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A B C
Occurs in the setting Occurs without other Occurs less than 2
Severity of extracardiac extracardiac conditions weeks after MI
conditions that
aggravate ischemia
I
De novo/aggravated(no IA IB IC
pain at rest)
II
Pain at rest but not in the IIA IIB IIC
last 48 hours
III
Pain at rest in the last 48
hours
IIIA IIIB IIIC
Clinical examination
ACS Aortic PE Pn.thorax Pneumonia/ Radiculitis Acute
dissection pleuresy pericarditis
BP () N
Pulse N
Left ventricular
dysfunction EPA unilat _ _ _ _
Right ventricular _
dysfunction ++ _ _
Condensation
syndrome
_ _ _ +++ _ _
Hyperresonance _ _ _ ++ _ _
ECG in acute thoracic pain
ECG +++ ++ _ _ ++
Localization of MI on ECG
Topol classification
Topol Category Occlusion location ECG - ST Mortality Mortality
class at 30 at 1 year
days
1 LAD -proximal Before the first septal V1-V6, DI, aVL 19.6% 25.6%
perforating artery and fascicular
block or bundle
branch block
2 LAD - medium After the first septal V1-V6, DI, aVL 9.2% 12.4%
perforating artery,
before the great
diagonal artery
3 LAD - distal or After the great diagonal V1-V4 or DI, aVL, 6.8% 10.2%
artery or first diagonal V5-6
Diagonal artery
leasion
4 Inferior Proximal RCA or CX DII, DIII, 6.4% 8.4%
aVF and any of
moderate MI the following:
(RV, posterior, -V1, V3R, V4R
lateral) -V5, V6
R>S in V1, V2
Cardiac
troponin
+++ _ _ _ _ _ _
Specific
enzymes
CK-MB
+++ _ _ _ _ _
Inflammatory
syndrome
/+ _ + _ +++ _ ++
Other causes of troponin I or T elevation
Myopericarditis
Severe trauma
Congestive heart failure
Pulmonary thromboembolism
Sepsis
Kidney failure
Collagen diseases
Radiologic examination for
chest pain
acute coronary Aortic PTE Pneumotho Pneumonia/ Neuralgia Acute
syndrome dissection rax pleurisy pericarditis
Cardiac
ultrasound + ++ + _ _ _ ++
CT _ _ ++ ++ _ /+ _
Scintigraphy _ ++ _ ++ _ _ _ _
Angiography ++ ++ ++ ++ _ _ _ _
MRI _ _ + + _ _ _ _
CT IN PULMONARY EMBOLISM
PTE:
Myocardial perfusion and ventilation
scintigraphy
Coronary angiography of MI
Aortography :
Differential diagnosis of AMI is
often very difficult
Conclusion:
Differential diagnosis of chest
pain is sometimes almost
impossible
CHEST PAIN
-second part-
TREATMENT
Acute coronary syndromes
(ACS)
Morphine (2-4 mg
diluted with antiemetic and
repeated at 15 min)
Mialgin analgesic solution:
1f. 100mg diluted to 10 ml,
1ml/min repeated at 10 min
until it relieves the pain)
Antiplatelet medication
1. Aspirin
325g/day initial (act. in 15) continued with 75-150mg/day
2. Clopidogrel (Plavix)(ADPdep)
Loading dose of 300 mg on the first day followed with 75mg/day
Comparable results to aspirin
Advantages:
prevents formation of new thrombi
decreases the incidence of angina, silent ischemia, AMI and death
potentiates the effect of aspirin
Disadvantages:
does not act on pre-existing thrombi
rebound at discontinuation
bioavailability varied and increased variability of response
Anticoagulant treatment
1. Heparin
Dose
initial IV bolus of 60 IU / kg (maximum 4000 IU)
followed by continuous infusion of 12 IU / kg / hour (maximum
1000 IU)
under control every 4-6 hours and dose adjustments to achieve
an aPTT between 50 and 70 s (1.5 - 2 x N)
AR:
Haemorrhages
thrombocytopenia
tissue necrosis
osteoporosis
Antidote
protamine sulfate
Calciparin- can be administered sc 1mg/kgc/12h
Anticoagulant treatment
2. Low molecular weight heparin
Enoxaparina (Clexane)
Fondaparinux (Arixtra)
Mechanism:
inhibits Xa factor
Advantages:
Dose:
Clexane: 1 mg/kgc at 12h
Anticoagulant treatment
3. Direct thrombin inhibitors
Bivalirudin alternative for heparin at patients with high bleeding
risk
Mechanism:
Inhibits directly thrombin activation
Advantages:
Similar efficacy with lower bleeding risk when compared with
unfractionated heparin and low molecular weight heparin in
patients with ACS moderate and high risk class benefiting from
early invasive treatment (PCI)
Disadvantages:
Exclusively reserved for patients with ACS moderate and high
risk class benefit of early invasive treatment (PCI)
Thrombolytic treatment
Advantages
Coronaro-dilatation
peripheral vasodilation
A. Non-dihydropyridines (diltiazem,verapamil)
Slows SAN activity
Without persistent
persistent ST
ST ASA, Heparin, -bl, nitrates
Stress test
Coronarography
Prompt diagnosis
Symptoms 112 ambulance arrival
T1 + T2 +
T3
Hospitalization tests
Reperfusion therapy:
Primary PCI
PCI (percutaneous coronary intervention) - Recommended as
first-line therapy for revascularization, where available
Advantages:
Restores normal epicardial coronary flow in> 90% of cases
Increased survival compared to thrombolysis
Lower rate of intracranial bleeding and recurrence of MI
compared to thrombolysis
Can be performed in patients with contraindications to
thrombolysis
Disadvantages:
increased costs
low accessibility
IMA LEFT MAIN
DIAGNOSTIC
IMA LEFT MAIN
POST PCI
3. Reperfusion therapy:
Indications
Streptokinase (SK)
Recombinant tissue plasminogen
activator (r-tPA)
Streptokinase-plasminogen activated
complex (APSAC)
Fibrinolytics
NB!: Dedicated intravenous line
r-tPA:
indications
all patients with AMI / UA without
complications
adjuvant treatment to fibrinolytic therapy
in order to slow VA / SV arrhythmia
conversion to RS
in patients with hypertension and / or
tachycardia (Forrester IB)
-blockers
Metoprolol:
iv: 5 mg slow bolus, repeated every 5
min. up to 15 mg
po: 50 mg x 2 for 24 h, followed by 100
mg x 2 daily
Esmolol
Nitrates
Indications: all with ischemic pain but sBP> 90 mm Hg and
no other contraindications
Contraindications:
sBP<90 mm Hg
Bradycardia /severe tachycardia
LV AMI (only with extreme caution)
Viagra administration in the last 24 hours
Duration:
continuously 24-48h after AMI (if ant. AMI , CHF, persistent /
recurrent ischemia , hypertension)
>48 h 48 h if it has recurrent angina or persistent pulmonary
congestion
NTG:
iv: 12,5-25g bolus followed by 10-20 g/min
sl: 1 tb repeated at 5 min.
spray: 2 puff
aspirin
other treatments (appropriate to the
situation)
those with positive serum markers,
ECG changes, alterations in functional
tests will be treated the same as those
at high risk
Complications of MI
majore:
rhythm and conduction disorders
pump dysfunction
persistent periinfarct myocardial ischemia
thromboembolism
Mechanical complications:
cardiac rupture (IVS ,free wall, pillar)
ventricular aneurysm
minore:
periinfarct pericarditis (serofibrinous)
Risk evaluation in the acute
phase of AMI
Killip functional classification
Functional class Clinical signs Acute mortality
I
No LVF 5-7%
(uncomplicated AMI)
dyspnoea
II
pulmonary stasis 10-15%
(HF mild / moderate)
protodiastolic gallop
III
APE 20-50%
(severe CHF)
IV hBP, peripheral
hypoperfusion and of 60-80%
(cardiogenic shock) vital organs
Risk evaluation in the acute
phase of AMI
Forrester classification
I B: Hyperdinamic
II : pulmonary
I A: compensated
congestion
2,2
Surgical treatment
of choice in acute proximal dissection
or complicated by organ failure,
rupture or impending rupture acute
dissection
c-ind.: 1 month old or type III without
compromised organ
Aortic dissection
Medical treatment
objectives:
stop progression of hematoma
pain relief
Physiopathology:
lower BP (120-130 mm Hg)
decrease LV contractility
associated with with negative inotropic vasodilator
nitroprusside 1-10 g/min + Propranolol (0,5 mg iv slowly, then 1
mg/5 min so that VA=60-80/min
trimetaphan
labetalol
enalapril (in cases with refractory hypertension) 1-2 mg/4-6h
Calcium blockers: Nicardipine
PTE treatment
Thrombolytics
in massive PTE
SK (250.000 U n 30 min. then 100.000 U/h) or UK
(4400U/kg in 10 min then 4400/kg/h) or tPA
Heparin
moderate / small PTE
bolus 10.000 U, then piv 1500-2000 U/h
Oral anticoagulants
Adjuvant measures:
oxygen
assisted ventilation
dobutamine (in case of cardiogenic shock)
NSAIDs (if pleuretic pain persists)
PTE treatment
Surgery treatment
pulmonary embolectomy
Note: imminent cardiogenic shock
high mortality
Prophylaxis
Secondary: inferior vena cava interruption (clip
ADAMS / filters)
Primary: tackling the risk factors for PTE
Treatment of acute pericarditis
Etiologic :
NSAIDs
antibiotic
stopping anticoagulants
anticancer therapy
tuberculostatics
corticosteroids (1 mg / kg / day with progressive
dose reduction)
Pathogenic :
in forms with CT : pericardiocentesis
Pneumothorax treatment
Lung decompression:
required in tension pneumothorax
Air decompression
aspiration
emergency pleural puncture
Oxygen therapy:
in forms with respiratory failure
Reexpansion of the lung:
usually spontaneously if pleural fistula is closed
oxygen in large quantities speeds reabsorption
drainage
Symptomatic medication
Treatment of pneumonia /
pleurisies
etiological
pathogenic
Neuralgia treatment
antiinflammatory
analgesics
THANK YOU FOR YOUR
ATTENTION!