3.3 case presentation - medically managed acs - dr. triandika sp.jp

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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3.3 case presentation - medically managed acs - dr. triandika sp.jp

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