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


AMI Patient ?


Candidate for fibrinolytic therapy ?

Consult Evaluate further

Fibrinolytic therapy

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



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 .

creatinine . if available and suitable.CCU .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 . Goal : 30 minutes from entry to ED Primary PTCA. (Goal : PTCA within 90 s 30 minutes) Admit .Lipid profile Initiate fibrinolysis if indicated.CBC . BUN.Electrolytes.

separated by at least 4 hrs  If only a single sample available.Enzymatic Criteria for Diagnosis of Myocardial Infarction  Serial increase. an elevation of troponin T or I or LDH-1 > LDH-2 . CK-MB elevation > twofold  Beyond 72 hrs. 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.

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 .

CABG) Continued observation in hospital Consideration of stress testing Clinical stability No Medical Therapy . Widespread ECG changes 4. Recurrent ischemia 2.Assess clinical status High-risk patient : 1. Depressed LV function 3. Prior MI Catheterization : Anatomy suitable for revascularization ? Yes Revascularization (PTCA.

Pharmacologic Management of Patients with MI Heparin Recommendation Class I Recommendations 1.5-2. 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 1.0 x control (50-70 sec) for 48 hrs . In patients undergoing percutaneous on surgical revascularization Class IIa Recommendations 1.

Intravenous unfractionated heparin (UFH) or low molecular weight heparin (LMWH) subcutaneously for patients with nonST elevation MI. Intravenously in patients treated with nonselective fibrinolytic agents (streptokinase. 3. Enoxaparin 1 mg/kg b.500 b. 4. In patients who are at high risk for systemic emboli (large or anterior MI. or known LV thrombus).i. intravenous heparin is preferred. . previous embolus.Pharmacologic Management of Patients with MI 2. 7. Subcutaneous UFH (eg.d) in all patients not treated with fibrinolytic therapy who do not have a contraindication to heparin. previous embolus. anistreplase. urokinase) who are at high risk for systemic emboli (large or anterior MI. or known LV thrombus). AF.d) or low molecular weight heparin (eg.i. AF.

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

b) PTCA. or d) alteplase/reteplase use (for ~ 48 hrs) SQ heparin for all other MI (7.i.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. c)      LV thrombus.500 u b.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 .

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

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

6. 5. 3. 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.Treatment Recommendations for Pharmacotherapy to prevent MI and Death and Reduce Symptoms Class I 1. . 4. 2. 8.

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

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

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

hyperthyroidism Yes Yes .g. Initiate primary prevention History suggests intermediate to high probability of CAD Yes Intermediate or high risk unstable angina? Features of intermediate. PTCA.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. CABG ? Yes No Conditions present that could cause angina? e. severe anemia..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.

hyperthyroidism Yes Angina resolves with treatment of underlying condition ? Yes No No History and/or exam suggests valvular. 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 . severe anemia. exam. 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.g..Conditions present that could cause angina? e.

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 .

Exercise program. Diabetes management .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.

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 .

69 .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 .



parenkim dan/atau vaskuler paru (antara a.COR PULMONALE CHRONICUM (CPC) Hipertrofi & dilatasi ventrikel kanan sebab hipertensi pulmonal akibat peny. pulmonal utama dan masuknya vv pulmonal ke atrium kiri) Etiologi Utama Penyakit paru obstruktif khronis (PPOK) akibat bronkhitis khronis atau emfisema paru .

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

Cystic fibrosis C. DISEASES AFFECTING AIR PASSAGES OF THE LUNG AND ALVEOLI A. 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. Chronic obstructive pulmonary diseases B. High-altitude disease . Upper airways obstruction F.ETIOLOGY OF PULMONARY HEART DISEASE (2) IV. Pulmonary resection G. Congenital development defects D.

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 .

kurang sensitif .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.

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

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

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

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 .

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.PENGELOLAAN ‡ OKSIGEN Diberikan kontinu 1-2 l/menit. fungsi RV .LV membaik ‡ BETA-ADRENERGIC AGONISTS Bronkhodilator ‡ VASODILATOR ? ‡ Atasi penyakit paru penyebabnya !!! .

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.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 +. hyponatremia .