KULIAH PENANGANAN MCI

The Management of Patients with Acute Myocardial Infarction

Report of The American College of Cardiology/ American Heart Association Task Force on Practice Guidelines April 2000

Emergency Department (ED) Algorithm/Protocol for Patients with Symptoms and Sign of AMI
Onset of symptoms

Ambulance presents patient to ED lobby

Patient presents to ED lobby

ED triage or charge nurse triages patient AMI symptoms and signs 12 lead ECG Brief, targeted history

Emergency nurse initiates emergency nursing care in acute care area of ED Cardiac monitor Blood studies Oxygen therapy Nitroglycerin IV D5W Aspirin

Emergency physician evaluates patient History Physical exam Interpret ECG

Yes

AMI Patient ?

Uncertain
Consult

No
Candidate for fibrinolytic therapy ?

Uncertain
Consult Evaluate further

Yes
Fibrinolytic therapy

No
Other indicated treatment: Other drugs for AMI (beta-blockers, heparin, aspirin, nitrates) Transfer to cath lab for PTCA or surgery for CABG Conduct education and follow-up instruction

Admit

Release

Differential Diagnosis of Prolonged Chest Pain

AMI Aortic dissection Pericarditis Atypical anginal pain associated with hypertrophic cardiomyopathy Esophageal, other upper gastrointestinal, or biliary tract disease Pulmonary disease Pneumothorax Embolus with or without infarction Pleurisy : infectious, malignant, or immune disease-related Hyperventilation syndrome Chest wall Skeletal Neuropathic Psychogenic

Algorithm for Initial Assessment and Evaluation of the Patient with Acute Chest Pain
Chest pain consistent with coronary ischemia Within 10 minutes Initial evaluation 12 lead ECG Establish IV access Establish continuous ECG monitoring Blood for baseline Aspirin 160 325 mg chewed serum cardiac markers Therapeutic/Diagnostic tracking according to 12-lead ECG results
Continue evaluation/monitoring in Emergency Department or Chest Pain Unit Serial serum cardiac marker levels-MB CK subforms Serial ECGs Consider noninvasive evaluation of ischemia Consider alternative diagnoses Assess suitability for reperfusion : ? Contraindications for fibrinolysis Availability and appropriateness of primary angioplasty Initiate anti-ischemia therapy Beta-blocker Nitroglycerin Analgesia

Anti-ischemia Therapy Analgesia

No evidence of MI or ischemia

MI or demonstrable ischemia

Admit to unit of appropriate intensity

Admission blood work

Discharge with follow-up as appropriate (Goal 8-12 hours)

Admission blood work - CBC - Electrolytes, BUN, creatinine - Lipid profile

Initiate fibrinolysis if indicated. Goal : 30 minutes from entry to ED

Primary PTCA, if available and suitable. (Goal : PTCA within 90 s 30 minutes)

Admit - CCU

Enzymatic Criteria for Diagnosis of Myocardial Infarction

 Serial increase, then decrease of plasma CKMB, with a change > 25% between any two values  CK-MB > 10-13 U/L or > 5% total CK activity  Increase in MB-CK activity > 50% between any two samples, separated by at least 4 hrs  If only a single sample available, CK-MB elevation > twofold  Beyond 72 hrs, an elevation of troponin T or I or LDH-1 > LDH-2

Recommendations for the Management of Patients with ST Elevation

ST elevation Aspirin; Beta-blocker e 12 h Eligible for fibrinolytic therapy Fibrinolytic therapy contraindicated Not a candicate for reperfusion therapy > 12 h Persistent symptoms ?

Fibrinolytic therapy

Primary PTCA or CABG

No Other medical therapy : ACE inhibitors ? Nitrates Anticoagulants

Yes Consider Reperfusion Therapy

Contraindications and Cautions for Fibrinolytic Use in Myocardial Infarction

Absolute contraindications  Previous hemorrhagic stroke at any time : other strokes or cerebrovascular events within 1 yr  Known intracranial neoplasm  Active internal bleeding (does not include menses)  Suspected aortic dissection

Contraindications and Cautions for Fibrinolytic Use in Myocardial Infarction

Cautions/Relative Contraindications  Severe uncontrolled hypertension on presentation (BP > 180/110 mmHg)  History of prior cerebrovascular accident or known intracerebral pathology not covered in contraindications  Current use of anticoagulants in therapeutic doses (INR u 2-3); known bleeding diathesis  Recent trauma (within 2-3 wks), including head trauma  Noncompressible vascular punctures  Recent (within 2-4 wks) internal bleeding  For streptokinase/anistreplase : prior exposure (especially within 5d-2y) or prior allergic reaction  Pregnancy  Active peptic ulcer  History of chronic hypertension

Recommendations for the Management of Patients with Non-ST Elevation MI

ST depression/T-wave inversion : Susptected AMI Heparin + Aspirin; Nitrates for recurrent angina Antithrombins : LMWH high-risk patients Anti-Platelets : GpIIb/IIIa inhibitor Patients without prior betablocker therapy or who are inadequately treated on current dose of beta-blocker Establish adequate beta-blockade Persistent symptoms in patients with rpior beta-blocker therapy or who cannot tolerate betablockers Add calcium antagonist

Assess clinical status High-risk patient : 1. Recurrent ischemia 2. Depressed LV function 3. Widespread ECG changes 4. Prior MI Catheterization : Anatomy suitable for revascularization ? Yes Revascularization (PTCA, CABG)
Continued observation in hospital Consideration of stress testing

Clinical stability

No Medical Therapy

Pharmacologic Management of Patients with MI

Heparin Recommendation
Class I Recommendations 1. In patients undergoing percutaneous on surgical revascularization

Class IIa Recommendations 1. Intravenously in patients undergoing reperfusion therapy with alteplase/reteplase. See table below for dosing :
1999 Recommendations Bolus Dose Maintenance Maximum aPTT 60 U/kg } 12 U/kg/hr 4000 U bolus 1000 U/h if > 70 kg 1.5-2.0 x control (50-70 sec) for 48 hrs

Pharmacologic Management of Patients with MI

2. Intravenous unfractionated heparin (UFH) or low molecular weight heparin (LMWH) subcutaneously for patients with nonST elevation MI. 3. Subcutaneous UFH (eg. 7.500 b.i.d) or low molecular weight heparin (eg. Enoxaparin 1 mg/kg b.i.d) in all patients not treated with fibrinolytic therapy who do not have a contraindication to heparin. In patients who are at high risk for systemic emboli (large or anterior MI, AF, previous embolus, or known LV thrombus), intravenous heparin is preferred. 4. Intravenously in patients treated with nonselective fibrinolytic agents (streptokinase, anistreplase, urokinase) who are at high risk for systemic emboli (large or anterior MI, AF, previous embolus, or known LV thrombus).

MI Management Summary
Initial Management in ED  Initial evaluation with ECG in < 10 minutes  O2 by nasal prongs, IV access, continual ECG  Sublingual TNG unless SBP < 90 or HR < 50 or >
   
100 Analgesia (MS or meperidine) Aspirin (160-325 mg chwed) Lipid panel, electrolytes, magnesium, enzymes Fibrinolysis or PTCA if ST elevation > 1 mV or LBBB (goal : door-needle < 30 minutes or doordilatation < 90 minutes)

MI Management Summary
MI Management in 1st 24 hours  Limited activity for 12 hrs, monitor u 24 hrs  No prophylactic antiarrhythmics  IV heparin if : a) large anterior MI; b) PTCA; c)

    

LV thrombus; or d) alteplase/reteplase use (for ~ 48 hrs) SQ heparin for all other MI (7,500 u b.i.d) Aspirin indefinitely IV TNG for 24-48 hrs if no o/q HR or qBP IV beta-blocker if no contraindications ACE inhibitor in all MI if no hypotension

MI Management Summary
In-Hospital Management in  Aspirin indefinitely  Beta-blocker indefinitely  ACE inhibitor (DC at ~ 6 wks if no LV dysfunction)  If spontaneous of provoked ischemia elective

   

cath Suspected pericarditis ASA 650 mg q4-6 hrs CHF ACE inhibitor and diuretic as needed Shock consider intra-aortic balloon pump + cath with PTCA or CABG RV MI-fluids (NS) + inotropics if hypotensive

The Management of Patients with Chronic Stable Angina

Report of The American College of Cardiology/ American Heart Association Task Force on Practice Guidelines March 2000

Clinical Assessment
a. Recommendations for History and Physical
Angina is a clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back, or arm. It is typically aggravated by exertion or emotional stress and relieved by nitroglycerin. Angina usually occurs in patients with CAD involving u 1 large epicardial artery, but can also occur in individuals with other cardiac problems

Clinical Assessment
b. Recommendations for Initial Laboratory Tests, ECG, and Chest X-Ray for Diagnosis
1. Hemoglobin 2. Fasting glucose 3. Fasting lipid panel, including total cholesterol, HDL cholesterol, triglycerides, and calculated LDL cholesterol 4. Rest electrocardiogram (ECG) in patients without an obvious noncardiac cause of chest pain 5. Rest ECG during an episode of chest pain 6. Chest x-ray in patients with signs or symptoms of congestive heart failure, valvular heart disease, pericardial disease, or aortic dissection/aneurysm

Treatment
Recommendations for Pharmacotherapy to prevent MI and Death and Reduce Symptoms Class I
1. 2. 3. 4. 5. 6. Aspirin in the absence of contraindications Beta-blockers as initial therapy in the absence of contraindications in patients with prior MI Beta-blockers as initial therapy in the absence of contraindications in patients without prior MI Calcium antagonists and/or long-acting nitrates as initial therapy when betablockers are contraindicated Calcium antagonists and/or long-acting nitrates in combination with betablockers when initial treatment with beta-blockers is not successful Calcium antagonists and/or long-acting nitrates as a substitute for betablockers if initial treatment with beta-blockers leads to unacceptable side effects Sublingual nitroglycerin or nitroglycerin spray for the immediate relief of angina Lipid-lowering therapy in patients with documented or suspected CAD and LDL cholesterol > 130 mg/dL with a target LDL of < 100 mg/dL

7. 8.

Treatment
Recommendations for Pharmacotherapy to prevent MI and Death and Reduce Symptoms Class IIa
1. Clopidogrel when aspirin is absolutely contraindicated 2. Long-acting nondihydropyridine calcium antagonists instead of beta-blockers as initial therapy 3. Lipid-lowering therapy in patients with documented or suspected CAD and LDL cholesterol 100 to 129 mg/dL, with a target LDL of 100 mg/dL

Treatment
Basic Treatment / Education
     Aspirin and Anti-anginal therapy Beta-blocker and Blood pressure Cigarette smoking and Cholesterol Diet and Diabetes Education and Exercise

Treatment
Coronary Disease Risk Factors and Evidence that Treatment can Reduce the Risk for Coronary Disease Events
1. Treatment of hypertension according to NHLBI Joint National Conference VI Report on Prevention, Detection, and Treatment of High Blood PRessure 2. Smoking cessation therapy 3. Management of diabetes 4. Exercise training program 5. Weight reduction in obese patients in the presence of hypertension, hyperlipidemia, or diabetes mellitus

Chest Pain Low

Clinical Assessment
No
History and appropriate No diagnostic tests Yes probability of demonstrate noncardiac CAD cause of chest pain Reconsider probability or CAD. Initiate primary prevention

History suggests intermediate to high probability of CAD

Yes
Intermediate or high risk unstable angina?

Features of intermediate- or high-risk Unstable Angina : Rest pain lasting > 20 min Age > 65 years ST and T wave change Pulmonary edema

Yes
Treat Appropriately See AHCPR Unstable Angina Guideline See appropriate ACC/AHA Guideline Angina resolves with treatment of underlying condition ?

No
Recent MI, PTCA, CABG ?

Yes

No
Conditions present that could cause angina? e.g., severe anemia, hyperthyroidism

Yes

Yes

Conditions present that could cause angina? e.g., severe anemia, hyperthyroidism

Yes

Angina resolves with treatment of underlying condition ?

Yes

No No
History and/or exam suggests valvular, pericardial disease or ventricular dysfunction Enter Stress Testing/Angiography Algorithm

Yes

Echocardiogram LV Abnormality ?

Severe primary valvular lesion ?

Yes

No No Yes
High probability of Yes CAD based on history, exam, ECG Indication for prognostic/risk assessment ?

See AHCPR ACC/AHA Valvular Heart Disease Guideline

No

Empiric therapy

Enter Treatment Algorithm

No Yes
Enter Stress Testing/Angiography Algorithm Factors necessary to determine the need for risk assessment Comorbidity Patient Preferences

For diagnosis (and risk stratification) in patients with chest pain and an intermediate probability of CAD OR For risk stratification in pts with chest pain and a high probability of CAD

Stress Testing/ Angiography

No
Need to guide medical management ?

No

Yes
Contraindications to stress testing ?

Yes
Consider coronary angiography

No
Symptoms or clinical findings warranting angiography ?

Yes

No Yes
Patient able to exercise ? Pharmacological imaging study

No

Yes
Previous coronary revascularization ?

Yes

No
Resting ECG interpretable ?

No

Exercise imaging study

Yes Yes
Perform exercise test

Test results suggest high-risk ?

No
Adequate information on diagnosis and prognosis available?

Test results suggest high-risk

Yes

Consider coronary angiography revascularization

Yes

No
Adequate information on diagnosis and prognosis available?

No

No

Consider imaging study angiography

Consider coronary angiography Enter Treatment Algorithm

Yes

Anti-anginal Drug Treatment Sublingual NTG History suggests Vasospastic angina? (Prinzmetal)

Chest pain Intermediate to high probability of CAD High-risk CAD unlikely Risk stratification complete or not required

Yes

Ca channel blocker, Long acting nitrate therapy Treat appropriately

Treatment
Successful Treatment ?

No
Medications or conditions that provoke or exacerbate angina?*

Yes

Yes

No

Yes
Beta-blocker therapy if no contraindication (Espec. If prior MI or other indication)

Yes

Successful Treatment ?

Serious

contraindication

Add or substitue CA channel blocker if no contraindication

Yes

Successful Treatment ?

Yes
Consider revascularization therapy

Serious

contraindication
Successful Treatment ?

No No

Add long-acting nitrate therapy if no contraindication

Yes

Yes

Education and Risk Factor Modification Initiate educational program Aspirin 81 to 325 mg OD if no contraindication Serious adverse effect or contraindication

Clopidogrel

Yes
Cigarette Smoking

No
Cholesterol High ?

Yes

Smoking Cessation program

See NCEP Guidelines

No
Blood Pressure High ?

Yes
See JNC VI Guidelines

Yes

Routine Follow Up including (as appropriate) : Diet, Exercise program, Diabetes management

Treatment
* Conditions that exarcebate or provoke angina Medications : Vasodilators Excessive thyroid replacement vasoconstrictors Other medical problem Profound anemia Uncotrolled hypertension Hyperthyroidism hypoxemia Other cardiac problems Tachyarrhythmias Bradyarrhythmias Valvular heart disease (espec AS) Hypertrophic cardiomyopathy

Clinical Classification of Chest Pain

Typical angina (definite) (1) Substernal chest discomfort with a characteristic quality and duration that is (2) provoked by exertion or emotional stress and (3) relieved by rest or nitroglycerin Atypical angina (probable) Meets 2 or the above characteristics Noncardiac chest pain Meets e of the typical angina characteristics

Pretest Likelihood of CAD in Symptomatic Patients According to Age and Sex

Nonanginal Chest Pain Age, y 30 40 50 39 49 59 Men 4 13 20 27 Women 2 3 7 14 Atypical Angina Men 34 51 65 72 Women 12 22 31 51 Typical Angina Men 76 87 93 94 Women 26 55 73 86

60 - 69

COR PULMONALE CHRONICUM (CPC)

Hipertrofi & dilatasi ventrikel kanan sebab hipertensi pulmonal akibat peny. parenkim dan/atau vaskuler paru (antara a. pulmonal utama dan masuknya vv pulmonal ke atrium kiri)

Etiologi Utama
Penyakit paru obstruktif khronis (PPOK) akibat bronkhitis khronis atau emfisema paru

ETIOLOGY OF PULMONARY HEART DISEASE (1)

I. DISEASES AFFECTING THE PULMONARY VASCULATURE A. Primary diseases of the arterial wall (1) Primary pulmonary hypertension (2) Granulomatous pulmonary arteritis (3) Toxin-induced pulmonary hypertension a. Aminorex fumarate b. Intravenous drug abuse (4) Chronic liver disease (5) Peripheral pulmonic stenosis B. Thrombotic disorders (1) Sickle cell diseases (2) Pulmonary microthrombi C. Embolic disorders (1) Thromboembolism (3) Other embolism (amniotic fluid, air) (2) Tumor embolism (4) Schistosomiasis and other parasitic diseases II. PRESSURE ON PULMONARY ARTERIES BY MEDIASTINAL TUMORS, ANEURYSMS, GRANULOMATA, OR FIBROSIS III. DISEASES OF THE NEUROMUSCULAR APPARATUS AND CHEST WALL A. Neuromuscular weakness D. Pleural fibrosis B. Kyphoscoliosis E. Sleep apnea syndromes C. Thoracoplasty F. Idiopathic hypoventilation

ETIOLOGY OF PULMONARY HEART DISEASE (2)

IV. DISEASES AFFECTING AIR PASSAGES OF THE LUNG AND ALVEOLI A. Chronic obstructive pulmonary diseases B. Cystic fibrosis C. Congenital development defects D. Infiltrative or granulomatous diseases (1) Idiopathic pulmonary fibrosis (2) Sarcoidosis (3) Pneumoconiosis (4) Scleroderma (5) Mixed connective tissue disease (6) Systemic lupus erythematosus (7) Rheumatoid arthritis (8) Polymyositis (9) Eosinophilic granuloma (10) Malignant infiltration (11) Radiation E. Upper airways obstruction F. Pulmonary resection G. High-altitude disease

PATHOGENESIS OF COR PULMONALE

Chronic lung disease Reduction in pulmonary vascular bed Acidosis and hypercapnia Polycythemia and hyperviscosity Pulmonary hypertension Hypertrophy and dilatation of the right ventricle Right ventricular failure

Hypoxia

PEMERIKSAAN PENDERITA CPC

Klinis : Pemeriksaan fisik susah karena emfisema pulm pada PPOK Systolic parasternal heave Tricuspid regurgitation P2 > Tanda gagal jantung kanan EKG :Sangat spesifik, kurang sensitif

ELECTROCARDIOGRAPHIC CHANGES IN COR PULMONALE (1)

ECG CRITERIA FOR COR PULMONALE WITHOUT OBSTRUCTIVE DISEASE OF THE AIRWAYS 1. Right-axis deviation with a mean QRS axis to the right of + 110 o 2. R/S amplitude ratio in V1 > 1 3. R/S amplitude ratio in V6 < 1 4. Clockwise rotation of the electrical axis 5. P-pulmonale pattern 6. S 1Q3 or S 1S 2S 3 pattern 7. Normal voltage QRS

ELECTROCARDIOGRAPHIC CHANGES IN COR PULMONALE (2)

ECG CHANGES IN CHRONIC COR PULMONALE WITH OBSTRUCTIVE DISEASE OF THE AIRWAYS 1. Isoelectric P waves in lead I or right-axis deviation of the P vector 2. P-pulmonale pattern (an increase in P-wave amplitude in II, III, AVf) 3. Tendency for right-axis deviation of the QRS 4. R/S amplitude ratio in V6 < 1 5. Low-voltage QRS 6. S1Q3 or S1S2S3 pattern 7. Incomplete (and rarely complete) right bundle branch block 8. R/S amplitude ratio in V1 > 1 9. Marked clockwise rotation of the electrical axis 10. Occasional large Q wave or QS in the inferior or midprecordial leads, suggesting healed myocardial infarction

X-Thorax Jantung dapat normal, atau membesar dengan apeks terangkat Dilatasi konus pulmonal + cabang besarnya, sedangkan cabang-cabang kecil tak terlihat karena vasokonstriksi PPOK : kelainan paru-paru terlihat Ekhokardiografi Doppler - ekho : - Tek. a. pulmonalis - TR - RV dilatasi

HIPOKSIA
Sebab terpenting hipertensi pulmonal pada PPOK Vasokonstriksi pulmonal (langsung atau lewat pelepasan zat vasoaktif) Proliferasi sel endotel dan penebalan intima arteriol Hipertrofi tunica media a. pulmonal Vasodilatasi terhambat

PENGELOLAAN
OKSIGEN Diberikan kontinu 1-2 l/menit, dapat memperbaiki prognosis karena mengurangi vasokonstriksi pulmonal dan memperbaiki hipoksia DIGITALIS Hanya bila juga ada gagal jantung kiri atau pada gagal jantung kanan akut THEOPHYLLINE Bronkhodilatasi, fungsi RV - LV membaik BETA-ADRENERGIC AGONISTS Bronkhodilator VASODILATOR ? Atasi penyakit paru penyebabnya !!!

Mechanisms of salt and water disturbance in patients with COPD

RBF Effective renal plasma flow Dopamine Filtration fraction Peritubular oncotic pressure PCO 2 Tubular Na +- H + exchange PCO 2

Dopamine ANP PRA ANP

Plasma renin activity

Angiotensin II ANG II Plasma aldosterone Na + retention: edema Natriuresis ANP Dopamine

ANP AVP

Arginine vasopressin level

H 2O retention; hyponatremia