1 Journal meeting with EMB 急診室的如臨大敵 STEMI ER 陳莉瑋醫師

2 Question 1 Is O2 need in every chest pain patient?

3 Revisiting the role of oxygen therapy in cardiac patients. Moradkhan R, Sinoway LI J Am Coll Cardiol. 2010;56(13):1013.

4 Chest pain->O2 to keep SpO2:100% Really good? hyperoxia reduced coronary blood flow (CBF),heart rate, cardiac output/index and cardiac oxygen consumption => a rise in blood pressure, systemic vascular resistance

5 Hyperoxia, which might occur with the administration of oxygen to normoxic individuals, has been shown to have a direct vasoconstrictor effect on the coronary arteries

6 The current guidelines of oxygen therapy are not based on randomized, double blinded and controlled studies We propose that such studies are imperative to delineate the precise role of oxygen therapy in these conditions

7 In conclusion… We recommend supplemental oxygen to patients with an arterial saturation less than 90 percent, patients in respiratory distress, or those with other high-risk features for hypoxia

8 Question 2 What if UGIB bleeding happen in treating ACS?

9 Gastrointestinal Bleeding in Patients With Acute Coronary Syndromes:Incidence, Predictors, and Clinical Implications J Am Coll Cardiol 2009; 54:1293–302

10 Objectives GIB is a potential hemorrhagic complication in patients with ACS treated with antithrombotic and/or antiplatelet medications.

11 Methods In the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial, 13,819 patients with moderate- and high-risk ACS, enrolled at 450 centers in 17 countries between August 2003 and December 2005, were randomized to the open-label use of 1 of 3 antithrombin regimens (heparin plus a glycoprotein IIb/IIIa inhibitor, bivalirudin plus a glycoprotein IIb/IIIa inhibitor, or bivalirudin monotherapy).

12 Results GIB within 30 days occurred in 178 patients (1.3%). Older age, baseline anemia, longer duration of study drug administration before angiogram, smoking, ST- segment deviation 1 mm, and diabetes were identified as independent predictors of GIB.

13  On multivariable analysis, GIB was strongly associated with 30-day all-cause mortality, cardiac mortality, and composite ischemia, as well as with 1-year all-cause mortality, cardiac mortality, myocardial infarction, and composite ischemia  Patients who experienced GIB had significantly higher rates of stent thrombosis compared with patients without GIB

14 Conclusions GIB is a serious condition in the scenario of ACS and is independently associated with mortality and ischemic complications.

15 Upper gastrointestinal bleeding in patients receiving dual antiplatelet therapy after coronary stenting. Internal Medicine. 48(19): ,  Concomitant use of an anti-secretory agent was associated with a reduced risk of UGI bleeding.  Use of PPI may be associated with an attenuation of the effect of dual antiplatelet therapy.

16 Gastrointestinal Bleeding in Percutaneous Coronary Intervention and Acute Coronary Syndromes This is true with regard to the elderly, women, and patients with lower weight, impaired renal function, or baseline anemia Early endoscopy is beneficial and indicated if GIB occurs in the setting of ACS, despite a higher risk, that occurs mostly in unstable patients. Intravenous PPI administration, both before and after endoscopy, can improve clinical outcomes. The American Journal of Cardiology Vol 104 (5A) September 7, 2009

17 感謝聆聽 敬請指教