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Next slide

BRADYCARDIASSlow(absolute bradycardia=rate < 60 bpm

orRelatively slow(rate less than expected relative to

underlying condition or cause)

PRIMARY ABCD SURVEY Assess ABCs ecure air!ay noninvasively "nsure monitor # de$ibrillator is available

SECONDARY ABCD SURVEY Assess secondary ABCs (invasive air!ay

management needed%) &xygen ' access ' monitor ' $luids

ital signs* pulse oximeter* monitor B+ &btain and revie! ,-'lead "C. &btain and revie! portable chest x'ray +roblem'$ocused history +roblem'$ocused physical examination Consider causes (di$$erential diagnoses)

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SERIOUS SIGNS OR SYMPTOMS ?SERIOUS SIGNS OR SYMPTOMS ?

/ue to the bradycardia%/ue to the bradycardia%

Tye II se!o"d#de$%ee AV &lo!'Tye II se!o"d#de$%ee AV &lo!'

ororT(i%d#de$%ee AV &lo!'?T(i%d#de$%ee AV &lo!'?

I"te%ve"tio" Se)*e"!eI"te%ve"tio" Se)*e"!e

At%oi"eAt%oi"e01 2 ,0 mg01 2 ,0 mg T%a"s!*ta"eo*s a!i"$T%a"s!*ta"eo*s a!i"$i$ availablei$ available Doa+i"eDoa+i"e1'-0 3g#4g per minute1'-0 3g#4g per minute Ei"e(%i"eEi"e(%i"e -',0 3g#min-',0 3g#min Iso%ote%e"olIso%ote%e"ol -',0 3g#min-',0 3g#min

NoNo YesYes

+repare $or transvenous pacer+repare $or transvenous pacer $ symptoms develop* use$ symptoms develop* use

transcutaneous pacema4er untiltranscutaneous pacema4er until

transvenous pacer placedtransvenous pacer placed

&bserve&bserve

NoNo YesYes

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Eval*ate atie"tEval*ate atie"t s patient stable or unstable%s patient stable or unstable%

Are there serious signs or symptoms%Are there serious signs or symptoms% Are signs and symptoms due to tachycardia%Are signs and symptoms due to tachycardia%

Sta&le atie"t, "o se%io*s si$"s o% sy+to+sSta&le atie"t, "o se%io*s si$"s o% sy+to+s nitial assessment identi$ies , o$ 5 types o$nitial assessment identi$ies , o$ 5 types o$

tachycardiastachycardias

U"sta&le atie"t, se%io*s si$"s o% sy+to+sU"sta&le atie"t, se%io*s si$"s o% sy+to+s "stablish rapid heart rate as cause o$ signs and"stablish rapid heart rate as cause o$ signs and

symptomssymptoms ate'related signs and symptoms occur at many rates*ate'related signs and symptoms occur at many rates*

seldom < ,10 bpmseldom < ,10 bpmPrepare for immediate cardioversion (see Fig. 10)Prepare for immediate cardioversion (see Fig. 10)

,, Atrial $ibrillationAtrial $ibrillation

Atrial $lutterAtrial $lutter-- 7arro!'complex7arro!'complex

tachycardiatachycardia88 table !ide'complextable !ide'complex

tachycardia9 un4no!n typetachycardia9 un4no!n type55 table monomorphic :table monomorphic :

and#or polymorphic :and#or polymorphic :

StableStable UnstableUnstable

Next slideNext slide

:he :achycardias9 &vervie! Algorithm:he :achycardias9 &vervie! Algorithm

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Evaluation focus: 4 clinicalEvaluation focus: 4 clinical

featuresfeatures

,, +atient clinically unstable%+atient clinically unstable%

-- Cardiac $unction impaired%Cardiac $unction impaired%

88 ;+; present%;+; present%

55 /uration

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Tachycardia: Atrial )ibrillation and )lutter

Atrial $ibrillation#Atrial $ibrillation#atrial $lutter !ithatrial $lutter !ith

Normal heartNormal heart

,, Control ateControl ate - Convert hythm- Convert hythm

Impaired heartImpaired heart WPWWPW eart unctioneart unction+reserved+reserved mpairedmpairedeart "eart "

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or additionalor additionaldrugs that aredrugs that areClass bClass brecommendationrecommendations*s*

see .uidelinessee .uidelinesor ACF textor ACF text

or additionalor additionaldrugs that aredrugs that are

Class bClass brecommendationrecommendations * sees * see

.uidelines or.uidelines orACF textACF text

Ea%ly !a%dioves%sio"Ea%ly !a%dioves%sio"

.. Begin heparin at onceBegin heparin at once

:"" to exclude atrial clot:"" to exclude atrial clot

T(e"T(e"

Cardioversion !ithin -5 hoursCardioversion !ithin -5 hours

T(e"T(e"

Anticoagulation x 5 more !ee4sAnticoagulation x 5 more !ee4s

mpairedmpairedheart ("heart ("

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Atrial fibrillationAtrial fibrillationatrial flutter 'ithatrial flutter 'ith

.. Normal heartNormal heart

Impaired heartImpaired heart

WPWWPW

/0 "ontrol *ate/0 "ontrol *ate 10 "onvert *hythm10 "onvert *hythm

2eart )unction2eart )unction(reserved(reserved

3mpaired 2eart E)3mpaired 2eart E)456 or "2)456 or "2)

Duration 47 2oursDuration 47 2ours Duration 847Duration 8472ours or Un&no'n2ours or Un&no'n

#(##(# Note:Note: If AF >!If AF >!ho"rs# d"ration$ "seho"rs# d"ration$ "se

agents %ith potentialagents %ith potentialto convert rh&thmto convert rh&thm%ith e'treme ca"tion%ith e'treme ca"tionin patients notin patients notreceiving ade"atereceiving ade"ateanticoag"lationanticoag"lationeca"se of possileeca"se of possileemolicemolic

complicationscomplications /C cardioversion/C cardioversion

O%O%

.. (rimary(rimaryantiarrhytmicantiarrhytmicagentsagents

Note:Note: If AF >! ho"rs#If AF >! ho"rs#d"ration$ "se agentsd"ration$ "se agents

%ith potential to%ith potential toconvert rh&thm %ithconvert rh&thm %ithe'treme ca"tion ine'treme ca"tion in

patients not receivingpatients not receivingade"ateade"ateanticoag"lationanticoag"lationeca"se of possileeca"se of possileemolicemolic

complicationscomplications /C cardioversion/C cardioversion

O%O%

AmiodaroneAmiodarone

(Class b)(Class b)

../C cardioversion/C cardioversion

O%O%

.. (rimary(rimaryantiarrhythmic agentsantiarrhythmic agents

*se onl& 1 of the*se onl& 1 of thefollo%ing agents (seefollo%ing agents (seenote elo%)+note elo%)+

AmiodaroneAmiodarone

(Class b)(Class b)

lecainidelecainide

(Class b)(Class b)

+rocainamide+rocainamide

(Class b)(Class b)

+ropa$enone+ropa$enone

(Class b)(Class b)

otalolotalol

Class bClass b

.. AvoidAvoidnonemergentnonemergent

CardioversionCardioversionunlessunlessanticoagulation oranticoagulation orclot precautions areclot precautions areta4en (see above)ta4en (see above)

AnticolagulationAnticolagulationas described above*as described above*

$ollo!ed by$ollo!ed by D" cardioversionD" cardioversion

Tachycardia: Atrial )ibrillation and flutter

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*se onl& 1 of the*se onl& 1 of thefollo%ing agentsfollo%ing agents(see note elo%)+(see note elo%)+

Amiodarone (ClassAmiodarone (Classb)b)

lecainidelecainide(Class b)(Class b)

+rocainamide+rocainamide(Class b)(Class b)

+ro$enone+ro$enone

(Class b)(Class b)

otalol (Class b)otalol (Class b)

Class Class

(can e harmf"l)(can e harmf"l)

AdenosineAdenosine

D'Bloc4ersD'Bloc4ers

Calcium bloc4ersCalcium bloc4ers

/igoxin/igoxin

mpaired heartmpaired heart

(2F 304 or -5F)(2F 304 or -5F)

/C cardioversion/C cardioversion

Amiodarone (ClassAmiodarone (Classb)b)

Class Class

(can e harmf"l)(can e harmf"l)

AdenosineAdenosine

D'Bloc4ersD'Bloc4ers

Calcium bloc4ersCalcium bloc4ers /igoxin/igoxin

;+; indicates ;ol$$'+ar4inson';hite syndrome9 A* atrial $ibrillationH 7* normal sinus rhythmH :""* transesophageal;+; indicates ;ol$$'+ar4inson';hite syndrome9 A* atrial $ibrillationH 7* normal sinus rhythmH :""* transesophageal

echocardiogramH and "* e?ection $ractionechocardiogramH and "* e?ection $raction

7ote9 &ccasionally - o$ the named antiarrithmic agents may be used* but use o$ these agents in combination may have7ote9 &ccasionally - o$ the named antiarrithmic agents may be used* but use o$ these agents in combination may have

proarrhythmic potential :he classes listed represent the Class o$ ecommendation rather than the aughn';illiamsproarrhythmic potential :he classes listed represent the Class o$ ecommendation rather than the aughn';illiams

classi$ication o$ antiarrhythmicsclassi$ication o$ antiarrhythmics

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Narro'$"omple% TachycardiaNarro'$"omple% Tachycardia

Narro'$"omple% SupraventricularTachycardia9Narro'$"omple% SupraventricularTachycardia9 Sta&leSta&le

.. # Blo!'e%# Blo!'e%

-- Ca.Ca.//!(a""el &lo!'e%!(a""el &lo!'e%

--A+ioda%o"eA+ioda%o"e

N, D" cardioversionN, D" cardioversion

Attempt therapeutic diagnostic maneuverAttempt therapeutic diagnostic maneuver

.. Va$al sti+*latio"Va$al sti+*latio"

--Ade"osi"eAde"osi"e

..A+ioda%o"eA+ioda%o"e

N, D" cardiversionN, D" cardiversion

nctnct;unctional tachycardia;unctional tachycardia

+reserved+reserved

eart $unctioneart $unction

"

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(aro%yamal supraventricular(aro%yamal supraventricular

tachycardiatachycardia(riority order:(riority order:

.. DC !a%diove%sio"DC !a%diove%sio"

-- Di$oxi"Di$oxi"


-- Diltia0e+Diltia0e+

(riority order:(riority order:

..AV "odal &lo!'adeAV "odal &lo!'ade

11 2#Blo!'e%2#Blo!'e%

11 Ca3/ !(a""el &lo!'e%Ca3/ !(a""el &lo!'e%

11 Di$oxi"Di$oxi"

-- DC !a%diove%sio"DC !a%diove%sio"--A"tia%%(yt(+i!sA"tia%%(yt(+i!s::

consider procainamide9consider procainamide9

amiodarone9 sotalolamiodarone9 sotalol

(reserved(reserved

heart functionheart function

E) 4569 "2)E) 4569 "2)

Ectopic or multifocalEctopic or multifocal

atrial tachycardiaatrial tachycardia

.. 2#Blo!'e%2#Blo!'e%

-- Ca3/ !(a""el &lo!'e%Ca3/ !(a""el &lo!'e%



(reserved(reserved

2eart function2eart function

E) 4569 "2)E) 4569 "2)

..A+ioda%o"eA+ioda%o"e

-- Diltia0e+Diltia0e+


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table entricular :achycardia9 >onomorphic and +olymorphictable entricular :achycardia9 >onomorphic and +olymorphic

table entricular :achycardiatable entricular :achycardia>onomorphic or +olymorphic%>onomorphic or +olymorphic%

>edications9 any one>edications9 any one ProcainamideProcainamide otalolotalol

&thers acceptable&thers acceptableAmiodaroneAmiodarone 6idocaine6idocaine

+olymorphic :+olymorphic : s Baseline I: interval prolonged%s Baseline I: interval prolonged%

7oteJ7oteJ7a& go direcl& to7a& go direcl& to

cardioversioncardioversion

>onomorphic :>onomorphic : s cardiac $unctions cardiac $unction impairedimpaired

7ormal baseline I: nterval7ormal baseline I: nterval

:reat ischemia:reat ischemia Correct electrolytesCorrect electrolytes

>edications9 any one>edications9 any one 89:locers89:locersoror 6idocaine6idocaineoror ProcainamideProcainamideoror otalolotalol

Fong baseline I: intervalFong baseline I: interval

Correct abnormal electrolytesCorrect abnormal electrolytes

:herapies9 any one:herapies9 any one 7agnesi"m7agnesi"m ;verdrive;verdrive IsoproterenolIsoproterenol Phen&toinPhen&toin 6idocaine6idocaine

+reserved+reservedheart $unctionheart $unction +oor e?ection $raction+oor e?ection $raction

7ormal baseline7ormal baselineI: intervalI: interval

+rolonged baseline+rolonged baseline

I: interval(suggests torsades)I: interval(suggests torsades)

Next slide

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A+ioda%o"eA+ioda%o"e

,10 mg over ,0 minutes,10 mg over ,0 minutes

oror4ido!ai"e4ido!ai"e

01 to 0K1 mg#4g push01 to 0K1 mg#4g push

:hen use:hen use

Sy"!(%o"i0ed !a%diove%sio"Sy"!(%o"i0ed !a%diove%sio"

Cardiac $unctionCardiac $unction

impairedimpaired

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Acute (ulmonary Edema9 2ypotension9 Shoc&

"linical signs9 hoc$ h&poperf"sion$

congestive heart fail"re$ ac"te p"lmonar& edema

>ost li4ely problem%

Acute pulmonary edema !olume (roblem (ump problem *ate problem

Tachycardia

(see algorithm)

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ystolic B+ B+

de$ines -ndline

o$ action (ee

belo!)

ystolic B+

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3schemic "hest (ain Algorithm3schemic "hest (ain Algorithm

Chest painChest pain

suggestive o$ ischemiasuggestive o$ ischemia

mmediate assessment (easure vital signs (automatic#standard B+ cu$$)

>easure oxygen saturation>easure oxygen saturation

&btain access&btain access

&btain ,-'lead "C. (physician revie!s)&btain ,-'lead "C. (physician revie!s)

+er$orm brie$* targeted history and physical examH+er$orm brie$* targeted history and physical examH

$ocus on eligibility $or $ibrinolytic therapy$ocus on eligibility $or $ibrinolytic therapy &btain initial serum cardiac mar4er levels&btain initial serum cardiac mar4er levels

"valuate initial electrolyte and coagulation studies"valuate initial electrolyte and coagulation studies

eLuest* revie! portable chest x'ray (

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Start ad?unctive treatmentsStart ad?unctive treatments

(as indicated9 no reper$usion delay)(as indicated9 no reper$usion delay)

2#Ad%e"o!eto% &lo!'e%s IV2#Ad%e"o!eto% &lo!'e%s IV

--

Nit%o$ly!e%i" IVNit%o$ly!e%i" IV

-- 6ea%i" IV6ea%i" IV

--ACE i"(i&ito%sACE i"(i&ito%s(a$ter 6 hours or(a$ter 6 hours or

!hen stable)!hen stable)

Start ad?unctive treatmentsStart ad?unctive treatments

(as indicated9 no contraindications)(as indicated9 no contraindications)

6ea%i"6ea%i"(*F5=67W5)(*F5=67W5)

Asi%i"Asi%i",60 to 8-1 mg Ld,60 to 8-1 mg Ld

Gly!o%otei" II&7IIIa %e!eto%Gly!o%otei" II&7IIIa %e!eto%

i"(i&ito%si"(i&ito%s

-- Nit%o$ly!e%i" IVNit%o$ly!e%i" IV

-- 2#Ad%e"e%$i! %e!eto% &lo!'e%s2#Ad%e"e%$i! %e!eto% &lo!'e%s

Meets !%ite%ia 8o% *"sta&leMeets !%ite%ia 8o% *"sta&le

o% "ew#o"set a"$i"a?o% "ew#o"set a"$i"a?

O%O%

T%oo"i" ositive?T%oo"i" ositive?

YesYes

:ime $rom onset o$ symptoms:ime $rom onset o$ symptoms Assess clinical statusAssess clinical status

elect a reper$usionelect a reper$usion

strategy based on localstrategy based on local

resources9resources9

AngiographyAngiography

+C (angioplasty O stent)+C (angioplasty O stent)

Cardiothoracic surgeryCardiothoracic surgery

bac4upbac4up

i$ signs o$ cardiogenic shoc4i$ signs o$ cardiogenic shoc4

or contraindications toor contraindications to

$ibrinolytics* +C is treatment$ibrinolytics* +C is treatment

o$ choice (Class ) i$ availableo$ choice (Class ) i$ available

$ +C is not available* use$ +C is not available* use

$ibrinolystics (i$ no$ibrinolystics (i$ nocontraindications)contraindications)

6i$(#%is' atie"t, de8i"ed6i$(#%is' atie"t, de8i"ed

&y&y

+ersistent symptoms+ersistent symptoms

ecurrent ischemiaecurrent ischemia

/epressed F $unction/epressed F $unction

;idespread "C. changes;idespread "C. changes

+rior A>* +C* CAB.+rior A>* +C* CAB.

"linically"linically

stablestable

Admit to "/ chest painAdmit to "/ chest pain

unitunit

&r to monitored bed&r to monitored bed

In 2, follo%In 2, follo%

serial cardiac mar4ersserial cardiac mar4ers

(including troponin)(including troponin)

epeat "C.#continuosepeat "C.#continuos

: monitoring: monitoring

Consider imagingConsider imaging

study (-study (-//

echocardiogharphy orechocardiogharphy or

radionuclide)radionuclide)

,- hours,- hours

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ibrinolytic therapy selectedibrinolytic therapy selected

ront'loadedront'loaded alteplasealteplaseoror

treptoinasetreptoinaseoror

APA-APA- oror

/eteplase/eteplaseoror

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The Acute "oronary SyndromesThe Acute "oronary Syndromes

3nitial @anagement in the )ield and Emergency Department3nitial @anagement in the )ield and Emergency Department

I++ediate T%eat+e"tI++ediate T%eat+e"t P%e(osital 5i&%i"olyti! T(e%ayP%e(osital 5i&%i"olyti! T(e%ay

(memory aid9 >&7A greets all patients(memory aid9 >&7A greets all patients >orphine>orphine &xygen&xygen 7itroglycerin7itroglycerin AspirinAspirin

I++ediate Assess+e"tI++ediate Assess+e"t ital signs* including blood pressureital signs* including blood pressure &xygen saturation&xygen saturation access access ,-'lead "C.,-'lead "C. Brie$* targeted history and physical exam (toBrie$* targeted history and physical exam (to

identi$y reper$usion candidates)identi$y reper$usion candidates) nitial cardiac mar4ersnitial cardiac mar4ers

nitial electrolyte and coagulation studiesnitial electrolyte and coagulation studies +ortable chest x'ray

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,%ygen,%ygen

I++ediate Ge"e%al T%eat+e"t 8o%I++ediate Ge"e%al T%eat+e"t 8o%

S*se!ted Is!(e+i! C(est Pai"S*se!ted Is!(e+i! C(est Pai" &xygen at 5 F#min per nasal cannula&xygen at 5 F#min per nasal cannula

If no contraindications$ addIf no contraindications$ add

Aspirin ,60 to 8-1 mgAspirin ,60 to 8-1 mg

7itroglycerin F or spray7itroglycerin F or spray

>orphine (pain unrelieved by>orphine (pain unrelieved bynitroglycerin)nitroglycerin)

Ratio"aleRatio"ale

upplementary oxygen may limit ischemicupplementary oxygen may limit ischemicmyocardial in?urymyocardial in?ury

&xygen reduces the amount o$ :'&xygen reduces the amount o$ :'segment elevation (e$$ect on morbidity orsegment elevation (e$$ect on morbidity ormortality in acute in$arction un4no!n)mortality in acute in$arction un4no!n)

,%ygen,%ygen

Re!o++e"datio"Re!o++e"datio"

ncomplicatedncomplicated

&xygen at 5 F#min per nasal cannula $or&xygen at 5 F#min per nasal cannula $or

$irst - to 8 hours (Class a)$irst - to 8 hours (Class a) +robably not help$ul beyond 8 to 6 hours+robably not help$ul beyond 8 to 6 hours

Co+li!ated MI 9Ove%t P*l+o"a%yCo+li!ated MI 9Ove%t P*l+o"a%yCo"$estio": SaOCo"$estio": SaO33;;

&xygen at 5 F#min per nasal cannula*&xygen at 5 F#min per nasal cannula*

titrate as needed (Class )titrate as needed (Class ) Continue therapy until patient is stable orContinue therapy until patient is stable or

hypoxemia correctedhypoxemia corrected

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Nitrates and NitroglycerinNitrates and Nitroglycerin

Re!o++e"datio"sRe!o++e"datio"s EffectsEffects

asodilatation through nitric oxide'asodilatation through nitric oxide'

induced relaxation o$ vascular smoothinduced relaxation o$ vascular smooth

muscle in veins* arteries* and arteriolesmuscle in veins* arteries* and arterioles 3ndications3ndications

' nitial antianginal $or suspected' nitial antianginal $or suspected

ischemic painischemic pain

' or the $irst -5 to 5 hours in patients' or the $irst -5 to 5 hours in patients

!ith acute!ith acute MI a"d C65MI a"d C65* large anterior* large anterior

!all in$arction* persistent or recurrent!all in$arction* persistent or recurrentischemia* or hypertensionischemia* or hypertension

' Continued use (beyond 5 hours) $or' Continued use (beyond 5 hours) $or

patients !ith recurrent angina orpatients !ith recurrent angina or

persistent pulmonary congestionpersistent pulmonary congestion

3nitial dose9 route3nitial dose9 route

' 9 ,-1 to -10' 9 ,-1 to -10 g bolus* ,0 to -0g bolus* ,0 to -0

g#min in$usion* titratedg#min in$usion* titrated oror

99 F9 05 mg* repeat x - at 1 minuteF9 05 mg* repeat x - at 1 minute

intervalsintervals oror

' pray9 - metered doses under or' pray9 - metered doses under or

onto tongueonto tongue "ontraindications"ontraindications

' ystolic blood pressure

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@orphine@orphine

.. Effects:Effects:AnalgesiaH venodilation reducesAnalgesiaH venodilation reduces

ventricular preload and oxygenventricular preload and oxygen

reLuirementsreLuirements

.. 3ndications:3ndications: :reatment o$ ischemic pain:reatment o$ ischemic painnot relieved by nitroglycerinH also use$ul tonot relieved by nitroglycerinH also use$ul to

redistribute blood volume in patients !ithredistribute blood volume in patients !ith

pulmonary edemapulmonary edema

.. "autions and complications:"autions and complications:/o not use/o not use

in patients !ith suspected hypovolemia $in patients !ith suspected hypovolemia $hypotension develops in absence o$hypotension develops in absence o$

pulmonary congestion* elevate patientEs legspulmonary congestion* elevate patientEs legs

and administer normal saline (-00 to 100 mFand administer normal saline (-00 to 100 mF

bolus)bolus)

@orphine@orphine

*ecommendations*ecommendations

.. ActionAction' +redominantly a venodilator that decreases F' +redominantly a venodilator that decreases Fpreloadpreload' /ecreases systemic vascular resistance* reducing' /ecreases systemic vascular resistance* reducingF a$terloadF a$terload' C7 analgesia S decreases anxiety by' C7 analgesia S decreases anxiety by

sympatholytic e$$ectssympatholytic e$$ects.. 3ndications3ndications

' schemic chest pain' schemic chest pain' A> !ithout hypotension' A> !ithout hypotension' Acute pulmonary edema' Acute pulmonary edema

.. DoseDose

' - to 5 mg * titrated to e$$ectH based on the' - to 5 mg * titrated to e$$ectH based on theACC#AA +ractice .uidelinesACC#AA +ractice .uidelines' epeat every 1 minutes to e$$ect' epeat every 1 minutes to e$$ect

.. (recautions(recautions' /o not administer i$ hypotensive' /o not administer i$ hypotensive' Fo! volume statesH respiratory depression' Fo! volume statesH respiratory depression$ hypotension develops* give -00 to 100 mF normal$ hypotension develops* give -00 to 100 mF normal

saline i$ no pulmonary congestionsaline i$ no pulmonary congestion


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AspirinAspirin

*ecommendations*ecommendations

.. ActionActionSS rreversibly inhibits platelet cyclo'oxygenaserreversibly inhibits platelet cyclo'oxygenaseSS nhibits thromboxane Anhibits thromboxane A-- pletelet aggregationpletelet aggregation

.. 3ndications3ndications

Acute :'elevation in$ractionAcute :'elevation in$ractionSS Coronary angioplastyCoronary angioplasty uspected ischemic'type painuspected ischemic'type pain

DoseDoseSS ,60 to 8-1 mg orally* crushed or che!ed,60 to 8-1 mg orally* crushed or che!edSS 8-1 mg suppository i$ nausea* vomiting8-1 mg suppository i$ nausea* vomiting

(recautions(recautions Active peptic ulcer disease (use rectalActive peptic ulcer disease (use rectalsuppositories)suppositories)SS istory o$ hypersensitivity or allergyistory o$ hypersensitivity or allergySS Bleeding disorders* serve hepatic diseaseBleeding disorders* serve hepatic disease

AspirinAspirin

Ratio"aleRatio"ale

.. Effects:Effects:A dose o$ ,60 to 8-1 mg causes immediateA dose o$ ,60 to 8-1 mg causes immediate

and near'total inhibition o$ thromboxane A- productionand near'total inhibition o$ thromboxane A- production:his rapid inhibition reduces coronary reocclusion and:his rapid inhibition reduces coronary reocclusion and

recurrent eents a$ter $ibrinolitic therapy Also e$$ectiverecurrent eents a$ter $ibrinolitic therapy Also e$$ective

$or patients !ith unstable angina$or patients !ith unstable angina

3ndications:3ndications:Administer to all !ith suspectedAdminister to all !ith suspected

AC* particulary reper$usion candidates* unlessAC* particulary reper$usion candidates* unless

hypersensitive to aspirin (ticlopidine#clopidogrel mayhypersensitive to aspirin (ticlopidine#clopidogrel maybe help$ul)be help$ul)

Dose9 route:Dose9 route:n the early hours a$ter in$raction* aspirinn the early hours a$ter in$raction* aspirin

is absorbed more Luic4ly !hen che!ed than !henis absorbed more Luic4ly !hen che!ed than !hen

s!allo!ed* particularly i$ morphine has been givens!allo!ed* particularly i$ morphine has been given

Aspirin suppositories (8-1 mg) are recommended $orAspirin suppositories (8-1 mg) are recommended $orpatients !ith severe nausea* vomiting* or upper .patients !ith severe nausea* vomiting* or upper .

disordersdisorders

"autions9 contraindications:"autions9 contraindications:elativelyelatively

contraindicated in patients !ith active peptic ulcercontraindicated in patients !ith active peptic ulcer

disease* a history consistent !ith aspirindisease* a history consistent !ith aspirin

hypersensitivity* or bleeding disordershypersensitivity* or bleeding disorders

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The Acute "oronary Syndromes

Assess the initial "C.Assess the initial "C.

:he ,-'lead "C. is central to triage o$ AC in the "mergency:he ,-'lead "C. is central to triage o$ AC in the "mergency/epartment/epartment

Classi$y patients as being in , o$ 8 syndromes !ithin ,0 minutes o$Classi$y patients as being in , o$ 8 syndromes !ithin ,0 minutes o$arrivalarrival

:'segment elevation or:'segment elevation orne! FBBBne! FBBB

7ondiagnostic or normal7ondiagnostic or normal"C."C.

:'segment depression#:'segment depression#dynamic :'!ave nversion9dynamic :'!ave nversion9

strongly suspicious $orstrongly suspicious $or

ischemiaischemia

: elevation: elevation , mm in - or, mm in - ormore contiguous leadsmore contiguous leads

7e! or presumably ne!7e! or presumably ne!

FBBB (BBB obscuring :'FBBB (BBB obscuring :'

segment analysis)segment analysis)

: depression , mm: depression , mm

>ar4ed symmetrical :'!ave>ar4ed symmetrical :'!ave

inversion in multiple precordial leadsinversion in multiple precordial leads

/ynamic :': changes !ith pain/ynamic :': changes !ith pain

: depression 01 to ,0 mm: depression 01 to ,0 mm

:'!ave inversion or $lattening:'!ave inversion or $lattening

in leads !ith dominant !avesin leads !ith dominant !aves

7ormal "C.7ormal "C.

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eper$usion therapyeper$usion therapy

AspirinAspirin eparin (i$ using $ibrin'eparin (i$ using $ibrin'speci$ic lytics)speci$ic lytics)

'Bloc4ers'Bloc4ers

7itrates as indicated7itrates as indicated

Antithrombin therapy !ithAntithrombin therapy !ithheparinheparin

Antiplatelet therapy !ithAntiplatelet therapy !ithaspirinaspirin

.lycoprotein ib#ia nhibitors.lycoprotein ib#ia nhibitors

'Bloc4ers'Bloc4ers

7itrates7itrates

AspirinAspirin

&ther therapy as&ther therapy asappropiteappropite

+atients !ith positive+atients !ith positiveserum mar4ers* "C.serum mar4ers* "C.changes* or $unctionalchanges* or $unctionalstudy9 manage as highstudy9 manage as highris4ris4

P0@ o$ patients !ith ischemic'P0@ o$ patients !ith ischemic'type chest pain and :'segmenttype chest pain and :'segmentelevation !ill develop ne! I !aveselevation !ill develop ne! I !avesor positive serum mar4ers $or A>or positive serum mar4ers $or A>

+atients !ith hyperacute : !aves+atients !ith hyperacute : !avesbene$it !hen A> diagnosis isbene$it !hen A> diagnosis iscertain epeat "C. may becertain epeat "C. may behelp$ulhelp$ul

+atients !ith : depression in+atients !ith : depression inearly precordial leads !ho haveearly precordial leads !ho have

posterior > bene$it !hen A>posterior > bene$it !hen A>diagnosis is certaindiagnosis is certain

igh'ris4 subgroup !ith increasedigh'ris4 subgroup !ith increasedmortality9mortality9

+ersistent symptoms* recurrent+ersistent symptoms* recurrent

ischemiaischemia

/i$$use or !idespread "./i$$use or !idespread ".abnormalitiesabnormalities

/epressed F $unction/epressed F $unction

Congestive heart $ailureCongestive heart $ailure

erum mar4er release9 positiveerum mar4er release9 positivetroponin or CT'>BUtroponin or CT'>BU

eterogeneous group9 rapideterogeneous group9 rapidassessment needed byassessment needed by

erial "C.serial "C.s

:'segment monitoring:'segment monitoring

erum cardiac mar4erserum cardiac mar4ers

urther ris4 assessment help$ulurther ris4 assessment help$ul

+er$usion radionuclide imaging+er$usion radionuclide imaging

tress echocardiographytress echocardiography

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ST$segment Depression9 Dynamic T$#ave "hanges:ST$segment Depression9 Dynamic T$#ave "hanges:

Non$$#ave 3nfarction = Unstable AnginaNon$$#ave 3nfarction = Unstable Angina

Non$$#ave 3nfarctionNon$$#ave 3nfarction

Eide+iolo$yEide+iolo$y nstable angina and non'I'!ave in$arction are pathological processes on a continuum9nstable angina and non'I'!ave in$arction are pathological processes on a continuum9

chronic stalechronic stale minimal m&ocardial damageminimal m&ocardial damage "nstale angina ? no"nstale angina ? no non9@9%avenon9@9%ave t&pical @9%avet&pical @9%aveanginaangina (troponin positive=-97: (troponin positive=-97: ser"m marer release infarction 7I ser"m marer release infarction 7I

negative)negative)

ncidence o$ non'I'!ave > is increasing $or several reasons9ncidence o$ non'I'!ave > is increasing $or several reasons9

' increasing pool o$ patients !ho are older and have more advanced disease' increasing pool o$ patients !ho are older and have more advanced disease

' !ider use o$ acute reper$usion strategies $or :'elevation in$arction (limited in$arction)9' !ider use o$ acute reper$usion strategies $or :'elevation in$arction (limited in$arction)9$ibrinolytic therapy and angioplasty$ibrinolytic therapy and angioplasty

' prophylactic e$$ects o$ greater use o$ aspirin*' prophylactic e$$ects o$ greater use o$ aspirin* 'bloc4er'bloc4er

&n presentation these patients are in a high'ris4 subgroup !ith a relatively high mortality&n presentation these patients are in a high'ris4 subgroup !ith a relatively high mortality

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MANAGEMENTMANAGEMENT

Ma@o% li+itatio",Ma@o% li+itatio",$ibrinolytic therapy does$ibrinolytic therapy does "ot"otbene$it patients !ith :'segment depressionbene$it patients !ith :'segment depression

$bloc&ade:$bloc&ade: start as 4ey ad?unctive therapy and optimiGestart as 4ey ad?unctive therapy and optimiGe

AddAddcalcium channel bloc&erscalcium channel bloc&ers$or persistent symptoms i$ any o$ the $ollo!ing are present9$or persistent symptoms i$ any o$ the $ollo!ing are present9'' 'bloc4ade intolerance'bloc4ade intolerance' contraindications to' contraindications to 'bloc4ers'bloc4ers' adeLuate bloc4ade $ails to reduce symptoms' adeLuate bloc4ade $ails to reduce symptoms

(otential benefit:(otential benefit:ne! antithrombin and antiplatelet agents have sho!n signi$icant bene$it inne! antithrombin and antiplatelet agents have sho!n signi$icant bene$it inselected patients !ithselected patients !ith "o"#ST#elevatio" MI"o"#ST#elevatio" MIandand*"sta&le a"$i"a*"sta&le a"$i"a' antiplatelet therapy !ith' antiplatelet therapy !ith C( 33b333a inhibitors0C( 33b333a inhibitors0' antithrombin therapy !ith' antithrombin therapy !ith lo' molecular 'eight heparin0lo' molecular 'eight heparin0

e$er toe$er to emergency coronary angiographyemergency coronary angiographyand possibleand possible revasculariFationrevasculariFation (!ith(!ith ("3("3oror

"A

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n general* treat these patientsn general* treat these patients!ith!ith bothboth

$ Antithrombin +heparin-$ Antithrombin +heparin- and anand an

$ Antiplatelet agent +aspirin-$ Antiplatelet agent +aspirin-

>odi$y this treatment i$ patient>odi$y this treatment i$ patientmeets criteria $ormeets criteria $or high ris&high ris&

Antithrombin +heparin-Antithrombin +heparin-plusplus

Antiplatelet +aspirin-Antiplatelet +aspirin-

2igh$*is& "riteria2igh$*is& "riteria : depression: depression , mm, mm +ersistent symptomsH recurrent+ersistent symptomsH recurrent

ischemiaischemia

/i$$use or !idespread "C./i$$use or !idespread "C.

abnormalitiesabnormalities /epressed F $unction/epressed F $unction Congestive heart $ailureCongestive heart $ailure Cardiac mar4er release9 positiveCardiac mar4er release9 positive

troponin or CT'>BUtroponin or CT'>BU

ST$segment Depression9 Dynamic T$#ave "hanges:ST$segment Depression9 Dynamic T$#ave "hanges:

Non$$#ave 3nfarction = Unstable AnginaNon$$#ave 3nfarction = Unstable Angina

Re!o++e"datio"s 8o% I"itial Ma"a$e+e"t a"d T(e%ayRe!o++e"datio"s 8o% I"itial Ma"a$e+e"t a"d T(e%ay

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+atients !ho meet high'ris4 criteria+atients !ho meet high'ris4 criteriabene$it $rom treatment !ithbene$it $rom treatment !ith AspirinAspirinandand C( 33b333a inhibitorsC( 33b333a inhibitorsandandunfractionated heparinunfractionated heparinoror Bo' molecular 'eight heparinBo' molecular 'eight heparin(e$$icacy and sa$ety combined !ith(e$$icacy and sa$ety combined !ith.+ b#a inhibitors under revie!).+ b#a inhibitors under revie!)

All patients 'ithout contraindicationsAll patients 'ithout contraindicationsshould receiveshould receive

(atients 'ho suffer recurrent angina(atients 'ho suffer recurrent angina

should also receiveshould also receive

As a third agent to use for refractoryAs a third agent to use for refractoryangina or in patients 'ith aangina or in patients 'ith a

contraindications to G$bloc&erscontraindications to G$bloc&ers

Antithrombin +heparin-Antithrombin +heparin-

plusplus

Antiplatelet +aspirin-Antiplatelet +aspirin-

(lus(lus

Clycoprotein 33b333a inhibitorsClycoprotein 33b333a inhibitors

$

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)A*@A,B,C3 A"BS)A*@A,B,C3 A"BS

3ngat tu?uan utama dalam A"BS:3ngat tu?uan utama dalam A"BS: Tore4si hipose4miaTore4si hipose4mia

>embuat sir4ulasi spontan dengan te4anan darah yang ade4uat>embuat sir4ulasi spontan dengan te4anan darah yang ade4uat

>engoptimal4an $ungsi ?antung>engoptimal4an $ungsi ?antung >ene4an dan mencegah aritmia yang berma4na>ene4an dan mencegah aritmia yang berma4na

>enghilang4an sa4it>enghilang4an sa4it

>engore4si asidosis>engore4si asidosis

>engobati gagal ?antung 4ongesti$>engobati gagal ?antung 4ongesti$

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lasifi&asi re&omendasi penggunaan obat$obatan atau tinda&an:lasifi&asi re&omendasi penggunaan obat$obatan atau tinda&an:

"lass 3:"lass 3:ndicated* acceptable* use$ul V e$$ectivendicated* acceptable* use$ul V e$$ective

"lass 33:"lass 33:Acceptable* uncertain e$$icacy* maybe controversialAcceptable* uncertain e$$icacy* maybe controversial"lass 33a:"lass 33a:avour o$ its use$ulness V e$icacyavour o$ its use$ulness V e$icacy

"lass 33b:"lass 33b:>aybe help$ul* probably not harm$ul>aybe help$ul* probably not harm$ul

"lass 333:"lass 333:nappropriate* no scienti$ic supporting data* maybe harm$ulnappropriate* no scienti$ic supporting data* maybe harm$ul

(ende&atan untu& mempela?ari farma&ologi dalam A"BS dengan(ende&atan untu& mempela?ari farma&ologi dalam A"BS dengan

w(y: w(e": (ow: wat!( o*t,w(y: w(e": (ow: wat!( o*t,

(y(yan agent is used (action) # 4enapa suatu obat diguna4anan agent is used (action) # 4enapa suatu obat diguna4an (e"(e"to use an agent (indication) # 4apan obat tersebut diguna4anto use an agent (indication) # 4apan obat tersebut diguna4an

6ow6owto use an agent (dosage) # bagaimana mengguna4annyato use an agent (dosage) # bagaimana mengguna4annya

;hat to;hat to wat!( o*twat!( o*tforfor(precaution) # a!asi(precaution) # a!asi

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, H Y C E N, H Y C E N(y(y

>ening4at4an te4anan o4sigen arterial>ening4at4an te4anan o4sigen arterial >ening4at4an 4andungan o4sigen arterial>ening4at4an 4andungan o4sigen arterial

>emperbai4i o4sigen ?aringan>emperbai4i o4sigen ?aringan

(e"(e"

7yeri dada a4ut yang mung4in disebab4an oleh is4emia ?antung7yeri dada a4ut yang mung4in disebab4an oleh is4emia ?antung

ipose4mia oleh berbagai sebabipose4mia oleh berbagai sebab

enti ?antung dan na$asenti ?antung dan na$as

6ow6ow

:anpa henti ?antung 9 - F # m:anpa henti ?antung 9 - F # m

/engan gangguan na$as ringan 9 12 6 F # m/engan gangguan na$as ringan 9 12 6 F # m

at!( O*tat!( O*t

Teracunan o4sigenTeracunan o4sigen

>engurangi rangsangan perna$asan pada pasien dengan retensi C&->engurangi rangsangan perna$asan pada pasien dengan retensi C&-

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E(3NE(2*3NEE(3NE(2*3NE(y(y

>ening4at4an 9>ening4at4an 9

esistensi vas4uler sistemi4esistensi vas4uler sistemi4

:e4anan darah sistoli4 dan diastoli4:e4anan darah sistoli4 dan diastoli4

A4tivitas darah 4e seberal dan 4oronerA4tivitas darah 4e seberal dan 4oroner

Aliran darah 4e serebral dan 4oronerAliran darah 4e serebral dan 4oroner

Te4uatan 4ontra4si mio4ardTe4uatan 4ontra4si mio4ard Tebutuhan o4sigen mio4ardTebutuhan o4sigen mio4ard

&tomatisitas&tomatisitas

(e"(e"

entricular ectopy* !ide complex tachycardias* ventricular tachycardia dan entricular ectopy* !ide complex tachycardias* ventricular tachycardia dan +ulseless : dan yang re$ra4ter terhadap terapi listri4 dan epine$rin+ulseless : dan yang re$ra4ter terhadap terapi listri4 dan epine$rin

+asien dengan risi4o ter?adinya aritmia ventri4el yang maligna+asien dengan risi4o ter?adinya aritmia ventri4el yang maligna

:a4 dire4omendasi4an lagi untu4 pemberian pencegahan rutin pada pasien dengan:a4 dire4omendasi4an lagi untu4 pemberian pencegahan rutin pada pasien dengan

>A>A

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E(3NE(2*3NEE(3NE(2*3NE

6ow6ow

/osis a!al 9 ,*0',*1 mg# 4g bolus/osis a!al 9 ,*0',*1 mg# 4g bolus

ia "": 9 -'-*1 x doseia "": 9 -'-*1 x dose

Bolus 4edua 9 0*1'0*K1 mg# 4g setelah ,0EBolus 4edua 9 0*1'0*K1 mg# 4g setelah ,0E Bolus tambahan 9 0*1'0*K1 mg# 4g every 1E',0E (bila masih tetap ada aritmia)* sampaiBolus tambahan 9 0*1'0*K1 mg# 4g every 1E',0E (bila masih tetap ada aritmia)* sampai

total98 mg#4gtotal98 mg#4g

Continuous iv in$usion 9 -'5 mg#min (pada sir4ulasi spontan)Continuous iv in$usion 9 -'5 mg#min (pada sir4ulasi spontan)

at!( o*tat!( o*t +erubahan neurologis+erubahan neurologis

/epresi mio4ard V sir4ulasi/epresi mio4ard V sir4ulasi

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ADEN,S3NEADEN,S3NE

(y(y

>emperlambat 4ondu4si melalui A node>emperlambat 4ondu4si melalui A node

>enghenti4an ?alur re'entri di A node>enghenti4an ?alur re'entri di A node

>engembali4an 4e irama sinus pada pasien dengan +:>engembali4an 4e irama sinus pada pasien dengan +:

espon $arma4ologinya sing4atespon $arma4ologinya sing4at

at!( o*tat!( o*t

Atrial $lutter # $ibrillation dengan sindrom ;+;Atrial $lutter # $ibrillation dengan sindrom ;+;

:* dapat menyebab4an hipotensi atau :* dapat menyebab4an hipotensi atau

ypotension* A' bloc4ypotension* A' bloc4

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A@3,DA*,NEA@3,DA*,NE(y(y "$e4ti$ untu4 supraventricular arrhythmia* ventricular arrhythmia"$e4ti$ untu4 supraventricular arrhythmia* ventricular arrhythmia entricular rate controlentricular rate control Tardioversi $arma4ologi4Tardioversi $arma4ologi4

>enguah 4ondu4si yang melalui accesory path!ay>enguah 4ondu4si yang melalui accesory path!ay

(e"(e" :erapi tambahan setelah electrical cardioversion pada +: yang re$ra4ter ( a):erapi tambahan setelah electrical cardioversion pada +: yang re$ra4ter ( a) Tardioversi $arma4ologis untu4 A (a)Tardioversi $arma4ologis untu4 A (a) Atrial tachycardia ( b)Atrial tachycardia ( b)

entricular rate control pada rapid atril arrhythmia pada pasien dengan $ungsientricular rate control pada rapid atril arrhythmia pada pasien dengan $ungsiventri4el yang buru4* atau pada pasien dengan 4ondu4si accesory path!ayventri4el yang buru4* atau pada pasien dengan 4ondu4si accesory path!ay

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A@3,DA*,NEA@3,DA*,NE

(e"(e" >enghenti4an : yang melibat4an ?alur rentri A node>enghenti4an : yang melibat4an ?alur rentri A node

6ow6ow

/osis a!al 9 6 mg bolus cepat dalam ,'8N dii4uti $lush cepat normal/osis a!al 9 6 mg bolus cepat dalam ,'8N dii4uti $lush cepat normalsalinesaline

/osis ulangan 9 ,-mg* ?i4a ta4 berespon dalam ,'- menit/osis ulangan 9 ,-mg* ?i4a ta4 berespon dalam ,'- menit

:eo$ilin menyebab4an 4urang sensiti$:eo$ilin menyebab4an 4urang sensiti$

at!( o*tat!( o*t

lushing* dyspnea* chest pain (biasanya hilang dalam ,'- menit)lushing* dyspnea* chest pain (biasanya hilang dalam ,'- menit)

:ransient bradycardia dan ventricular ectopy:ransient bradycardia dan ventricular ectopy

:a4 terlalu berpengaruh pada hemodinami4:a4 terlalu berpengaruh pada hemodinami4

! i l )ib ill i ( l l ! i l T h di! t i l )ib ill ti ( l l ! t i l T h di

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