Sie sind auf Seite 1von 47

Myocardial Infarction :

Role of General Practitioner


Outline
Emergency Ward :
• Symptoms of Ischemia ( Acute Vs Stable )
• Angina Equivalent & Associated Symptoms ( Risk factors )
• Ruling in & Ruling Out Acute Coronary Syndrome
• Heart Score & Probability
Acute Coronary Syndrome :
• The Spectrum
• Time is Muscle & Survival
• Team Approach
• Safe Referral System : PCI Capable Centre
Pitfalls & Problems
• Challenging ECG
• Initial Tx : One may not fits all
• ACLS & ACS
Take Home Messages
The Emergency Ward
Battle Field
Chest Pain Evaluation

Problems Solutions
• Prolonged ED • Consensus definition
Evaluation • Validated Clinical
• Unnecessary admission Decision Rules
• Safe discharge – missed • Evidence Based
dx < 1% Medicine
• Cost

Scoring System +/- Algorithm


Levine's sign is a clenched fist held over
the chest to describe ischemic chest pain
Pain Distribution in Myocardial Ischemia
Typical Atypical

Right side Jaw

Epigastric Back
Atypical Chest Pain
• Atypical presentations include epigastric pain, indigestion-like
symptoms and isolated dyspnoea
• Atypical complaints are more often observed in
the elderly, in women and in patients with diabetes, chronic renal
disease or dementia.
• The exacerbation of symptoms by physical exertion and their
relief at rest increase the probability of myocardial ischaemia
Indonesia ?
Angina Pectoris
Typical Unstable

• Typical Characterictic and • Prolonged (20 min) anginal


Duration pain at rest; ( 80% )
• Aggreviated w/ : • New onset (de novo) angina
• Emotion (CCS II or III ) ( +20% )
• Exercise
• Exposire to cold
• Crescendo angina (Recent
• Eating destabilization of previously
stable, ≥ CCS III ) (+20% )
• Alleviated by :
• Rest • Post MI
• Nitrates
By the End of the Day

JAMA. 2015;314(18):1955-1965
2015;314(18):1955-1965.
Clinical Scenario
Clinical Scenario
Discussion

• We found that the accuracy of risk factors and symptoms was


generally poor, and that any individual element was unlikely to be
helpful in making an ACS diagnosis.
• Moreover, even those risk factors and symptoms that performed
better tended to be more specific than sensitive, and most
parameters had poor sensitivity.
• Overall clinical impression, incorporating all elements of the
history and physical examination performed better, but the best
diagnostic tests were clinical prediction tools (eg, TIMI score,
HEART score, and HFA/CSANZ rule) that incorporated historical
elements along with the initial ECG and cardiac troponin results

JAMA. 2015;314(18):1955-1965
Single Parameter First Question
Outline
Emergency Department :
• Symptoms of Ischemia ( Acute Vs Stable )
• Angina Equivalent & Associated Symptoms ( Risk factors )
• Ruling in & Ruling Out Acute Coronary Syndrome
• Heart Score & Probability
Acute Coronary Syndrome :
• The Spectrum
• Time is Muscle & Survival
• Team Approach
• Safe Referral System : PCI Capable Centre
Pitfalls & Problems
• Challenging ECG
• Initial Tx : One may not fits all
• ACLS & ACS
Take Home Messages
CAD Clinical Spectrum

 Asymptomatic
 Prinzmetal Angina
 Stable Angina
 Unstable Angina
 Myocardial Infarction
 Heart Failure
 Syncope
 Sudden Death
n engl j med 376;21 nejm.org May 25, 2017
European Heart Journal (2018) 00, 1–33
European Heart Journal (2018) 00, 1–33
IRD Acute Cardiac Care ICCU Cath Labs
Outline
Emergency Department :
• Symptoms of Ischemia ( Acute Vs Stable )
• Angina Equivalent & Associated Symptoms ( Risk factors )
• Ruling in & Ruling Out Acute Coronary Syndrome
• Heart Score & Probability
Acute Coronary Syndrome :
• The Spectrum
• Time is Muscle & Survival
• Team Approach
• Safe Referral System : PCI Capable Centre
Pitfalls & Problems
• Challenging ECG
• ACLS & ACS
• Initial Tx : One may not fits all
Take Home Messages
STEMI
Challenging ECG
NSTEACS
NSTEMI Treatment Strategy and Timing According to Risk Stratification1

Reference: 1. Adapted from : Roffi M et al. Eur Heart J 2016;37(3):267-315

41
Risk Criteria Mandating Invasive Strategy in NSTE-ACS1

HIGH RISK VERY HIGH RISK

• Relevant rise or fall in troponin • Hemodynamic instability or cardiogenic shock


• Dynamic ST- or T-wave changes (symptomatic or • Recurrent or ongoing chest pain refractory to
silent) medical treatment
• GRACE Score > 140 • Life-threatening arrhythmias or cardiac arrest
• Mechanical complications of MI
INTERMEDIETE RISK • Acute heart failure
• Recurrent dynamic ST-T wave changes,
• Diabetes mellitus particularly with intermittent ST-elevation
• Renal insufficiency (eGFR <60 mL/min/1.73 m²)
• LVEF < 40% or congestive HF LOW RISK
• Early post infarction angina
• Prior PCI • Any characteristics not mentioned above
• Prior CABG
• GRACE risk score 109 - 140

Reference: 1. Roffi M et al. Eur Heart J 2016;37(3):267-315

42
• Fluid Resuscitation as needed
• Lasix for ove
• Norepinephrine for cardiogenic shock w/ severe
hypotension
• Inotropes for predominant low cardiac output
• Report
How to Report
• Male/46
• STEMI Anterior Onset 3 hours
• VS : 120/70 mmHg/105x/28x/afebris/96% O2 Nasal
• Ronkhi +/Murmur (-)
• IV Line NS/Aspirin 300/Plavix 300/Lasix 2 amp
• Risk factors : Smoking

Das könnte Ihnen auch gefallen