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

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The Management of AMI and ACS Patients

in the Emergency Department

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Part 2:AMI/ACS Treatment

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Acute Myocardial Acute Myocardial Infraction Part II:Infraction Part II:

Reperfusion Therapies Reperfusion Therapies for UA, NSTEMI, for UA, NSTEMI,

and STEMIand STEMI

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Professor

Department of Emergency Medicine, University of Illinois at Chicago

Chicago, IL

([email protected])

Edward P. Sloan, MD, MPH, FACEP

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Attending Physician Attending Physician Emergency MedicineEmergency Medicine

University of Illinois Hospital

Our Lady of the Resurrection

Medical Center

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Global ObjectivesGlobal 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

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Session ObjectivesSession Objectives

Provide AMI, ACS overview Ask clinically relevant questions

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AMI/ACS Rx:Global Objectives

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AMI/ACS Rx: ObjectivesAMI/ACS Rx: Objectives

What are the global objectives of AMI Rx in the ED?

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AMI/ACS Rx: ObjectivesAMI/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

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AMI/ACS Rx:Pharmacological

Interventions

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Pharmacotherapy of AMI/ACS

ASA NTG Morphine Heparin, LMW Thrombolytics Antidysrhythmics Fluid & pressure therapies

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AMI/ACS Rx: OxygenAMI/ACS Rx: Oxygen

AMI/ACS Limited O2 delivery Increased myocardial O2 use IV, O2, monitor NC at 4 L/min Quick, easy, cheap

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AMI Rx: ASA, Platelet MedsAMI Rx: ASA, Platelet Meds

When are ASA and other platelet meds indicated?

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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

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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%

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AMI/ACS Rx: Platelet Rx

Dipyridamole Ticlopidine Clopidogrel

Consider when ASA allergic Caution in acute setting!

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AMI/ACS Rx: NitratesAMI/ACS Rx: Nitrates

When are nitrates indicated? What is the appropriate dose of

NTG in AMI/ACS patients?

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AMI/ACS Rx: NitratesAMI/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

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AMI/ACS Rx: NitratesAMI/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

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AMI/ACS Rx: NitratesAMI/ACS Rx: Nitrates

Expect SBP to drop with NTG SBP drop 10% with normal BP SBP drop 30% with elevated BP

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AMI/ACS Rx: NitratesAMI/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%

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AMI/ACS Rx: MorphineAMI/ACS Rx: Morphine

What are the indications for morphine in AMI/ACS patients?

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AMI/ACS Rx: MorphineAMI/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

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AMI/ACS: AntidysrhythmicsAMI/ACS: Antidysrhythmics

What are the indications for antidysrhythmics in AMI/ACS patients?

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AMI/ACS Rx: VT, VF RxAMI/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

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Monomorphic VTachMonomorphic VTach

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Polymorphic VTachPolymorphic VTach

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AMI/ACS Rx: AFib RxAMI/ACS Rx: AFib Rx

Cardioversion: unstable patients Rapid digitalization IV Beta blockers Diltiazem or verapamil Heparin

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Atrial FibrillationAtrial Fibrillation

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AMI/ACS Rx: AdenosineAMI/ACS Rx: Adenosine

Slow conduction thru AV node Interrupts reentrant pathways Used in PSVT 6 mg IVP, then 12 mg IVP

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Paroxysmal SVTParoxysmal SVT

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AMI/ACS Rx: AmiodaroneAMI/ACS Rx: Amiodarone

Class III agent Treats supraventricular and

ventricular dysrhythmias Prolongs refractory period Sustained monomorphic VT VF and unstable VT

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AMI/ACS Rx: AtropineAMI/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

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AMI/ACS Rx: Beta-blockadeAMI/ACS Rx: Beta-blockade

What are the indications for beta-blockade in AMI/ACS patients?

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Ischemic penumbra preserved Decreased catecholamines Decreased dysrhythmias Decreased HR and BP Decreased infarct size

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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

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Contraindications Moderate to severe CHF COPD/asthma Bradycardia Hypotension 2nd or 3rd degree A-V blocks

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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

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AMI/ACS Rx: CaAMI/ACS Rx: Ca++++ Channel Channel

Rate control in atrial fib, flutter If unable to provide beta blockade Not viewed in same way a use of

metoprolol in AMI

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AMI/ACS Rx: DigitalisAMI/ACS Rx: Digitalis

Rapid load in rapid atrial fibrillation Provided before beta blocker use Not used for its inotropic effects

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AMI/ACS Rx: LidocaineAMI/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

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AMI/ACS Rx: MagnesiumAMI/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?

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Torsade de PointesTorsade de Pointes

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AMI/ACS: BP/Fluid RxAMI/ACS: BP/Fluid Rx

How should BP and fluids be managed in AMI/ACS patients?

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AMI/ACS Rx: IV FluidsAMI/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?

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Normal saline Bolus hypotensive pts Starling curve supports use 200 cc even with CHF RV AMI: Repeated boluses

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AMI/ACS Rx: DopamineAMI/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

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AMI/ACS Rx: DobutamineAMI/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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AMI/ACS Rx: NorepinephrineAMI/ACS Rx: Norepinephrine

Used in refractory hypotension No response to other pressors Increased myocardial O2 use Improved inotropy, but no increase in

cardiac output as SVR is increased Ectopy, dysrhythmias can occur

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AMI/ACS Rx: InotropesAMI/ACS Rx: Inotropes

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AMI/ACS Rx: DiureticsAMI/ACS Rx: Diuretics

Furosemide: NaCl clearance Used in pulmonary edema & LV

dysfunction Volume, Starling effects More optimal LV filling, stroke

volume, and cardiac output

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AMI/ACS Rx: ACE InhibitorsAMI/ACS Rx: ACE Inhibitors Reduces LV dilatation and

dysfunction, improves remodeling Slows development of CHF AMI/ACS patients, especially

critically ill anterior wall MI patients with pulmonary edema show greatest benefit

Captopril, enalapril, or lisinopril Early use may reduce mortality

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AMI/ACS Rx: ACE InhibitorsAMI/ACS Rx: ACE Inhibitors

Not mandated to be ED Rx Contraindications

Hypotension Bilateral renal artery stenosis Renal insufficiency/failure

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AMI/ACS Rx: Clot TherapiesAMI/ACS Rx: Clot Therapies

What are the indications for heparin, IIb/IIIa, and thrombolytic therapy?

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AMI/ACS Rx: Heparin (LMW)AMI/ACS Rx: Heparin (LMW)

What are the indications for heparin and LMW heparin in AMI/ACS patients?

How does LMW heparin work differently than un-fractionated heparin?

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Prevents late thrombus formation Maintains patent coronary artery Prevents mural thrombus from

forming in anterior wall MI Prevents cerebral emboli with AMI Doesn’t Rx already formed thrombi Platelet Rx: White clot, ACS, NSTEMI Thrombolytic Rx: Red clot, STEMI

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Thrombin inhibition Prevents clot propagation, formation High embolism risk pts identified:

Large or ant MI, Afib, previous embolus, known LV thrombus

Complication reduction: Reinfarction reduced by 30% Mortality reduced by 21%

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Indicated in patients with PCI or surgical revascularization

Also used in pts who get tPA and those with ACS, NSTEMI

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AMI/ACS Rx: HeparinAMI/ACS Rx: Heparin

Over 1300u/hr associated with bleeding complications

Attempt to achieve a PTT that is 1.5-2.0 times normal (60-85 seconds)

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AMI/ACS Rx: HeparinAMI/ACS Rx: Heparin

Bolus: 60 units/kg Infusion: 12 U/kg per hour Max recommended dose

4000 units bolus 1000 units per hour infusion

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AMI/ACS Rx: LMW HeparinAMI/ACS Rx: LMW Heparin

Similar indications to heparin 1 mg/kg SQ BID Prior suggestion that heparin

preferred in highest risk pts Some prefer heparin prior to PCI No demonstrated difference between

heparin and LMW in these patients

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AMI/ACS Rx: IIb/IIIa InhibitorsAMI/ACS Rx: IIb/IIIa Inhibitors

What are the indications for IIb/IIIa inhibitors in AMI/ACS patients?

How do these drugs work?

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Abciximab (ReoPro): long acting Ab Eptifibatide (Integrillin): peptide Tirofiban (Aggrastat): peptide Used in ACS, NSTEMI patients,

especially those who undergo PCI High risk patients (positive troponin) Requires 48-72 hrs of infusion to

demonstrate benefits

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Useful in treatment of pts with refractory unstable angina

Treats white clot: ACS, NSTEMI Few head to head studies that

compare IIb/IIIa inhibitors Rate of ICH lower than with

fibrinolysis

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50,000 receptors per platelet Final common pathway Platelets bind with fibrinogen Forms hemostatic plug (white clot) IIb/IIIa glycoprotein prevents this

binding and formation of white clot

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Platelet ActivationPlatelet Activation

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Inhibit 80% of receptors, then there is no platelet aggregation

Prevents ongoing platelet deposition No effect on thrombin generation No effect on coagulation, inflammation Combo therapy with thrombin drugs Use with heparin is indicated

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White Clot: ACS, NSTEMIWhite Clot: ACS, NSTEMI• Platelets, Fibrin, Red CellsPlatelets, Fibrin, Red Cells

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Beneficial effects of platelet inhibition Decreased re-occlusion after

thrombolysis and/or PCI Decreased re-infarction risk because

of better coronary artery healing Minimizes extent of occlusion as a

result of acute plaque disruption

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Clinical use in ED is indicated in ACS Actual use is somewhat limited by

availability of PCI for most critically ill ACS, NSTEMI patients

Although use should begin in ED, many cardiologists begin infusion following PCI

Still important prior to transfer for PCI

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AMI/ACS Rx: ThrombolyticsAMI/ACS Rx: Thrombolytics

What are the indications for thrombolytic therapy in AMI/ACS patients?

How do thrombolytics work?

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Red Thrombus in STEMIRed Thrombus in STEMI Thrombin, fibrin, clotting factors

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Time is muscle Restoration of TIMI-3 flow Myocardial salvage Reduced ventricular dysfunction Reduced ectopy Sudden death less likley

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Indications Classic history EKG with > 1mm ST in 2 limb

leads or > 2mm ST in > 2 precordial leads

New LBBB

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No contraindications No cardiogenic shock (??)

Presentation within 12 hours of symptom onset

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Maximal benefit when given within first 2 hours of infarct

Greater mortality benefit in patients with anterior wall AMI as opposed to those with inferior wall AMI

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Streptokinase APSAC tPA Retavase (rPA) TNK t-PA

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tPA

Clot specificNot antigenicReduces mortality 28%½ life only 5 minutesHigher risk of ICH than SK

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tPA

Dosing: 15 mg IV over 2 min 0.75 mg/kg (max 50) over 30 min 0.50 mg/kg (max 35) over 60 min

Start heparin, ASA concurrently

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Retavase (rPA) At least as effective as SK Comparable tPA mortality benefit Dosing: 10mg IV bolus at 0 min

and 30 min

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TNK t-PA

Genetic variant of tPA Slower plasma clearance Greater fibrin specificity 0.53 mg/kg bolus, 50mg max Heparin infusion, ASA use

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Absolute contraindications Any active bleeding Recent GI bleed (within 10

days) Hemorrhagic CVA at any time Non-hemorrhagic CVA in last 6

months

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Absolute contraindications Aortic dissection Pericarditis Childbirth within 10 days HTN (SBP >200 or DBP>120)

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Absolute contraindications Intracranial/spinal mass lesion,

aneurysm, AV malformation Surgery within 2 months Serious head trauma in last month Bleeding disorder Pregnancy

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Relative Contraindications Traumatic CPR PUD Current anticoagulant use Hx of HTN with DBP > 100

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Relative contraindications Diabetic/hemorrhagic retinopathy Non-compressible vein cannulation Over age 70

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AMI/ACS Rx:Mechanical

Interventions

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AMI/ACS Rx: Cardiac PacingAMI/ACS Rx: Cardiac Pacing

What are the indications for cardiac pacing in AMI/ACS patients?

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For large anterior STEMIs Not as an Rx for vagal reaction To Rx symptomatic bradycardia Overdrive suppression (+/-)

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Transcutaneous Cardiac PacingTranscutaneous Cardiac Pacing

Sinus brady, low BP, no Rx effect Mobitz type II second degree block Third degree block Bifascicular block LBBB RBBB or LBBB & first degree AV block Less so for stable bradycardia, RBBB

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Transvenous Cardiac PacingTransvenous Cardiac Pacing Asystole Sinus brady, low BP, no Rx effect Mobitz type II second degree block Third degree block Bifascicular block RBBB & first degree AV block (+/-) Overdrive suppression for VT (+/-) 3 sec sinus pauses, no Rx effect (+/-)

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Cardiac Pacing ApproachCardiac Pacing Approach Establish rhythm disturbance Determine that rate, rhythm are

effecting adequate perfusion Attempt to Rx BP Attempt to improve rate with atropine Attempt transcutaneous pacing Place sheath for transvenous pacer Insert transvenous pacer as needed

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AMI/ACS Mechanical Interventions

Mechanical Ventilation

Intubation, mechanical ventilation Decreased work of breathing Increases BP (hopefully) Decreases myocardial O2 use Increases O2 delivery (CHF) Critical in cardiogenic shock

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Intraaortic Balloon Pump

What are the indications for intraaortic balloon pump support in AMI/ACS patients?

How does the intraaortic balloon pump work?

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Intraaortic Balloon Pump

Refractory cardiogenic shock Fluids, pressors without effect Persistent pain, shock Rapid systole balloon deflation Vacuum assists LV function Improves cardiac output

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Intraaortic Balloon Pump Refractory cardiogenic shock As a stabilizing measure prior to PCI Acute mitral regurgitation, VSD

(STEMI mechanical complications) Intractable ventricular dysrhythmias Refractory post-MI ischemia, as bridge Unstable pts when LV is “at risk” (+/-)

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AMI/ACS Mechanical InterventionsPercutaneous Coronary Interventions

What is PCI? What are the PCI indications? What is the goal of PCI? Over what time period should

revascularization occur?

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AMI/ACS Rx: RevascularizationAMI/ACS Rx: Revascularization

Over what time period should revascularization occur?

ACEP and AHA/ACC guidelines 120 minutes door to balloon time If not, consider tPA use in ED

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PCI optimal for single lesion, grafts May be able to treat multiple lesions May require multiple procedures Extensive small vessel disease

precludes effective PCI Rx Multiple occluded vessels: CABG

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PCI is the industry standard Door to balloon time can be > 120 min When PCI is imminent:

Front loaded tPA not often utilized IIb/IIIa inhibitors not often utilized

Need to optimize ED process

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AMI/ACS Rx: EMS TriageAMI/ACS Rx: EMS Triage

Is there evidence to support directed triage to “cardiac” centers?

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AMI/ACS Rx: EMS TriageAMI/ACS Rx: EMS Triage Is there evidence to support directed

triage to “cardiac” centers? No. It is unclear that door to balloon time is

significantly decreased, nor is patient outcome worsened if a transfer agreement is in place

Caveat: cardiogenic shock patients probably would benefit from direct triage for immediate PCI

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AMI/ACS Rx: Pre-hospital RxAMI/ACS Rx: Pre-hospital Rx

What out-of-hospital therapies have been demonstrated to improve outcome in AMI?

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AMI/ACS Rx: Pre-hospital RxAMI/ACS Rx: Pre-hospital Rx

911 activation Early defibrillation, first responders 12 lead EKG, thrombolysis (+/-)

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AMI/ACS: Specific Issues

Elderly and females associated with more atypical presentations

Pts with symptoms of AMI/ACS after PCI should be assumed to have abrupt vessel closure

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AMI/ACS: Hospital Admission

Pts at high risk for CAD, AMI, or death admit to ICU

ED observation units and non-ICU monitored beds are safe for pts with normal ECGs and low to moderate risk

Low risk patients: 2 hour rule out and outpatient stress testing

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History

Case #1

58 year old male Chest pain, sub-sternal, severe Onset less than one hour prior Nausea, diaphoresis No known cardiac history Smoker, ?cholesterol

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Px

Case #1

98.8 100/60 110 24 Gen: Screaming in pain, diaphoretic Chest: BS equal CV: Reg rhythm without

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Diagnosis

Case #1

Having the big one. Acute anterior wall MI Complete occlusion of the left main

coronary artery

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Treatment

Case #1

IV NTG ASA, Oxygen Morphine Heparin Cardioversion (200j) (VTach) Rapid transfer for PTCA

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History

Case #2

48 year old male Sudden onset of chest pain SOB, nausea ? Cardiac hx, on ASA

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Px

Case #2

98.6 160/90 116 24 Gen: Diaphoretic, pale, anxious Chest: Clear BSBE CV: Reg without Exam otherwise normal

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Diagnosis

Case #2

Inferior wall MI Likely R coronary artery occlusion

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Treatment

Case #2

IV NTG ASA, Oxygen Morphine Heparin Rapid transfer for PTCA

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ConclusionsConclusions

AMI/ACS Rx in the E.D.AMI/ACS Rx in the E.D.

Common problem ED staff has an important role Many therapies are available Chance to make a difference Good guidelines exist Interested consultants

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ConclusionsConclusions

AMI/ACS: Relevant QuestionsAMI/ACS: Relevant Questions Is there an acute plaque rupture? Is this ACS (white clot) req platelet Rx? Is this STEMI (red clot) req TT, PCI? What Rx must be provided in the ED? How can revascularization best be

achieved given the ED processes?

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AMI/ACS DiagnosisAMI/ACS DiagnosisQuestions?Questions?

2002, 2004 ACC/AHA guidelines www.acc.org or www.americanheart.org 2000 ACEP guidelines www.acep.org www.guidelines.gov PDF file allows for optimal printing

[email protected] (312) 413-7490

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

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