2. Tatalaksana MCI Di Praktek Umum in ACS PDUI-Dr

8/10/2019 2. Tatalaksana MCI Di Praktek Umum in ACS PDUI-Dr

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Tatalaksana MCI/SKA di

praktek dokter umum

Daniel Tobing

Department of Cardio logy and Vascular Medicine

Faculty of Medicine, University of Indonesia

National Cardiac Centre Harapan Kita


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ACS Is a Growing Worldwide Problem:

Acute MI 20012011

US 2001 2011

Incident MI 405,100 485,200

Europe* 2001 2011

Incident MI 291,100 327,700

Japan 2001 2011Incident MI 23,200 28,400

Decision Resources, Inc.

*Estimates for Europe cover France, Germany, Italy, Spain, and the UK


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Harapan Kita Hospital

Percentage of patient diagnosed with ACS

admitted to emergency room

8060

1499

(18,6%)

8306

1678

(20,2%)

8007

1882

(23,5%)

7663

2332

(30,4%)

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Patient

2005 2006 2007 2008

Year

Total patient admitted to ER Number of ACS patient

Source: Medical record unit + ER report


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Harapan Kita Hospital

ACS registry patient distribution

2007-2009

Consecutive ACS

N= 1073

STEMIN= 359 (33,5%)

NSTEMIN= 330 (30,8%)

FibrinolyticN= 57 (15,9%)

Primary PCIN= 82 (22,8%)

No reperfusionN= 220 (61,3%)

UAPN= 384 (35,8%)


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ST SEGMEN ELEVASI MI


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Symptom

Recognition

Call toMedical System ED

Cath LabPreHospital

Delay in Initi ation of Reperfusion Therapy

Increasing Loss of Myocytes

Treatment Delayed is Treatment Denied


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Options for Transport of Patients With

STEMI and Initial Reperfusion Treatment

EMS Transport

Onset of

symptoms of

STEMI

9-1-1

EMS

Dispatch

EMS on-scene Encourage 12-lead ECGs.

Consider prehospital fibrinolytic if

capable and EMS-to-needle within

30 min.GOALS

PCI

capable

Not PCI

capable

Hospital fibrinolysis:

Door-to-Needle

within 30 min.

Inter-

Hospital

Transfer

Golden Hour = first 60 min. Total ischemic time: within 120 min.

Patient EMS Prehospital fibrinolysis

EMS-to-needle

within 30 min.

EMS transpor t

EMS-to-balloon within 90 min.

Patient self-transport

Hospital door-to-balloon

within 90 min.Dispatch

1 min.

5

min.8

min.


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Rapid Assessment of STEMI

HISTORY

EXAMINATIONECG

CARDIAC ENZYMES

CXR

OTHERS


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ED Evaluation of

Patients With STEMI

1. Airway, Breathing, Circulation (ABC)

2. Vital signs, general observation

3. Presence or absence of jugular venous distension

4. Pulmonary auscultation for rales5. Cardiac auscultation for murmurs and gallops

6. Presence or absence of stroke

7. Presence or absence of pulses

8. Presence or absence of systemic

hypoperfusion (cool, clammy,

pale, ashen)

Brief Physical Examination in the ED


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Diagnosis of ACS

Presentation: Classic story most oftenseen in younger (50-65) patients, males

Those who present atypically tend topresent further on in their disease andhave worse outcomes (REACT)

Typical versus Atypical

Elderly: tend to present with shortness ofbreath

Diabetics: vague symptoms

Women: complain of feeling fatigued

Missed Diagnosis of Acute Cardiac Ischemia in the

Emergency Department.

N Engl J Med. 2000. April 20; 342 (16): 1163-70.


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Symptoms

Chest pain (variously described, but

classically it is pressure-like)

Shortness of breath

Nausea/Vomiting (especially in

inferior MI)

Diaphoresis

Weakness

Syncope


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ECG

Very specific and a good test, particularlyhelpful if positive:

Should be done with in 10 minutes of arrivalon anyone with suspected ACS

Serial ECGs in the ED are a must whenlooking for changes, especially if the patientis initially pain-free or has atypicalsymptoms

Can have a normal ECG with significantdisease, particularly if the patient is painfree

Tells us the most likely artery affected andarea of myocardium affected

Kumar, Amit, et al. Acute Coronary Syndromes: Diagnos is and Management,Part 1. Mayo Clin Proc. October 2009;84(10):917-938


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ECG

Inferior : II, III, AVf

Anterior : V1-V6

Lateral : I, AVL, V5, V6

Posterior: depression V1-V3 with tall Rwaves

Right ventricular infarct: right sidedleads

Wellens (indicates significant LADdisease) : T wave inversions V2-V4without pain


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Inferior MI


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Right Ventricular MI


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Lateral MI


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Laboratory Examinations

Laboratory examinations should be performed as part of the

management of STEMI patients, but should not delay the

implementation of reperfusion therapy.

Serum biomarkers for cardiac damage Complete blood count (CBC) with platelets

International normalized ratio (INR)

Activated partial thromboplastin time (aPTT)

Electrolytes and magnesium

Blood urea nitrogen (BUN) Creatinine

Glucose

Complete lipid profileACC/AHA 2007 STEMI Guidelin es Focused Update


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Biomarkers

CK, CK-MB, myoglobin, Troponin I,Troponin T

CK: not specific or sensitive, not a goodmarker

CKMB: low sensitivity early (


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Biomarkers

Troponin T or I: most cardiac specific butnot sensitive in the first 6 hours after onsetof pain

Preferred marker, if available

Troponin is also an independent predictorof outcomes.

Patients with symptoms consistent withACS need to have biomarkers re-measured at 8-12 hours after symptomonset

Anderson JL et al. J Am Coll Card 2007. 50(7): e1-157


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Cardiac-specific troponins should be used as theoptimum biomarkers for the evaluation of patients

with STEMI who have coexistent skeletal muscle

injury.

For patients with ST elevation on the 12-lead ECG

and symptoms of STEMI, reperfusion therapy

should be initiated as soon as possible and is not

contingent on a biomarker assay.

Biomarkers of Cardiac Damage

ACC/AHA 2007 STEMI Guidelin es Focused Update


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Universal Defenition of MI 2007


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Reperfusion Strategies


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Reperfusion Therapy

Reperfusion therapy is indicated in all patients with

history of chest pain/discomfort of ,12 h and with

persistent ST-segment elevation or (presumed)

new left bundle-branch block

Reperfusion therapy should be considered if there is

clinical and/or ECG evidence of ongoing ischaemia

even if, according to patient, symptoms started .12 h

before

Reperfusion using PCI may be considered in stable

patients presenting .12 to 24 h after symptom onset

PCI of a totally occluded infarct artery .24 h after

symptom onset in stable patients without signs ofischaemia

Class Level

I A

II A C

II B B

III B


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Fibrinolytics

Indications: ST segment elevation of at least 1mm in tw o or

more contiguous leads

Pain for < 12 hours

Symptoms consistent with acute myocardialinfarction

No contraindications

Fibrinolytics are particularly effective within the firstsix hours after pain onset and in those with newleft bundle branch block and anterior wallmyocardial infarctions

Kumar, Amit and Christopher Cannon.Acu te Coronary Syndrome: Diagn osis and Management, Part II .Mayo Clin Proc. November 2009;84(11):1021-36


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Fibrinolytics

Absolute Contraindications:Any previous ICH

Known structural cerebrovascular lesions

Known malignant intracranial neoplasm

Ischemic stroke within 3 months, except foracute ischemic stroke within 3 hours

Suspected aortic d issection

Active bleeding or bleeding diathesis(excluding menses)

Severe closed head or facial trauma within 3months


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Fibrinolytics

Streptokinase: reduces mortalitysignificantly (ISIS-1), lowest cost

Retevase: no difference between Retevaseand tPA (GUSTO III) but easy dosing for ER(10 mg bolus 30 minutes apart)

Alteplase (tPA):GISSI-2, ISIS-3, GUSTOshowed likely more favorable outcome thanstreptokinase; tPA slightly more likely tocause intracranial hemorrhage

Tenecteplase (TNK): equivalent to tPA,

weight based dosing may make it moredifficult for ER patients, however, it is a onetime dose


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Effect of fibrinolytic therapy on mortality riskaccording to findings on admission electrocardiography.

Kumar A , Cannon C P Mayo Clin Proc. 2009;84:1021-1036


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PCI in STEMI

Coronary angioplasty with or withoutstenting

Preferred at centers where availableas some studies point to betteroutcomes than fibrinolytics(GUSTOIIb).

Depends on whether it is available atyour facility and how quickly the

patient can get to the cath lab


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Treatment of STEMI

Many of the same anti-platelet andanti-thrombin therapies used

Fibrinolytics are indicated in STEMI

but not in UA/NSTEMI Emergency physicians are held tomultiple benchmarks for STEMI (doorto ECG, door to medications, door toballoon time)


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Newer Modalities

Coronary CT angiogram to diagnoseCAD and/or ACS

Bivalirudin: ACUITY trial showedsimilar 30 day rates of death, MI orunplanned revascularisation withlower bleeding rates in the bivalirudinalone arm.

Stone, GW et al. Bivalirudin fo r patients with acute coronary syndromes. N Engl J

Med 2006; 355: 2203-16


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NON-ST ELEVATION MI


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Importance of Oral Platelet Inhibition in the Care of

Acute Coronary Syndromes

Invasive vsNoninvasiveStrategy

Secondary Prevention

Risk Assessment

Early Invasive

Medical Treatment

Preclinical Care Hospital Treatment

Diagnosis


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First line for diagnosis and treatment

Earlier treatment = better outcomes

When to refer ??

We will miss some people with ACS, butwe can minimize it by being aware of theincorrect assumptions

Discuss and coordinate with your

hospitals cardiology department to havea stream-lined plan for ACS patients

Role of general physician

(Conclusion)


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2. Tatalaksana MCI Di Praktek Umum in ACS PDUI-Dr

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