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8/18/2019 3.3 Case Presentation - Medically Managed ACS - Dr. Triandika Sp.jp
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Case presentation
Medically managed acs
patient
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Case
• 54 year old male with history of DM2 for 20 years, HTN, whopresented to the ED with 4 hour onset of chest pain which was described as in the anterior chest without radiation. Thepain seemed to improve when he sits down and worsening
when he walked upstairs
• VS: T 36.9, HR: 105, BP: 135/86, RR 22, O2 sat. 99% RA
• ECGs are shown as followed
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• What will you do?
– What’s your diagnosis?
– What should be done now?
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Acute Coronary Syndrome
Definition: a constellation of symptoms related toobstruction of coronary arteries with chest pain beingthe most common symptom in addition to nausea, vomiting, diaphoresis etc.
Chest pain concerned for ACS is often radiating to theleft arm or angle of the jaw, pressure-like in character,and associated with nausea and sweating. Chest pain isoften categorized into typical and atypical angina.
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EKG
STEMI:Q waves , ST elevations, hyper acute T waves; followed by T wave
inversions.
Clinically significant ST segment elevations: > than 1 mm (0.1 mV) in at least two anatomical contiguous leads
or 2 mm (0.2 mV) in two contiguous precordial leads (V2 and V3)
Note: LBBB and pacemakers can interfere with diagnosis of MI on EKG
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Cardiac Enzymes
• Troponin is primarily used for diagnosing MI because it has
good sensitivity and specificity.
– CK-MB is more useful in certain situations such as postreperfusion MI or if troponin test is not available
• Other conditions can cause elevation in troponin such asrenal failure or heart failure
• The increasing troponin trend is the important thing to look for in diagnosing MI. Order Troponin together with ECG
when doing serial testing to rule out ACS.
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Diagnosis
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A summary of important delays andtreatment goals in the management of acuteST-segment elevation myocardial infarction
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Early response: treatment is timecritical
Time from symptom onset and likely outcome
< 1 hour
Aborted heart attack or only little heart muscle damage
1 –2 hours
Minor heart muscle damage only2 –4 hours
Some heart muscle damage with moderate heart muscle salvage
4 –6 hours
Significant heart muscle damage with only minor heart muscle salvage
6 –12 hours
No heart muscle salvage (permanent loss) with potential infarcthealing benefit
> 12 hours
Reperfusion is not routinely recommended if the patient is
asymptomatic and haemodynamically stable
In cases of major delay to hospitalisation (> 30 minutes) ambulance crews should consider pre-
hospital fibrinolysis.
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Recommendations for reperfusion therapy
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Choice of reperfusion therapy
• In general, PCI is the treatment of choice, providing it can be performed
promptly by a qualified interventional cardiologist in an appropriate
facility.1
• All PCI facilities should be able to perform primary angioplasty within
90 minutes of patient presentation.
• Fibrinolysis should be considered early if PCI is not readily available.
Reference
1. Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184(8 Suppl):S9 –29.
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STEMI Management
Initial management for STEMI:
Cardiac monitor
Supplemental O2
Good IV access
Nitrates*Beta blocker
Morphine
Clopidogrel
AspirinCall expert
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Bleeding Risk
• age > 75 years• female
• history of bleeding
• history of stroke or transient ischaemic attack (TIA)
• creatinine clearance rate < 60 mL/min
• diabetes
• heart failure• tachycardia
• blood pressure < 120 mmHg or ≥ 180 mmHg
• peripheral vascular disease (PVD)
• anaemia
• concomitant use of GP IIb/IIIa inhibitor
• enoxaparin 48 hours prior
• switching between unfractionated heparin and enoxaparin
• procedural factors (femoral access, prolonged, intra-aortic balloon pump, right heartcatheterisation).
The following risk factors should be considered when assessing bleeding risk and choosing
antithrombotic therapies in patients with ACS (Grade B):
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FIBRINOLYSIS
Relative contraindications
• Current use of anticoagulants.
• Non-compressible vascular punctures.
• Recent major surgery (< 3 weeks).
• Traumatic or prolonged (> 10 mins) CPR.
• Recent internal bleeding (within 4 weeks).
• Active peptic ulcer.
• History of chronic, severe, poorly controlled hypertension.
• Severe uncontrolled hypertension on presentation (systolic ≥ 180 mmHg or
diastolic ≥ 110 mmHg).
• Ischaemic stroke > 3 months ago, dementia or known intracranial abnormality.
• Pregnancy.
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Fibrinolitic therapy
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Doses of antiplatelet & antithrombin
co-therapies
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Management of hyperglycaemia in
ST-segment elevation myocardial infarction
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Checklist of treatments when an ACS
diagnosis appears likely
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Measures checked at discharge
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hank You
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