ischemic heart disease
TRANSCRIPT
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Ronald Chrisbianto Gani405090223
Faculty of MedicineTarumanagara University
EMERGENCY MEDICINE BLOCK
ISCHEMIC HEART DISEASE
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APPROACH TO PATIENT WITH CHEST PAIN
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APPROACH TO PATIENT WITHCHEST PAIN
Rosen’s Emergency Medicine 7th Ed
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INITIAL ASSESSMENT
Rosen’s Emergency Medicine 7th Ed
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ACS CHEST PAIN GUIDELINE
Rosen’s Emergency Medicine 7th Ed
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Rosen’s Emergency Medicine 7th Ed
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NON-ACS CHEST PAIN GUIDELINE
Rosen’s Emergency Medicine 7th Ed
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ISCHEMIC HEART DISEASES
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ISCHEMIC HEART DISEASE
Ischemic Heart Disease
Coronary Artery Disease
Acute Coronary Syndromes
UA & NSTEMI
STEMI
Harrison’s Principle of Internal Medicine 18th Ed
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ISCHEMIC HEART DISEASE
• 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
Harrison’s Principle of Internal Medicine 18th Ed
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ISCHEMIC HEART DISEASE
Rosen’s Emergency Medicine 7th Ed
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ACUTE CORONARY SYNDROMES
Harrison’s Principle of Internal Medicine 18th Ed
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UNSTABLE ANGINA & NON-ST-ELEVATION MYOCARDIAL INFARCTION
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PATHPHYSIOLOGY
Braunwald’s Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
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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
Harrison’s Principle of Internal Medicine 18th Ed
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CLINICAL PRESENTATION
• Cardiac Biomarkers– CKMB and Troponin, if elevated NSTEMI, if not
elevated UA
Harrison’s Principle of Internal Medicine 18th Ed
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DIAGNOSTIC EVALUATION AND RISK STRATIFICATION
Harrison’s Principle of Internal Medicine 18th Ed
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CLINICAL CLASSIFICATION
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DIFFERENTIAL DIAGNOSIS
Rosen’s Emergency Medicine 7th Ed
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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
Harrison’s Principle of Internal Medicine 18th Ed
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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
Harrison’s Principle of Internal Medicine 18th Ed
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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)
Harrison’s Principle of Internal Medicine 18th Ed
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MANAGEMENT
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Harrison’s Principle of Internal Medicine 18th Ed
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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.
Harrison’s Principle of Internal Medicine 18th Ed
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ST-ELEVATION MYOCARDIAL INFARCTION
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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
Harrison’s Principle of Internal Medicine 18th Ed
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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
Harrison’s Principle of Internal Medicine 18th Ed
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CLINICAL PRESENTATION
• 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
Braunwald’s Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
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CLINICAL PRESENTATION
• 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
Braunwald’s Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
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CLINICAL PRESENTATION
• 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
Braunwald’s Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
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CLINICAL PRESENTATION
• Cardiac Examination– ↓ intensity of 1st heart sound– 3rd or 4th heart sound may be audible– Murmur or friction rubs
Braunwald’s Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
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CLINICAL PRESENTATION
• 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
Harrison’s Principle of Internal Medicine 18th Ed
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CLINICAL PRESENTATION
Braunwald’s Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
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CARDIAC BIOMARKERS
Rosen’s Emergency Medicine 7th Ed
Braunwald’s Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
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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
Harrison’s Principle of Internal Medicine 18th Ed
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PREHOSPITAL CARE
• Major elements– Recognition of symptoms– Rapid deployment of EMS– Expeditious transportation– Expeditious implementation of reperfusion
Harrison’s Principle of Internal Medicine 18th Ed
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MAJOR COMPONENTS OF TIME DELAY
Braunwald’s Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
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STEMI ALGORYTHM
Braunwald’s Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
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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
Harrison’s Principle of Internal Medicine 18th Ed
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MANAGEMENT STRATEGY
Braunwald’s Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
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LIMITATION OF INFARC SIZE
Rosen’s Emergency Medicine 7th Ed
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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
Harrison’s Principle of Internal Medicine 18th Ed
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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)
Harrison’s Principle of Internal Medicine 18th Ed
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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
Harrison’s Principle of Internal Medicine 18th Ed
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PHARMACOTHERAPY
• Antithrombotic Agents– Aspirin + Clopidogrel – G IIB/IIIA receptor inhibitor– UFH / LMWH, warfarin
• Beta Blockers– Acute IV Beta blockers– Long term therapy
Harrison’s Principle of Internal Medicine 18th Ed
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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
Harrison’s Principle of Internal Medicine 18th Ed
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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