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Acute Coronary Syndromes

Acute Coronary Syndromes. Henry Z. Pitzele, MD, FACEP Deputy Chief, Section of Emergency Medicine Jesse Brown VA Medical Center, Chicago, IL. Overview. Why? Pathophysiology Treatment. Definition. Acute Myocardial Infarction Troponin Symptoms Q or STD PCI Unstable Angina

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Acute Coronary Syndromes

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  1. Acute Coronary Syndromes Henry Z. Pitzele, MD, FACEP Deputy Chief, Section of Emergency Medicine Jesse Brown VA Medical Center, Chicago, IL

  2. Overview • Why? • Pathophysiology • Treatment

  3. Definition • Acute Myocardial Infarction • Troponin • Symptoms • Q or STD • PCI • Unstable Angina • Ischemic symptoms • Different from Previous

  4. Significance • 5 Million per year • 1-2 percent sent home • Highest medical malpractice payouts

  5. Hector Pope Tom Smykowski

  6. Pathophysiology • Ischemia • Infarction • Time is tissue • Window of opportunity

  7. Pathophysiology

  8. Pathophysiology

  9. Pathophysiology • Ischemia • Infarction • Time is tissue • Window of opportunity

  10. Pathophysiology

  11. Pathophysiology • Ischemia • Infarction • Time is tissue • Window of opportunity

  12. Pathophysiology • Ischemia • Infarction • Time is tissue • Window of opportunity

  13. Pathophysiology • Ischemia • Infarction • Time is tissue • Window of opportunity

  14. Treatment • Open them up • Keep them open • Maximize oxygen delivery to myocardium

  15. Open up!

  16. Treatment: Reperfusion • PTCA • Thrombolysis

  17. Treatment

  18. Treatment

  19. The AHA Document

  20. The a-ha Document

  21. Treatment: Oxygen Delivery • Oxygen • Morphine • NTG • b Blockade

  22. Treatment: Morphine

  23. Treatment: Morphine

  24. Treatment: Morphine?

  25. Treatment: Morphine

  26. Treatment: Oxygen Delivery • Oxygen • Morphine • NTG • b Blockade

  27. Nitro

  28. Nitro: a-ha!

  29. Nitro • 1 tab q5 min • Fail  IV @ 10 mcg/min • Contraindications: • Systolic < 90 • Sildenafil in past 24h

  30. Nitro: uh-oh!

  31. Nitro: uh-oh! • 120/90 -------------> 8/2

  32. Nitro

  33. Nitro

  34. Nitro

  35. Treatment: Oxygen Delivery • Oxygen • Morphine • NTG • b Blockade

  36. beta

  37. beta • What drug? • What route?

  38. beta • What drug? • It truly does not matter

  39. beta • What drug? • It truly does not matter • Metoprolol is mentioned quite fondly, though

  40. beta • What route? • a-ha: • Class I: Oral beta blocker therapy should be initiated within the first 24h for patients who do not have contraindications • Class II: It is reasonable to administer IV BB at the time of presentation for hypertension to UA/NSTEMI patients who do not have contraindications

  41. beta • a-ha: • Class III: It may be harmful to administer IV BB to UA/NSTEMI patients who have contraindications to beta blockade

  42. beta

  43. beta

  44. beta • Oral beta blockade is recommended.

  45. Treatment: Oxygen Delivery • Oxygen: yes! • Morphine: probably… • NTG: watch pressure and RVI • b Blockade: oral unless you’ve got a good reason

  46. Treatment: Antithrombosis • ASA: dosage • Heparin/LMWH • GpIIb/IIIa inhibitors • Clopidogrel

  47. Aspirin • Potent irreversible antiplatelet • The most important intervention • Fifty. Percent. Mortality. Reduction.

  48. Aspirin

  49. Aspirin

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