CPR in ACUTE CORONARY SYNDROM دکتر سعید رضا نامی متخصص بیهوشی فلوشیپ بیهوشی قلب

symptoms of AMI may be more intense than angina and most often persist for longer periods of time (eg, longer than 15–20 minutes). classic symptom : chest discomfort , shortness of breath Diaphoresis , sweating, nausea, vomiting, and dizziness  Atypical or unusual symptoms are more common in women, the elderly, and diabetic patients. The physical examination of the patient with ACS is often normal

تغییرات اصلی : 1- نوارقلب قبل بیمارستان ومداخله 2-انتخاب استراتژی ریپرفیوژن هنگامی که امکان فیبرینولیزقبل بیمارستانی وجود دارد PCI انتخاب استراتژی در بیمارستانهای بدون امکان- 3 4-کاربرد تروپونین بعنوان شاخصی که کدام بیماران رامیتوان بدون خطر از اورژانس مرخص نمود 5-مداخلات قبل بیمارستانی که میتوانند سودمند یا بی اثر باشند

نوار قلب ومداخلات قبل بیمارستانی: نوار قلب 12 لیدی توسط پرسنل اورژانس غیر پزشک آموزش دیده آنالیز کامپیوتری برای کمک به پزشک یا پرسنل اورژانس در تشخیص STEMI برای بیماران STEMI توسط اورژانس پیش بیمارستانی به کت لب اطلاع داده شود مداخلات پیشرفته برای بیماران STEMI در بیمارستان صورت پذیرد

جدید (2015): اگر در STEMI دسترسی به فیبرینولیز اولیه ویا مستقیما مرکز PCI اولیه میسر است میبایست پس از تریاژ به مرکز PCIارجاع گردد ._(ریسک خونریزی مغزی) STEMI در دپارتمان اورژانس بیمارستان فاقد PCI سریعا انتقال به مرکزPCI بدون فیبرینولیز STEMI درمواردی که امکان انتقال نیست ویا درزمان مناسب نمیرسد باید تحت فیبرینولیز قرار بگیرد سپس آنژیوگرافی اولیه شود بجای انتقال مستقيم به مرکز PCI تمام بیماران تحت فیبرینولیز اولیه باید در 3تا6 ساعت اول وحداکثر 24ساعت اول بعد PCI اعزام جهت آنژیو(کاهش ریسک انفارکت مجدد)

تروپونین بعنوان شاخص ترخیص بی خطر از اورژانس تروپونین منفی I&T ساعت 0و2 رد کننده ACS نیست ولی ریسک وقایع قلبی در 30 روز بعد ترخیص ( (MACE کمتر از 1% در همراهی با شاخص TIMI score 0 یا 1 ویا ونکوور low risk score major adverse cardiac event (MACE). Thrombolysis in Myocardial Infarction [TIMI]

negative troponin I or troponin T measurements at 0 and between 3 and 6 hours may be used together with very low-risk stratification (TIMI score of 0, low risk score per Vancouver rule, North American Chest Pain score of 0 and age less than 50 years, or low-risk HEART score) to predict a less than 1% chance of 30-day MACE.

Troponin to Identify Patients Who Can Be Safely Discharged From the Emergency Department Also, 2010 (Old): If biomarkers are initially negative within 6 hours of symptom onset, it was recommended that biomarkers should be remeasured between 6 to 12 hours after symptom onset. Why: Relying on a negative troponin test result, either alone or in combination with unstructured risk assessment, results in an unacceptably high rate of MACE at 30 days. However, predictions based on negative troponin test results, combined with structured risk assessment, carry a risk of less than 1% of MACE at 30 days.

Other Interventions neither additional benefit nor harm compared with waiting to administer it in the hospital. Unfractionated heparin (UFH) administered to patients with STEMI in the prehospital setting has not been shown to provide additional benefits to giving it in the hospital. Adenosine diphosphate inhibition for hospital patients with suspected STEMI has been recommended weak evidence of no benefit and possible harm prompted a recommendation that supplementary oxygen was not needed for patients with ACS who had an oxyhemoglobin saturation of 94% or greater

For STEMI patients, prehospital administration of UFH or bivalirudin is reasonable. For suspected STEMI patients who are being transferred for PPCI, enoxaparin is a reasonable alternative to UFH

Public education campaigns increase patient awareness and knowledge of the symptoms of ACS, yet have only transient effects on time to presentation.32,33 For patients at risk for ACS (and for their families), primary care physicians and other healthcare providers should consider discussing the appropriate use of aspirin and activation of EMS system. Furthermore, an awareness of the location of the nearest hospital that offers 24-hour emergency cardiovascular care can also be included in this discussion. Previous guidelines have recommended that the patient, family member, or companion activate the EMS system rather than call their physician or drive to the hospital if chest discomfort is unimproved or worsening 5 minutes after taking 1 nitroglycerin treatment.34

Because aspirin should be administered as soon as possible after symptom onset to patients with suspected ACS, it is reasonable for EMS dispatchers to instruct patients with no history of aspirin allergy and without signs of active or recent gastrointestinal bleeding to chew an aspirin (160 to 325 mg) while awaiting the arrival of EMS providers.39-44 (Class IIa, LOE C)

If the patient is dyspneic, hypoxemic, or has obvious signs of heart failure, providers should titrate therapy, based on monitoring of oxyhemoglobin saturation, to ≥94%.45 (Class I, LOE C)

EMS providers should administer nonenteric aspirin (160. to 325. mg) EMS providers should administer nonenteric aspirin (160* to 325* mg). (Class I, LOE B Class I, LOE C)

patient should chew the aspirin up to 3 nitroglycerin doses (tablets or spray) at intervals of 3 to 5 minutes. Nitrates in all forms are contraindicated systoloic blood pressure <90 mm Hg or ≥30 mm Hg below baseline right ventricular infarction phosphodiesterase-5 (PDE-5) inhibitor within 24 hours (48 hours for tadalafil  Caution inferior wall STEMI, extreme caution, inferior STEMI and suspected right ventricular (RV)

Chest Pain Discomfort / ACS The administration of Aspirin was moved to early on in the protocol. The administration of Morphine has been changed to a standing order of 2 mg every 5 minutes to a total dose of 10 mg or relief of pain. In the presence of hypotension or bradycardia the ALS provider should consider the use of Fentanyl. The protocol was revised to incorporate a standing order for Fentanyl at 50 micrograms repeated every 5 minutes to a total dose of 150 micrograms.

Morphine is indicated in STEMI when chest discomfort is unresponsive to nitrates. (Class I, LOE C) LAST UPDATED: OCT 2010 Morphine should be used with caution in unstable angina (UA)/NSTEMI due to an association with increased mortality in a large registry.53 (Class IIa, LOE C)

ED Evaluation quickly assess patients with possible ACS. Ideally within 10 minutes of ED arrival history while a monitor is attached to the patient and a 12-lead ECG is chest discomfort, associated signs and symptoms, prior cardiac history, risk factors for ACS, fibrinolytics or other therapies the goals of reperfusion are to administer fibrinolytics within 30 minutes of arrival (30-minute interval “door-to-drug”) or to provide PCI within 90 minutes of arrival (90- minute interval “door-to-balloon”). (Class I, LOE A) LAST UPDATED: OCT 2010

Routine consultation with a cardiologist or another physician is not recommended except in equivocal or uncertain cases. Consultation delays therapy and is associated with increased hospital mortality rates. (Class III, LOE B) LAST UPDATED: OCT 2010

ST-segment elevation: 2 or more contiguous leads J-point elevation 0.2 mV (2 mm) in leads V2 and V3 and 0.1 mV (1 mm) in all other leads (men ≥40 years old) J-point elevation 0.25 mV (2.5 mm) in leads V2 and V3 and 0.1 mV (1 mm) in all other leads (men <40 years old); J-point elevation 0.15 mV (1.5 mm) in leads V2 and V3 and 0.1 mV (1 mm) in all other leads (women).

UA/NSTEMI Ischemic ST-segment depression >0.5 mm (0.05 mV) or dynamic T- wave inversion with pain or discomfort Nonpersistent or transient ST-segment elevation ≥0.5 mm for <20 minutes Threshold values for ST-segment depression consistent with ischemia are J-point depression 0.05 mV (-.5 mm) in leads V2 and V3 and -0.1 mV (-1 mm) in all other leads (men and women). patients with normal ECGs and those with ST-segment deviation of <0.5 mm (0.05 mV) or T-wave inversion of ≤0.2 mV. This category of ECG is termed nondiagnostic. requiring further risk stratification

ST-Segment Elevation or New or Presumably New LBBB: Evaluation for Reperfusion Step 1: Assess time and risk Time since onset of symptoms Risk of STEMI Risk of fibrinolysis Time required to transport to skilled PCI catheterization suite Step 2: Select reperfusion (fibrinolysis or invasive) strategy Note: If presentation <3 hours and no delay for PCI, then no preference for either strategy. Fibrinolysis is generally preferred if: Early presentation (≤3 hours from symptom onset) Invasive strategy is not an option (eg, lack of access to skilled PCI facility or difficult vascular access) or would be delayed – Medical contact-to-balloon or door-balloon >90 minutes – (Door-to-balloon) minus (door-to-needle) is >1 hour No contraindications to fibrinolysis An invasive strategy is generally preferred if: Late presentation (symptom onset >3 hours ago) Skilled PCI facility available with surgical backup Medical contact-to-balloon or door-to-balloon <90 minutes (Door-to-balloon) minus (door-to-needle) is <1 hour Contraindications to fibrinolysis, including increased risk of bleeding and ICH High risk from STEMI (CHF, Killip class is ≥3) Diagnosis of STEMI is in doubt

Selection of Initial Treatment Strategy for Patients With Non-ST-Elevation ACS: Invasive Versus Conservative Strategy* Preferred Strategy Patient Characteristics Invasive Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy Elevated cardiac biomarkers (TnT or TnI) New or presumably new ST-segment depression Signs or symptoms of HF or new or worsening mitral regurgitation High-risk findings from noninvasive testing Hemodynamic instability Sustained ventricular tachycardia PCI within 6 months Prior CABG High-risk score (eg, TIMI, GRACE) Reduced LV function (LVEF less than 40%) Conservative Low-risk score (eg, TIMI, GRACE) Patient or physician preference in absence of high-risk features

Prognosis of NSTEMI vs STEMI: Short-term (in-hospital or one month) mortality is lower in NSTEMI (3-5%) compared to STEMI (10-15%). Re-infarction rate (further heart attack) is higher in NSTEMI (15-25%) after hospital discharge compared to STEMI (5-8%). Long-term mortality is similar or higher in NSTEMI compared to STEMI (two year mortality is approximately 30% in both cases).

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