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Suryono
6th Surabaya Cardiology Update
Surabaya, Saturday 12th September 2015
How To Manage The Complication of
ACS Patients
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Complications in Acute Coronary Syndromes
ACS complication includes :
1. Conduction diturbances
2. Hemodynamic disturbances
3. Mechanical complication
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1. Conduction Disturbances
Sinus Bradycardia
Sinus Tachycardia
Atrial Fibrillation
Ventricular Arrhythmias
Heart Block
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Sinus Bradycardia
Occurs in 15-25% of AMI, usually inferior wall or RV
Usually transient and resolves within 24 hours
Caused by increased vagal tone, SA node ischaemia,
drugs (BB), reperfusion after fibrinolysis
Treatment :
1. Atropine
2. Temporary pacing
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Sinus Tachycardia
Occurs in 30-40% of AMI
Persistent tachycardia more common with larger
MI and anterior MI
Associated with higher morbidity and mortality
Treatment :
Beta Blocker
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Atrial Fibrillation
Incidence 5-18%
Usually associated with comorbidities : heart failure,
kidney diseases, hypertension, diabetes, pulmonary
diseases
Treatment :
1. Rate control with BB
2. Amiodarone
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Ventricular arrhythmias in STEMI (all
locations) :Non Sustained VT (<30 seconds) :
No treatment unless frequent and symptomatic :
BB, Amiodarone, Procainamide
Sustained MonomorphicVT (>30 seconds)
with hemodynamic symptom :
Usually transient, Due to ischaemia in first 48
hours of AMI
Cardioversion, Amiodarone, Procainamide,
Lidocaine
,
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VF :
Usually occurs in 48-72 hours after MI
The persence of ST elevation is the most powerful predictor of
VF
Other predictors : early repolarization, hypokalemia,
hypotension, higher troponins, severe LV dysfunction
Associated with higher in-hospital mortality
Treatment : Defibrillate, Amiodarone, Reperfusion
ICD have been shown to reduce mortality in
post MI pts with EF ≤ 30%
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Heart Block of MI
Inferior Wall MI :
1st degree and Weckenbach occur in the AV node and usually due
to RCA occlusion. Usually resolves within 5-7 days. Usually it
requires no treatment.
Anterior Wall MI :
More serious block that occurs below the AV node with wide
QRS
Second Degree type 2 and Third Degree more common
High mortality rate : 80%
Tx : Temporary pacing
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2. Hemodynamic Disturbances :Cardiogenic Shock
Causes :
Extensive LV infarction
Mechanical complication
Mortality rate : 80-90%
The larger the infarct the more pump failure occurs
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Management of Cardiogenic Shock
(ACC/AHA Guidelines) :
Emergency revascularization with either PCI or CABG
for cardiogenic shock due to pump failure after STEMI
(Class Ib)
Immediate transfer to a PCI-capable facility with one-
site cardiac surgical back up is indicated for patients
with STEMI and CS
Fibrinolytic therapy for patients without
contraindication and when revascularization is not
feasible
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Usual medical treatment of STEMI except Beta
Blocker
Inotropic and vassopressor support
IABP (Class IIa)
Especially for RVMI : volume load & avoid diuretic to
keep PWP optimal (usually around 18 mmHg)
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Right Ventricular Infarction :
40% incidence with inferior MI :
- Most often proximal RCA occlusion
- Higher mortality when RV infarcted
Pathophysiology of RVMI :
Decreased right ventricular compliance
Reduced RV filling
Decreased RV stroke volume
Decreased LV filling Periferal hypoperfusion : hypotension,
tachycardia
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Right Ventricular Infarction :
Diagnosis : clinical triad of Hypotension, Elevated JVP,
Clear lung fields (decreased PWP)
Get right side chest lead (V4R –V6R) with all inferior wall MI
Treatment :
Fluid to increase LV filling
Avoid preload reduction (Nitrat, diuretic)
Inotropes (Dobutamine, Dopamine)
Maintain atrial kick (Cardioversion of AF may be needed)
Temporary pacing if bradycardia
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3. Mechanical Complication :
Papillary Muscle Rupture Acute Mitral
Regurgitation
Ventricular Septal Rupture
Ventricular Free Wall Rupture
Cardiac Tamponade
Ventricular Aneurysm
Thromboembolism
Acute Right to Left Shunt Through Foramen
Ovale
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Papillary Muscle Rupture Life threathening
It causes Acute Mitral regurgitation
More common in inferior MI
Occurs 2-7 days after MI
Present with : hypotension, acute dyspneu, heart failure
pulmonary edema, new systolic murmur
Diagnosis by : Cardiac echo (TEE or TTE)
Management :
Afterload reduction : Nitroprusside, IABP
Diuretics
Emergent surgery for mitral valve repair (if no papillary muscle
necroses) or replacement
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Ventricular Septal Rupture
Occurs equally in anterior and inferior MI :
- Anterior MI : rupture usually in apical septum
- Inferior MI : usually at the base of the heart
- Usually occurs within 3-5 days after MI (sometimes
in first 24 hours)
Risk factor :
- “Wrap around” LAD (ST elevation in anterior and
inferior leads)
- Large infarct
- RV infarction
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Present with :
1. Sudden onset of hypotension
2. Biventricular failure (mostly right sided due to left to right shunt)
3. New harsh holosystolic murmur
Diagnosed by :
1. Doppler echo
2. Right heart cath showing left to right shunt through septum
Management :
Afterload reduction (Nitroprusside, IABP)
Diuretics
Inotropes (if cardiogenic shock +)
Surgery repair : Surgery is urgent if shock present but can be delayed
for weeks untill infarct heals if patient stable enough
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LV Free Wall Rupture Present in up to 26% of patient who died with AMI
Occurs within 5 days in 50% cases and within 2 weeks in 90%
cases
Risk factors for rupture :
Fibrinolytic therapy (higher incidence than PCI)
No history of angina or previous MI (less collateral circulation)
ST elevation or Q waves on initial ECG
Large infarcts, higher biomarkers
Anterior MI
Age > 70
Female
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Complete rupture or Incomplete / subacute rupture
Diagnosed by : echocardiogram, pericardiocentesis if fluid
present, emergency surgery if fluid is blood
Management :
Fluids, Inotropes, Vassopressor
IABP
Surgical repair
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Ventricular Aneurysm
Occurs in 8-15% of MI
Diagnose :
oOften prolonged ST elevation following anterior wall
MI
oCardiac enlargement and dyskinetic area on echo
o 3rd and 4th heart sounds, systolic murmur and mitral
regurgitation
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Complication with LV aneurysm :
o Heart failure – bulging of aneurysm during systole steals parts of
stroke volume so CO and volume load
o Ventricular arrythmias
o Thromboembolism
o Ventricular rupture
Management :
Afterload reduction (usually with ACEI)
Anti ischaemic medication for angina
Anticoagulation
Surgical aneurismectomy
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Thromboembolism
Mural thrombi at the site of infarction (especially
large anterior MI)
In atria during atrial fibrillation
Treatment :
ANTICOAGULANT
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Cardiac Tamponade
Occur due to rupture at the site of infarction
Present with : hypotension, JVD, muffled heart sound
Treatment :
Pericardiocentesis
Surgery if blood in pericardium
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Acute Right to Left Shunt Through Patent
Foramen Ovale
Rare complication
Presents : Patients with RVMI shown with hypotension, clear
lung fields, and decreased blood saturation (cyanotic)
Diagnosed by : TEE
Management :
Principle : to optimize the right ventricular function to minimize
shunting
Surgical intervention is required, includes :
1. Coronary artery bypass grafting
2. Closure of atrial septal defect
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THANKS FOR ATTENTION