whom to admit !! Whom to discharge !!
• According to the ACC and AHA , Patients in whom e/o ischemia or other high risk indicators should be
admitted to a cardiac care unit.

• Patients with a low risk can be observed for several hours while undergoing serial ECG and cardiac
markers monitoring.

• Patients in whom recurrent pain or other high risk predictors do not develop can either be discharged
home or be scheduled for early noninvasive testing before or after discharge.

• Patients with normal troponins, no ECG abnormalities, and a TIMI risk score of 0 have an extremely
low risk can be considered for discharge to home or non-invasive stress testing(before discharge)

• Outpatient stress testing is a reasonable option if the patient is at low risk for ACS and if the testing can
be accomplished within 72 hours; such a strategy can be safe.
• Such patients can receive aspirin and/ beta blockers and sublingual nitroglycerin
 IMMEDIATE
MANAGEMENT &
REPERFUSION THERAPY
 SUPPORTIVE
TREATMENT
• Oxygen — administer supplemental oxygen to MI patients who have SpO2 less than 90
%. In most normoxic patients (oxygen saturation ≥90 percent) of MI, do not administer
it. (exception -normoxic heart failure patients where it is reasonable to use
supplemental oxygen)
Hyperoxia, with the administration of oxygen to normoxic individuals, has been shown
to have a direct vasoconstrictor effect on the coronary arteries

• Analgesics
• Secure IV access
• Beta blockers — Controlled trials have documented the beneficial effects of beta
blockers in patients with acute MI with normal hemodynamic parameters (meto/ateno)

Defer intravenous beta blockers in patients who are hemodynamically compromised in

whom mortality may actually be increased.(COMMIT/CCS2 trial, the largest placebo-
controlled trial ever performed with beta-blockers in acute MI)
 STEMI – Early presenters (<12hrs)
• Once diagnosis of STEMI has been made then, without any delay patient should
be shifted to

1. CATH LAB(if PCI capable hospital) after administration of anti-coagulants, anti-

platelets and/or GP inhibitors within the next 30 minutes.
(FMC to balloon time ≤ 90minutes)

2. PCI capable hospital if anticipated FMC-device time is 120 minutes. DIDO

(shifting time) ≤30min

3. Treat with fibrinolysis(<30min) if PCI unavailable and anticipated FMC-device

time is >120 minutes, symptoms <12 hours, and no contraindications.
• Give aspirin 325 mg (nonenteric coated) to be chewed and swallowed (unless aortic
dissection is being considered). If oral administration is not feasible, give as rectal
suppository.

• Start 80 mg of atorvastatin as early as possible and preferably before PCI in patients

not on statin. If patient is taking a low- to moderate-intensity statin, switch to
atorvastatin 80 mg.

• Give three sublingual nitroglycerin tablets (0.4 mg) one at a time, spaced five
minutes apart, or one aerosol spray under tongue every 5 minutes for 3 doses

IF patient has persistent chest discomfort, hypertension, or signs of heart

failure AND there is no sign of hemodynamic compromise (eg, right ventricular
infarction) and no use of phosphodiesterase inhibitors (eg, for erectile dysfunction);
add IV nitroglycerin for persistent symptoms.
ANTIPLATELET THERAPY (IN ADDITION TO ASPIRIN) TO ALL PATIENTS:

1. Patients treated with fibrinolytic therapy: Clopidogrel loading dose 300 mg if age ≤75 yrs;
if age over 75 years, give loading dose of 75 mg.

2. Patients treated with no reperfusion therapy: Give ticagrelor loading dose 180 mg.

3. Patients treated with primary PCI: Ticagrelor loading dose of 180 mg or prasugrel loading dose
of 60 mg
(if no contraindications: prior stroke or TIA, or relative contraindications for prasugrel such as
those age 75 years or older, weight less than 60 kg).

For patients at high risk of bleeding or those for whom prasugrel or ticagrelor cannot be used, we
give clopidogrel 600 mg.
ANTICOAGULANT THERAPY TO ALL PATIENTS:
1. For patients treated with primary PCI, we prefer UFH to bivalirudin.
For patients who receive a potent oral antiplatelet agent (ticagrelor or prasugrel), prefer UFH.
For patients who receive clopidogrel, prefer bivalirudin.

•Dosing of UFH: An initial IV bolus of 50 to 70 units/kg up to a maximum of 5000 units.

•Dosing of bivalirudin: Initial bolus of 0.75 mg/kg IV followed by IV infusion of 1.75 mg/kg per hour;
2. For patients treated with fibrinolysis,
prefer enoxaparin for patients not at high bleeding risk
fondaparinux for those at high bleeding risk.
patients in whom PCI is possible after fibrinolytic therapy, UFH is preferred.

•Dosing of enoxaparin
• Patients <75 years: Loading dose of 30 mg IV bolus f/b 1 mg/kg s.c. every 12 hours;
Renal impairment (CrCl <30 mL/min): Loading dose of 30 mg IV f/b 1 mg/kg s.c. every 24 hours.
• Patients ≥75 years: No IV loading dose. Administer 0.75 mg/kg s.c. every 12 hours;
Renal impairment (CrCl <30 mL/min): No IV loading dose. Administer 1 mg/kg s.c. every 24 hours.
• Supplemental IV bolus dose for patients who will receive PCI after >1 dose of therapeutic enoxaparin: 0.3 mg/kg if last
enoxaparin dose was given 8 to 12 hours earlier; no supplemental IV dose if last enoxaparin dose was within 8 hours; use
UFH if last enoxaparin dose was more than 12 hours ago.
•Dosing of UFH: IV bolus 60 to 100 U/kg to a maximum of 4000 U, f/b an IV infusion of 12 units/kg per hour (maximum 1000 U/hr)
adjusted to achieve a goal aPTT of approximately 50 to 70 seconds (1.5 to 2 times control).
•Dosing of fondaparinux: 2.5 mg intravenously, followed by 2.5 mg s.c. every 24 hours. avoided in CrCl <30 mL/min.

3. For patients not receiving reperfusion therapy, we use enoxaparin or UFH.

Dosing of enoxaparin: Dose same as for patients treated with fibrinolysis
 STEMI – Late presenters (>12-24hrs)
• For patients with symptoms of >12 hours, fibrinolytic therapy is not indicated, but
emergent PCI may be considered, particularly for patients with evidence of ongoing
ischemia or those at high risk of death.

• The 2013 ACCF/AHA STEMI guidelines state that “Delayed PCI of a totally occluded
infarct artery greater than 24 hours after STEMI should not be performed in
asymptomatic patients with 1- or 2-vessel disease if they are
hemodynamically(clinically) and electrically stable and don’t have evidence of severe
ischemia”

Clinical stability is defined as “absence of low cardiac output or hypotension,

persistent tachycardia, apparent shock, high-grade ventricular or symptomatic
supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.”
 STEMI – Late presenters (>12-24hrs)
• The 2017 Cardiological Society of India for the management of STEMI states –
In late presenters of STEMI (>24 hours) with evidence of shock, pulmonary edema,
electrical instability, or ongoing ischemia, coronary angiogram with intent to
revascularize should be done asap.

• In addition, clinically stable patients with diabetes and LVEF below 40% should
undergo a coronary angiogram with PCI if subtotal occlusion is there. In cases of
total occlusion, myocardial viability needs to be established prior to PCI.

• Hemodynamically stable patients without high-risk features should undergo a

stress test prior to discharge based on which a decision to revascularize should be
made.
 NSTEMI
• FIBRINOLYSIS IS NOT DONE
Immediate angiography and revascularization — Pts who have a NSTE-ACS and one or
more of the following characteristics are at extremely high risk of an adverse
cardiovascular event in the short term:

1. Hemodynamic instability or cardiogenic shock

2. Severe left ventricular dysfunction or heart failure
3. Recurrent or persistent rest angina despite intensive medical therapy
4. New or worsening mitral regurgitation or new ventricular septal defect
5. Sustained ventricular arrhythmias

We recommend that patients with any of these five characteristics be referred

for immediate coronary arteriography and revascularization – INVASIVE APPROACH
(No time frame has been mentioned but the majority undergo within 24 hours)
ANTIPLATELET THERAPY (IN ADDITION TO ASPIRIN) TO ALL PATIENTS:

1. Patients treated with NON-INVASIVE APPROACH: TICAGRELOR LOADING DOSE 180 mg. For these patients who
are at very high risk (recurrent ischemic discomfort, dynamic ECG changes, or hemodynamic instability), consider
adding a GP IIb/IIIa inhibitor

2. For patients managed with an INVASIVE APPROACH: TICAGRELOR LOADING DOSE OF 180 mg at presentation.
Prasugrel loading dose of 60 mg may be used as an alternative.

For patients aged 75 years or older, who weigh less than 60 kg, or with past stroke or TIA, ticagrelor or clopidogrel
are preferred to prasugrel.
Clopidogrel may be given in a dose of 300 to 600 mg, but prefer 600 mg.

For patients treated with an invasive approach & who receive bivalirudin, GP IIb/IIIa inhibitor not recommended;
For those patients treated with heparin and who are troponin-positive, add a GP IIb/IIIa inhibitor (abciximab or
eptifibatide) after diagnostic angiography.

For those undergoing an invasive approach who are at very high risk (recurrent ischemic discomfort, dynamic ECG
changes, hemodynamic instability), consider adding a GP IIb/IIIa inhibitor both prior (eptifibatide/tirofiban) and after
diagnostic angiography (abciximab or eptifibatide)
ANTICOAGULANT THERAPY IN ALL PATIENTS:

1. For patients undergoing URGENT CATHETERIZATION (WITHIN 4 HRS) or those managed with an EARLY INVASIVE
STRATEGY (ANGIOGRAPHY WITHIN 4 TO 48 HRS), use either heparin or bivalirudin.
Prefer initiation of heparin in the ER and switch to bivalirudin in the catheterization laboratory.

•Dose of UFH: IV bolus of 60 to 70 units/kg (max. 5000U), f/b by an IV infusion of 12 U/kg per hour to achieve aPTT
of 50-70 seconds (1.5 to 2 times control).

•Dose of bivalirudin: IV bolus of 0.1 mg/kg and an infusion of 0.25 mg/kg per hour before angiography.
After PCI an additional 0.5 mg/kg bolus is given, and infusion rate is increased to 1.75 mg/kg per hour.

2. For patients receiving a NONINVASIVE APPROACH, we recommend either fondaparinux or enoxaparin.

•Enoxaparin: Dosing is 1 mg/kg s.c. every 12 hours; renal impairment (CrCl <30 mL/min): 1 mg/kg s.c. every 24
hours. No loading dose is necessary.

•Fondaparinux: 2.5 mg s.c. every 24 hours. This drug should be avoided in patients with a CrCl <30 mL/min.
 PRIMARY ANGIOPLASTY REGISTRY OF KERALA
• Two important studies on Cardiovascular Sciences were published from Kerala, the
Kerala Acute Coronary Syndrome (ACS) Registry and the Cardiological Society of India
(CSI), Kerala Chapter Coronary Artery Disease and its Risk Factors Prevalence
Study (CSI Kerala CRP Study).

• Clinician-initiated prospective state-wide longitudinal hospital-based registry of

patients undergoing primary PCI for STEMI.
• The registry aims to document the efficacy and safety of the real-world use of primary
PCI in Indian patients presenting with STEMI, in order to achieve regional adoption of
global standard performance indicators.
• the registry also analyzes procedural variations in the performance of primary PCI and
assesses its impact on relevant patient-centered outcomes.
• Proves that even in a resource-poor setting, high-quality cardiovascular research can be
undertaken successfully
 • BRAUNWALD’s Heart Disease: a textbook of
cardiovascular medicine 11TH edition
• https://www.ahajournals.org/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PM
REFERENCE C5313452/
S • https://www.uptodate.com/
• API UPDATE 2021 volume 1
• Indian Heart Journal 69 (2017) 777–783
THANK YOU