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MI1
AcuteCoronarySyndromes?ObjectivesIdentifypatientswithacutecoronarysyndromesOutlineacutemanagementofunstableangina,non-QwaveandQ-wavemyocardialinfarctionIdentifypatientswhoarecandidatesforrevascularizationinterventionsRecognizehigh-riskpatientsandearlycomplicationsofmyocardialinfarctionMI2
?AcuteCoronarySyndromesOverlappingclinicalconditionsUnstableanginaNon-Q-wavemyocardialinfarction(MI)Q-wave(ST-segmentelevation)myocardialinfarctionVariabledegreesofcoronaryarteryocclusionProcessofinflammation,plateletactivation/aggregation,thrombusformation,microembolizationMI3
?ChestPainAlgorithmPatientwithchestpain
History,physicalexamination,ECG,chestradiograph
MIwithST-segmentelevationpresent?
Yes
ToMI
algorithmNo
Unstableanginapresent
No
Consideralternativeevaluation
UnstableAnginaandNon-Q-WaveMyocardialInfarctionEvaluationandmanagementsimilarPreliminarydiagnosisClinicalsymptomsRiskfactorsElectrocardiogramCardiacenzymesAssessshort-termrisks
ChestPainAlgorithm Unstableanginapresent
Admit,monitorECG,O2
Aspirin Sublingualorspraynitroglycerin Intravenousnitroglycerin Heparin(unfractionated,lowmolecularweight)
-blocker
GPIIb/IIIainhibitor(high-riskpatients)
Symptomsrelieved?
Yes
Elective
evaluation No(nextslide)
ChestPainAlgorithm
Symptomsrelieved?
No
Adjustdoseofnitroglycerin,-blockerConsidercalciumchannelblocker
Symptomsrelieved?
Yes
Elective
evaluation No
Emergencyconsultation/transferCautionsNitroglycerinAvoiddecreaseinbloodpressure10%Adjustunfractionatedheparininfusion-blockercontraindicationsHeartrate<60beats/minModerate-severeheartfailureAtrioventricularblock>firstdegreeSystolicbloodpressure<100mmHgPeripheralhypoperfusionBronchospasticdiseaseQ-Wave(ST-segmentelevation)MyocardialInfarctionOcclusionofcoronaryarterybythrombusProgressionofnecrosiswithtimeDiagnosisClinicalsymptomsElectrocardiogramCardiacenzymesAdmit,O2
AspirinSublingual,sprayand/orivnitroglycerinMorphineHeparin(unfractionated,lowmolecularweight)
-blocker
Candidateforthrombolytic?
No
Emergencyconsultation/transferforprimaryPTCAQ-Wave(ST-segmentelevation)MyocardialInfarctionDefiniteIndicationsforThrombolyticTherapy
ConsistentClinicalSyndromeChestpain,newarrhythmia,unexplainedhypotensionorpulmonaryedemaDiagnosticECGSTelevation
1mmin
2contiguousleadsornewleftbundle-branchblockLessthan12hourssinceonsetofpainRelativeIndicationsforThrombolyticTherapy
ConsistentClinicalSyndromeChestpain,newarrhythmia,unexplainedhypotensionorpulmonaryedemaNondiagnosticECGLeftbundle-branchblockofunknownduration
AbsoluteContraindicationsforThrombolyticTherapy
HistoryofhemorrhagicstrokeStrokeorCVAwithin1yearAllergytotheagentSurgeryortraumainpast2wksKnownintracranialneoplasmSuspectedaorticdissectionActiveinternalbleeding
(exceptmenstruation)RelativeContraindicationsforThrombolyticTherapy
Severeuncontrolledhypertension(>180/110mmHg)HistoryofchronicseverehypertensionCVAorintracerebralpathology>1yragoCurrentanticoagulantuseRecenttrauma(within2-4weeks)AllergyorpriorexposuretostreptokinaseRelativeContraindicationsforThrombolyticTherapy
ActivepepticulcerdiseaseSignificanthepaticdysfunctionRecent(2-4weeks)internalbleedingBleedingdiathesisNoncompressiblearterialorcentral
venouspuncturePregnancyQ-Wave(ST-segmentelevation)MyocardialInfarction Candidateforthrombolytic?
No
Emergency
consultation/transfer Yes forprimaryPTCA
Thrombolyticagentgiven
ComplicationsofMI
Yes
Emergency
consultation/transfer No
ElectiveevaluationContinuingTherapyHeparininfusionafterthrombolysis(exceptafterstreptokinase)AspirindailyNitroglycerinfor24-48hours
-blockerunlesscontraindicatedAngiotensin-convertingenzyme(ACE)inhibitorwithinfirst24hoursCardiologyconsultationand/ortransferComplicationsofMyocardialInfarction
Heartfailure:SystolicBP>100mmHgVasodilatorsNitroglycerinNitroprussideInotropesDobutamineMilrinoneLoopdiureticsHeartfailure:SystolicBP<90mmHgVasopressorsinitiallyNorepinephrineDopamineInotropeswhenBPstableConsiderPTCAorintra-aorticballoonpumpCardiologyconsultationComplicationsofMyocardialInfarctionComplicationsofMyocardialInfarction
RecurrentischemiaorinfarctionFollowunstableanginaalgorithmCardiologyconsultationConsiderrepeatthrombolysiswithnon-streptokinaseagentAngioplastyorbypassComplicationsofMyocardialInfarction
ArrhythmiasProphylacticdrugsnotrecommen
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