ST- ELEVATION

MYOCARDIAL
INFARCTION :
MANAGEMENT

Typical angina pain > 20

minutes.
2. ECG changes : ST segment
elevation.
3. Increase cardiac enzyme.
1.

1.

Inferior wall ( limb lead ;lead II, III, aVF

2 of 3 ) ST elevation : 1 mV.

2. Anterior wall ( Precordial lead; V1 V6 )

ST elevation : minimal 2 mV 3 of 6.

Assessment of
Reperfusion Option for
Assess time
and risk
STEMI
Patients
Time since onset of symptoms
Risk of STEMI
Risk of fibrinolysis
Time required for transport to a skilled
PCI lab

Fibrinolysis is generally
preferred if :

Early persentation ( < 3 hr )

Invasive strategy is not an option.
Delay to invasive strategy.

An invasive strategy is
generally preferred if :

Skilled PCI lab available with

surgical backup.
High risk from STEMI.
Contraindication to fibrinolysis.
Late persentation.

Contraindications and
Cautions for Fibrinolytic Use
Absolute
contraindication:
in
STEMI

Any prior intracranial hemorrhage.

Known structural cerebral vascular lesion.
Ischemic stroke within 3 months EXECEPT acute
ischemic stroke within 3 hours.
Suspected aortic dissection .
Acute bleeding.
Significant closed head or facial trauma within 3
months.

Fibrinolytic therapi

Streptokinase , tPA: 1,5 jt unit dalam 60 menit.

Patency IRA -infarct related artery : 50 60 %.
Alteplase (rt-PA) : 15 mg bolus
0,75
mg/kg (max 50 mg) >30 mnt
0,5 mg/kg
(max 35 mg ) > 1 hour.
Reteplese (r-PA): 10 U bolus 2x,interval 30 mnt.
Tenecteplase TNK-PA);
< 60
kg
= 30 mg.
60 69 kg = 35 mg
70 79 kg = 40 mg
80 - 89 kg = 45 mg
>90 kg
= 50 mg

Provisional Stent.
Stent positioning and deployment with prior
balloon dilatation of the stenosis.
Direct Stent.
Stent positioning and deployment without
prior balloon dilatation of the stenosis.
Primary Stenting.
Stent implantation as the first choice to
revascularize patients presenting with acute
myocardial infarction.

The current gold standard reperfusion of STEMI

STEMI onset of symptom < 12 h, more benefit <
6 hours.
The necessary backup : Suction thrombus,
TPM, IABP.
Drug : Gp II b / IIIa.
Open : infarct related artery only.
Provisional or direct stent (BMS, DES)

Emergency ward.
1.Oxygen 2 3 l /m
2.IV line
3.Nitrate 5 mg sublingual.
Nitrate intravenous
-ISDN (isosorbide dinitrate ) 1-2 mg /h (syringe
pump 10 mg or 1amp/50 cc)
- Nitroglycrine : 10 200 micro U/ m
(Nitrocine 10 mg / 50 cc-syringe pump)

4. Killing pain : Morphin 2,5 5 mg (Dilute, IV,

if HR > 90 x / m. Pethidine 25 50 mg
(Dilute, IV, if HR < 90 x /m).

Emergency ward.
5. Clopidogrel (75 mg/tab) : 600 mg (onset 1- 2 h) ;
300 mg (onset 4 hours), 75 mg/d
Aspirin : 300 mg (enteric coated- chewed)
80 , 100 , 0r 160 mg /d
Anticoagulant :
-UFH (unfractionated heparin) : bolus 5000
units, maintenance 750 1000 U/h
Controle :aPTT 2 3 normal.

Emergency ward.
6. - LMWH.
=Enoxaparine or dalteparine ( Porcine) 100 U/ kg,
twice daily or 60 mg / 12 h)

-> care in ICCU / ICU ward.

MANAGEMENT
ACUTE DECOMPENSATED HEART
FAILURE

1.

Acute decompensation heart failure is a cardiac

emergency and high mortality rate.

2.

Management of acute decompensation heart failure

depend on subset of hemodynamic, underlying cause,
precipitating cause, medicaments and
revascularization to maintainance reperfusi vital organ

I. GENERAL
1.
2.
3.
4.
5.
6.
7.

Emergency case
Intensive Care Unit
Up right position
O2 4 -6 l/min + pulse oximeter
( ABG if need,PO2 < 50 / PCO > 50 mmHg
Ventilator)
I. V. line D5W /0,9% Nacl (microdrip)
Negative fluid balances,normal electrolyte
Monitor Blood Pressure,Heart rate and rhythm
Small and frequent feeding. Diminish anxiety (Diazepam
2 mg tid) Diet reduced Nacl 1-2 g/day ( Eliminated
cheese,bread,cereals,canned vegetables and soup )

II.

CORRECTION UNDERLYING CAUSE

1.

Ischaemic heart dss ( 75% cases )

Risk factor control, medicament and revascularization.

2. Hypertensive heart,valvular,pericardial and congenital heart dss

III. CORRECTION PRECIPITATING CAUSE

1.

Infection

Fever

tachycardia

2.
3.
4.
5.

Anemia
tachycardia
Thyrotoxicosis
tachycardia
Pregnancy
tachycardia
Drug discontinuation, high salt intake, chemotherapy, blood
transfusion, steroid and non steroid anti inflammation (NSAID)

IV.

MEDICAMENT
1. Furosemide : 0,5 1,0 mg / Kg BW/IV
Initial dose 20 mg / IV and max 80 mg/IV
For Acute Pulmonary Edema and CHF
Side effect hypo Na and hypo K
2. Dopamine : 2 -12 microgram/KgBW /IV/min
For symptomatic shock, BP 70 100 mmHg
Side effect : tachycardia,disrythmia
3. Dobutamine : 2 -12 microgram/KgBW /IV/min
For asymptomatic shock, BP 70 100 mmHg
Side effect : tachycardia,disrythmia
4. Nor epinephrine :0,04 -0,4 microgram / Kg BW / IV
For Systolic BP < 70 mmHg
Side effect : tachycardia, disrythmia

5. Nitroglycerine : 10 - 20 microgram / min/IV

For Ischaemic heart ( BP > 100 mmHg )
Side effect : hypotension, tachycardia
6. Morphine : 2 - 4 mg/IV
For acute pulmonary edema ( BP > 100 mmHg )
Side effect : hypotension,resp. depression
7. Nitroprusside : 0,1 - 5,0 microgram/ Kg/min
For CHF cause of hypertensive crisis
Side effect : hypotension, ischaemic coronary steal
phenomenon, Thiocyanate intoxicity
( nause and vomiting )
8. Digoxin : 0,01 mg/Kg/IV/digitalization
For CHF with rapid atriall fibrillation
Side effect : digitalis intoxicity

9.

Anti Coagulants
Heparin : 100 unit /Kg /IV /bolus
15 25 unit /Kg /hour /drips
check aPTT to 1,5 2,5 x N
Warfarin : Late effect ( 1 4 days )
Check INR to 1,5 2,5 x N
Dosis 5 10 mg / day for 2 days
Than titrated dose 1 2 mg/day
Indication for atriall fibrillation and high risk
thromboembolic patient

10. Brain Natriuretic peptide ( R Natrecor )

Dosis : 2 microgram / Kg/IV/bolus
0,01 0,03 microgram/Kg/min
For acute pulmonary edema ( BP > 100 mmHg )
Not first line therapy ( very expensive )

V. INTRA AORTIC BALLON PUMP (IABP)

For cardiogenic shock
Contra indication : Aortic Insufficiency, aortic
dissection and
anti coagulant therapy

VI. REVASCULARIZATION / SURGERY

For Acute myocard infarction shock. PTCA is more
effective
than thrombolytic therapy. CABG when PTCA cannot
done

Clinical Signs : Shock, hypoperfusion,

congestive heart failure, acute pulmonary edema
Most likely major underlying disturbance?

Acute
pulmonary
edema

Hypovolemia

Low outputcardiogenic
shock

Dysrhythmia

Bradycardia
1 st : Acute pulmonary edema

Furosemide
IV 0.5 to 1.0 mg/kgS
Morphine IV 2 to 4 mg
Nitroglycerin SL
Oxygen/intubation as needed

Administrter
Fluids
Blood transfusions
Cause-specific intervention
Consider vasopressors
Blood pressure?

Tachycardia

Systolic BP
BP defines 2d
line of action (see below)

Norepinephrine
0.5 to 30 g/min IV

Systolic BP
<70 mmHg
Signs/symptoms
of shock

Systolic BP
70 - 100 mmHg
Signs/symptoms
of shock

Dopamine
5 to 15 g/kg
per min IV

Systolic BP
70 - 100 mmHg
No Signs/symptoms
of shock

Dobutamine
2 to 20 g/kg
per min IV

Systolic BP
> 100 mmHg

Nitroglycerin
10 to 20 g/ min IV
Consider
Nitroprusside *
0.1 to 5.0 g/kg
per min IV

2d : Acute pulmonary edema

Nitroglycerin if systolic BP > 100 mmHg systolic
Dopamine if BP = 70 - 100 mmHg, signs/symptoms of shock
Dobutamine if BP 70- 100 mmHg, no signs/symptoms of shock
ACE inhibitors if systolic BP not < 30 mmHg below baseline

Further diagnostic/therapeutic considerations

Diagnostic
Therapeutic
Pulmonary artery catheter
Intraaortic ballon pump
Echocardiogarpy
Reperfusion/revascularization
Angiography for MI/ischemia
Additional diagnostic studies