1. Treatment of Acute Coronary Syndrome with ST elevation ESC guidelines 2008 Dr. David Tran A&E dept. FVH 22/12/09

2. Initial diagnosis & early stratification Chest pain or discomfort First ECG showing persistent ST elevation Elevated biomarkers of necrosis (2D echocardiography)

3. Relief pain & anxiety Morphine 0.1mg/Kg loading dose followed by 2mg bolus Oxygen if breathless or desaturation

4. Reperfusion strategies

5. PCI = invasive reperfusion Fibrinolysis = pharmacological reperfusion

6. Primary PCI strategy Time between first medical care & balloon < 90 min Medical treatment: Aspirin, Clopidogrel and Heparin

7. Primary fibrinolytic strategy If PCI cannot be performed within 90 min. In the absence of contraindications Associated treatment: Aspirin, Plavix & Heparin

8. Problems of bleeding complications after fibrinolyse Intracranial bleeding = 1% Major non cerebral bleeding = 4-13%

9. Facilitated PCI ? No place for a prior fibrinolytic treatment before a planned PCI…

10. Anti-platelet co-therapies Aspirin 250mg Plavix 600mg (PCI) or 300mg (fibrinolytic)

11. Antithrombin co-therapies Unfractionated heparin iv bolus 100 UI/Kg Enoxaparin iv bolus 30mg followed by s.c. dose of 1mg/Kg/12h

12. Therapy without reperfusion strategy or view later (>12h) Aspirin Plavix Anti-thrombin agent (heparin or Enoxaparin)

13. Management of arrhythmias in acute phase of ACS Cardioversion Amiodarone Beta blocker

14. Recommended doses for anti- arrhythmic medications

15. Problem of betablockers Early use of iv beta-blockers has to be conterbalanced by the risk of cardiogenic shock

16. Problems of nitrates The routine use of nitrates in the initial phase of a STEMI is not recommended

17. Interest of Statins in the acute phase of STMI MIRACL study: 80mg Atorvastatin in the first days of an acute coronary syndrome > 26% less of recurrent ischemia PROV-IT study: 80mg Atorvastatin versus 40mg Pravastatin > 29% less of recurrent instable angina with 80mg Atorvastatin A to Z study: 40mg Simvastatin versus placebo > less cardiovascular mortality

18. Acute Coronary Syndrome (ACS)  ECG 12 derivations  +/- V7,V8, V9, V3r, V4r  Troponine (if pain > 6h) ACS with ST elevation First medical treatment  ASPEGIC 250mg IV  PLAVIX 600mg loading dose (8 tab. 75mg)  Heparine 70UI/Kg IV loading dose  Morphine 0.05mg/Kg IV first dose  Atorvastatine 80mg Primary PCI reperfusion  Contact Tam Duc Hospital for agreement  Transfert the patient with SMUR  Ideal timing < 45 min. between 1st ECG and arrival in cathlab. ACS without ST elevation First medical treatment  ASPEGIC 250mg IV  PLAVIX 300mg loading dose (4tab. 75mg)  LOVENOX 0.1ml/10Kg of weight s/cut.  LIPITOR 80mg high dose (4tab. 20mg)  Metoprolol 50mg if pulse > 80/min, TA >120  ISOKET IV if persistent chest pain (TA > 120)  Morphine bolus IV If severe pain Transfert to an Hospital with cathlab & cardiologic intensive care Improvement?  Chest pain relieved or decreased  Patient stable (pulse, pressure)  Next ECG stable or improved Hospitalazation in USC/ICU  Agreement of cardiologist  Refer to cardiologist YES NO