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The Management of AMI and ACS Patients in the Emergency Department

The Management of AMI and ACS Patients in the Emergency Department. Part 2: AMI/ACS Treatment. Acute Myocardial Infraction Part II: Reperfusion Therapies for UA, NSTEMI, and STEMI. Edward P. Sloan, MD, MPH, FACEP. Professor Department of Emergency Medicine, University of Illinois at Chicago

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The Management of AMI and ACS Patients in the Emergency Department

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  1. The Management of AMI and ACS Patients in the Emergency Department

  2. Part 2:AMI/ACS Treatment

  3. Acute Myocardial Infraction Part II:Reperfusion Therapies for UA, NSTEMI, and STEMI

  4. Edward P. Sloan, MD, MPH, FACEP Professor Department of Emergency Medicine, University of Illinois at Chicago Chicago, IL (edsloan@uic.edu)

  5. Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Medical Center

  6. Global Objectives • Learn more about AMI and ACS • Increase awareness of Rx options • Enhance our ED management • Improve patient care & outcomes • Maximize staff & patient satisfaction • Be prepared for the EM board exam

  7. Session Objectives • Provide AMI, ACS overview • Ask clinically relevant questions

  8. AMI/ACS Rx:Global Objectives

  9. AMI/ACS Rx: Objectives • What are the global objectives of AMI Rx in the ED?

  10. AMI/ACS Rx: Objectives • Maximize coronary dilatation and myocardial O2 delivery • Minimize myocardium O2 demand • Achieve TIMI-III coronary flow • Minimize myocardium damage • Minimize chronic LV dysfunction • Prevent dysrhythmias, sudden death

  11. AMI/ACS Rx:Pharmacological Interventions

  12. Pharmacotherapy of AMI/ACS • ASA • NTG • Morphine • Heparin, LMW • Thrombolytics • Antidysrhythmics • Fluid & pressure therapies

  13. AMI/ACS Rx: Oxygen • AMI/ACS • Limited O2 delivery • Increased myocardial O2 use • IV, O2, monitor • NC at 4 L/min • Quick, easy, cheap

  14. AMI Rx: ASA, Platelet Meds • When are ASA and other platelet meds indicated?

  15. AMI/ACS Rx: Aspirin • ISIS 2: as good as streptokinase • Decreased platelet aggregation (Tbx A2) • 160-325 mg ASAP • High dose: prostacyclin production decreases, with decreased benefits

  16. AMI/ACS Rx: Aspirin • All AMI/ACS pts should get ASA • Dose of 162 mg reduces • mortality by 23% • reinfarction by 49% • stroke by 46%

  17. AMI/ACS Rx: Platelet Rx • Dipyridamole • Ticlopidine • Clopidogrel • Consider when ASA allergic • Caution in acute setting!

  18. AMI/ACS Rx: Nitrates • When are nitrates indicated? • What is the appropriate dose of NTG in AMI/ACS patients?

  19. AMI/ACS Rx: Nitrates • Coronary dilation • Increased collateral flow • Decrease preload, myocardial O2 use • SL 1/150, 1/400 • Spray, paste, IV • SL rarely causes critical hypotension

  20. AMI/ACS Rx: Nitrates • SL NTG 1/150 • 400 ucg q 5 minutes • 80 ucg per minute • Good bioavailability • NTG drip: can start at > 10 ucg/min • Critical hypotension reversible

  21. AMI/ACS Rx: Nitrates • Expect SBP to drop with NTG • SBP drop 10% with normal BP • SBP drop 30% with elevated BP

  22. AMI/ACS Rx: Nitrates • Caution with RV infarction! • Reduces preload & LV filling • Reduces cardiac output • Hypotension can occur • Must still maximize O2 delivery • Can reduce mortality by 35%

  23. AMI/ACS Rx: Morphine • What are the indications for morphine in AMI/ACS patients?

  24. AMI/ACS Rx: Morphine • Provides analgesia • Reduces central sympathetic output • May  myocardial O2 consumption • May mask ongoing ischemia?? • Risk/benefit favors use • Use with marked pain and anxiety • 2-5 mg IVP

  25. AMI/ACS: Antidysrhythmics • What are the indications for antidysrhythmics in AMI/ACS patients?

  26. AMI/ACS Rx: VT, VF Rx • VF: Shock at 200j, 300j, 360j, unsynch • VT (Polymorphic, unstable): same • VT (Monomorphic, unstable): 100j, synch • VT (Monomorphic, stable): • Amiodarone: 150-300 slow IVP • Lidocaine: 1-1.5 mg/kg bolus injection • Procainamide: 12-17 mg/kg, 20-30/min • Synch cardioversion, 50j, 100j

  27. Monomorphic VTach

  28. Polymorphic VTach

  29. AMI/ACS Rx: AFib Rx • Cardioversion: unstable patients • Rapid digitalization • IV Beta blockers • Diltiazem or verapamil • Heparin

  30. Atrial Fibrillation

  31. AMI/ACS Rx: Adenosine • Slow conduction thru AV node • Interrupts reentrant pathways • Used in PSVT • 6 mg IVP, then 12 mg IVP

  32. Paroxysmal SVT

  33. AMI/ACS Rx: Amiodarone • Class III agent • Treats supraventricular and ventricular dysrhythmias • Prolongs refractory period • Sustained monomorphic VT • VF and unstable VT

  34. AMI/ACS Rx: Atropine • Sinus brady, poor perfusion, PVCs • Sinus brady, low SBP after NTG • Inferior AMI with high grade block • Inferior AMI, symptomatic brady • N/V after morphine • EMD, with epinephrine

  35. AMI/ACS Rx: Beta-blockade • What are the indications for beta-blockade in AMI/ACS patients?

  36. AMI/ACS Rx: Beta-blockade • Ischemic penumbra preserved • Decreased catecholamines • Decreased dysrhythmias • Decreased HR and BP • Decreased infarct size

  37. AMI/ACS Rx: Beta-blockade • Consider in all AMI and ACS pts • Continued, recurrent ischemic pain • Tachyarrhythmias: rapid AFib, Flutter • May even be useful in patients with relative contraindications • Metoprolol 5mg IV q5mx3 • Within 12 hours of presentation

  38. AMI/ACS Rx: Beta-blockade • Contraindications • Moderate to severe CHF • COPD/asthma • Bradycardia • Hypotension • 2nd or 3rd degree A-V blocks

  39. AMI/ACS Rx: Beta-blockade • Not consistently achieved in AMI • Why do clinicians defer this Rx? • May be optimal with HTN, tachycardia • With HR < 80, normal BP, less use • Not mandated in the ED, prior to PCI

  40. AMI/ACS Rx: Ca++ Channel • Rate control in atrial fib, flutter • If unable to provide beta blockade • Not viewed in same way a use of metoprolol in AMI

  41. AMI/ACS Rx: Digitalis • Rapid load in rapid atrial fibrillation • Provided before beta blocker use • Not used for its inotropic effects

  42. AMI/ACS Rx: Lidocaine • Limited use • New, symptomatic VT • Malignant dysrhythmias, VF • 1-1.5 mg/kg, 2-4 mg/min drip • Caution in ventricular escape rhythm • Can cause asystole • No real prophylactic use

  43. AMI/ACS Rx: Magnesium • Documented Mg deficit with diuretics • Prolonged QT, torsade de pointes VT • 1-2 gram bolus over 5 minutes • Empiric therapy in refractory VF?

  44. Torsade de Pointes

  45. AMI/ACS: BP/Fluid Rx • How should BP and fluids be managed in AMI/ACS patients?

  46. AMI/ACS Rx: IV Fluids • What are the indications for an acute fluid bolus? • When should large volumes of IVF be infused in a hypotensive AMI/ACS patient?

  47. AMI/ACS Rx: IV Fluids • Normal saline • Bolus hypotensive pts • Starling curve supports use • 200 cc even with CHF • RV AMI: Repeated boluses

  48. AMI/ACS Rx: IV Fluids

  49. AMI/ACS Rx: Dopamine • Dopamine useful in ED • Enhanced vital organ flow • Supports nitrates with labile BP • Increases HR, SVR, cardiac O2 use • Increased inotropy • Ischemia, dysrhythmias can occur

  50. AMI/ACS Rx: Dobutamine • Dobutamine can also be used in ED • Pulmonary edema, LV dysfunction • No endogenous norepi release • Less myocardial O2 use increase • Improved inotropy • Improved coronary artery flow • Can be used with dopamine

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