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Assistant Professor & Head Department of Cardiology PUMHSW, Nawabshah (SBA).

ACS;STEMI/NSTEMI; Pathophysiology

Coronary plaque fissuring & rupture Platelet aggregation & activation Activation of coagulation cascade Generation of Thrombin Formation of thrombus Vasospasm Complete occlusion of coronary vessel In absence of collaterals lead to STEMI Partial obstruction--------NSTEMI

Differential Diagnosis

ACS; Clinical Diagnosis


History ECG within 5 minutes of presentation MONA(Previous guidelines) Establishment of eligibility criteria for reperfusion therapy

ST-segment elevation of >1mm in at least two contiguous leads New or presumably new onset LBBB. No contraindication to fibrinolytic therapy. Window period.

ACS; Initial Management


Admit in CCU. MONA; Morphine, Oxygen, NG, Aspirin. I/V line. History & Examination ( Rapid ). ECG; Thrombolytic??? Blood chemistry, Cardiac Enzymes. CXR ( Portable ).

ACS; Examination
Not helpful in diagnosis of AMI but it is helpful in

excluding other D/D Heamodynamic status of patient with MI Mechanical complication of MI Evidence of risk factors Evidence of other co-existing disease Risk stratification

STEMI; Exam:Risk stratification


KILLIP CLASSIFICATION Class Characteristics Pts;

Mortality 5% 13.6%

I II

No evid; of HF

85%

Rales, JVP,or S3 13%

III
IV

Pulm; edema
Card; shock

1%
1%

32.2%
57.8%

ACS; Antiplatelates

ACS; Management
Anti-coagulant therapy heparin, low molecular weight heparin (LMWH), warfarin, hirudin, hirulog

Thrombolytics are not indicated lytic agents may stimulate the thrombogenic process and result in paradoxical aggravation of ischemia and myocardial infarction

TIMI IIIB Investigators Circulation 1994; 89:1545-1556

ACS; Management

Beta Blockers

ACS; Management
a

ACEI

ACS; Management

Nitrates

ACS; Management

Statins

ACS; Management
General care
Diet Bowel Sleep Mobilization DM management if diabetic

UA/NSTEMI; Risk Stratification.

UA/NSTEMI; Cardiac Catheterization Indications


Prior revascularization (PCI or CABG).
CHF. Depressed LV function (EF<50%).

Malignant Ventricular Arrhythmias.


Persistent or Recurrent angina or ischemia Large perfusion defect on non-invasive functional

test. Significant valvular heart disease.

UA/NSTEMI; CABG/PCI
Age
Co morbidities Severity of CAD Prior revascularization procedures Technical feasibility Durability of percutaneous revascularization

AU/NSTEMI; CABG vs PCI


CABG preferred if; DM LVD Significant burden of CAD:

LMD 3-VD 2-VD with proximal LAD, LVD or ischemia on stress testing.

UA/NSTEMI
DESPITE OPTIMUM MEDICAL TREATMENT PATIENTS ARE AT RISK OF;
RECURRENT ANGINA MI DEATH

UA/NSTEMI;
EARLY DETERMINATION OF CORONARY

ANATOMY MAY IDENTIFY THE PATIENTS THAT WOULD BE MOST APPROPRIATELY TREATED WITH PCI OR SURGICAL REVASCULARIZATION, THEREFORE REDUCING COSTS, HOSPITAL ADMISSIONS AND LENGTH OF STAY

USA/NSTEMI: TREATMENT
THE ULTIMATE GOAL OF TREATMENT IS :

RESTORATION OF MYOCARDIAL

PERFUSION THROUGH RESTORATION OF CORONARY BLOOD FLOW

USA/NSTEMI: Catheter based Reperfusion

PERCUTANEOUS CORONARY INTERVENTION(PCI)

REPERFUSION: STEMI
RESTORATION OF BLOOD FLOW
Targets
Fibrinolytic: Door to needle time <30 minutes

Cath based: Door to balloon time <90minutes

STEMI; Fibrinolytic therapy


Streptokinase
Alteplase Reteplase Tenekteplase

STEMI; Cntraindications for Fibrinolytic therapy


Absolute
Any prior intracranial hemmorhage AVM Malignant intracranial neoplasm Ischemic stroke <3 months except < 3hrs Suspected aortic dissection Active bleeding or bleeding diathesis

Significant closed head or facial trauma <3month

STEMI; contraindications for thrombolytic therapy


Relative H/O chronic severe poorly controlled HTN Severe uncontrolled HTN on presentation (SBP>180 & DBP>110) History of prior ischemic stroke>3months, dementia, or known intracranial pathology Traumatic or prolonged CPR(.10 min) or major surgery <3weeks Recent internal bleeding

STEMI; Relative contraindications for thrombolytic therapy; cntd


Non compressible vascular punctures
Prior exposure to streptokinase >5 days or allergic

reaction Pregnancy Active peptic ulcer Current use of anticoagulants: Higher the INR, higher the risk of bleeding

STEMI; Catheter based Reperfusion


POBA
Primary angioplasty ( PCI ) Rescue angioplasty Facilitated angioplasty

PCI: Percutaneous Coronary Intervention

PCI

PCI

PCI

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