ischemic heart disease

Ronald Chrisbianto Gani405090223

Faculty of MedicineTarumanagara University

EMERGENCY MEDICINE BLOCK

ISCHEMIC HEART DISEASE

APPROACH TO PATIENT WITH CHEST PAIN

APPROACH TO PATIENT WITHCHEST PAIN

Rosen’s Emergency Medicine 7th Ed

INITIAL ASSESSMENT


ACS CHEST PAIN GUIDELINE


NON-ACS CHEST PAIN GUIDELINE


ISCHEMIC HEART DISEASES


Ischemic Heart Disease

Coronary Artery Disease

Acute Coronary Syndromes

UA & NSTEMI

STEMI

Harrison’s Principle of Internal Medicine 18th Ed


• Main symptom : Angina Pectoris– Stable : chest/arm discomfort reprudicibly

associated with physical exertion or stress and is relieved within 5-10mins by rest or sublingual nutroglycerin

– Unstable : at least have one of three features• Occurs at rest, lasting >10mins• Severe and new onset• Crescendo pattern


ACUTE CORONARY SYNDROMES


UNSTABLE ANGINA & NON-ST-ELEVATION MYOCARDIAL INFARCTION

PATHPHYSIOLOGY

Braunwald’s Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed

CLINICAL PRESENTATION

• History & Physical Examination– Chest pain in substernal or epigastrium region

radiates to neck, left arm, left shoulder– Large infarction diaphoresis, pale cool skin, sinus

tachycardia, 3rd and 4th heart sound, basilar rales, LVD hypotension

• ECG– ST : depression or transient elevation– T –waves inversion



• Cardiac Biomarkers– CKMB and Troponin, if elevated NSTEMI, if not

elevated UA


DIAGNOSTIC EVALUATION AND RISK STRATIFICATION


CLINICAL CLASSIFICATION

DIFFERENTIAL DIAGNOSIS


MANAGEMENT

• Combination of Bed Rest, Nitrates, Beta Blocker, + Continuous ECG Monitoring

• Antithrombotic Therapy (Table) • Long term therapy consist of – Beta Blockers + Statin + ACEi + Aspirin +

Clopidogrel for 12 months– Aspirin continued to prevent thrombosis


MANAGEMENT

• Drugs– Nitrates• Sublingual or IV• Avoid in hypotension, patients with sildenafil

– Beta Blockers• Used in unstable angina• Avoid when : PR interval >0,24s, AV block, HR<60x, BP

<90mmHg, Shock, LV Failure, Airway disease


MANAGEMENT

– CCB• If both above drugs cannot relieve symptoms• Avoid in Pulmonary Edema and LV dysfunction

– Morphine• Analgesics, if pain persist after 3 nitroglycerin• Avoid in hypotension, Respiratory distress, confusion,

obtudantion.– Antithrombotic Agents (Next slide)


MANAGEMENT

PRINZMETAL ANGINA

• A syndrome of ischemic pain that occurs at rest but not usually with exertion and associated with transient ST elevation

• Caused by focal spasm of coronal artery severe myocardial infacrtion

• Managed by Nitrates and CCB. Avoid aspirin.


ST-ELEVATION MYOCARDIAL INFARCTION

PATHOPHYSIOLOGY

• Thrombotic occlusion of Coronary artery with atherosclerosis Coronary blood flow ↓

• Coronary artery thrombus develop rapidly at vascular injury site

• Affected by : Smoking, HT, Lipid accumulation• Atherosclerotic plaque disrupted

thrombogenesis (collagen, ADP, epinefrin, serotonin) + Thromboxane A2 platelet active


PATHPHYSIOLOGY

• Myocardial damage depends on– Territory supplied by affected vessel– Whether or not the vessel become total occluded– Duration of occlusion– Quantity of blood supplied by collateral vessels– Demand of oxygen– Native factors that can produce spontaneous lysis– Adequacy of reperfusion after flow restored



• Precipitating factor– Physical exercise, emotional stress,

medical/surgical illness– Symptoms does not subsides after rest / nitrates

• General Appearance – Anxious, distress, chest pain radiates to left arm

and neck and jaw, Levine Sign, weakness, sweating, nausea, vomiting



• Heart Rate– May vary from bradycardia or tachycardia– When in pain tachycardia

• Blood Pressure– Uncomplicated normotensive– Systolic ↓ Diastolic ↑– When in pain hypertension– LV dysfunction hypotension



• Temperature & Respiration– Fever (38oC - 39oC) in 24-48h, subsides in 4-5days– RR elevated when STEMI occurs

• Carotid pulse– Small pulse Reduced Stroke Volume– Sharp Brief mitral regurgitation, ventricular

septum rupture– Pulsus alternans LV dysfunction



• Cardiac Examination– ↓ intensity of 1st heart sound– 3rd or 4th heart sound may be audible– Murmur or friction rubs



• Laboratory Findings– ECG ST evelation, Evolve Q waves– Cardiac Biomarkers (Table on next slide)– PMN Leukocytosis (12000-15000)– ESR N in 1st and 2nd day, elevated in 4th day– Imaging • Echocardiography : abnormal wall motion• Radionuclide Imaging Techniques• High Resolution MRI + contrast


CARDIAC BIOMARKERS



MANAGEMENT

• Initial Management– Prehospital care– Management in Emergency Department– Control of Discomfort– Management strategies– Limitation of Infarc size– Reperfusion (PCI or Fibrinolytic)– Hospital Care Management– Pharmacotherapy


PREHOSPITAL CARE

• Major elements– Recognition of symptoms– Rapid deployment of EMS– Expeditious transportation– Expeditious implementation of reperfusion


MAJOR COMPONENTS OF TIME DELAY


STEMI ALGORYTHM


MANAGEMENT IN EMERGENCY DEPARTMENT

• Face mask oxygen• Aspirin 160-235mg chewed • To relief discomfort– Sublingual nitroglycerin : 3x0,4mg /5mins, avoided

when BP <90mmHg– Morphine : analgesic, may cause constriction, AV

block atropine– IV beta blocker metoprolol 3x5mg/2-5mins


MANAGEMENT STRATEGY


LIMITATION OF INFARC SIZE


REPERFUSION THERAPY

• Primary Percutaneous Coronary Intervention– Angioplasty or stenting– More effective than fibrinolysis– Better short and long term outcomes– Preffered when diagnosis in doubt, cardiogenic

shock, bleeding risk, symptoms have been present for 2-3h

– Very expensive


REPERFUSION THERAPY

• Fibrinolysis– Agents : tPA, streptokinase, TNK, rPA– Initiated within 30mins– Benefits seen if administered in 1-6hrs– More preffered if symptoms still in 1st hour– tPA 15mg bolus 50mg IV / 30mins 35mg IV /

60 mins– Contraindication (next slide)


CONTRAINDICATIONS OF FIBRINOLYSIS

CLEAR / ABSOLUTE• History of Cerebrovascular

hemorrhage• Marked Hypertension• Suspicion of aortic disection• Active internal bleeding

RELATIVE• Current use of

antucoagulants• Recent invasive surgical

procedure• Prolonged cardiopulmonary

ressucitation• Known bleeding diathesis,

pregnancy, DM, hemmorhagic ophtalmic

• History of severe HT


PHARMACOTHERAPY

• Antithrombotic Agents– Aspirin + Clopidogrel – G IIB/IIIA receptor inhibitor– UFH / LMWH, warfarin

• Beta Blockers– Acute IV Beta blockers– Long term therapy


PHARMACOTHERAPY

• ACEi– Reduce ventricular dysfunction– Reduce risk of CHF– Reduce risk of reocclusion– ARB for intolerance patients

• Others – Strict control of blood glucose, serum magnesium,

etc


REFERENCES

• Longo D, Fauci AS, Kasper D, Hauser S, Jameson JL, Loscalzo J, editors. Harrison’s Principle of Internal Medicine. 18th Ed. New York : McGraw-Hill, 2011

• Bonnow RO, Mann DL, Zipes DP, Libby P. Braunwald’s Heart Disease 9th Ed. Philadelpia : Elsevier Saunders, 2012

• Marx JA, Hockberger RS, Walls RM, Adams JG, editors. Rosen’s Emergency Medicine Concepts and Clinical Practice. 7th Ed. Philadelpia : Mosby Elsevier, 2010

ischemic heart disease

Documents