Murtagh - Chest pain cont. management of acute coronary syndromes Flashcards
general principles of management of acute coronary syndromes
12 lead ECG should be arranged ASAP
call a mobile coronary care unit
achieve coronary perfusion and minimise infarct size
have a defibrillator available to prevent ventricular fibrillation
give aspirin as early as possible if no contraindications
optimal treatment for acute coronary syndromes
modern day coronary care unit with continuous ECG monitoring (first 48 hours) and a peripheral IV line (consider intranasal oxygen only if hyperaemic <94% saturation)
management of STEMI
urgent referral to a coronary catheter laboratory ideally with 60 minutes (the golden hour) of the onset of pain for assessment after coronary angiography for percutaneous transluminal coronary angioplasty
the principle is a achieve rapid reperfusion via primary angioplasty with a stent
adjunct therapy will include dual antiplatelet therapy and anticoagulation with low molecular weight heparin or unfractionated heparin , a statin and an ACE inhibitor
urgent reperfusion guidelines
within 60 minutes of symptom onset STEMI: PCI (optimal)
within 90 minutes of symptom onset STEMI: PCI (acceptable)
if these targets are not reached: fibrinolysis within 30 minutes of arrival
if angioplasty is not achievable
either through timing or unavailability (rural location)
thrombolysis is indicated for STEMI and the sooner the better, but preferably within 12 hours of chest pain
further management of STEMI
antiplatelet therapy
beta blocker
consider glyceryl trinitrate
start early introduction of aace inhibitors
statin therapy to lower cholesterol
treat hypokalaemia
consider magnesium sulphate
consider frusemide
post AMI drug treatment
beta blockers within 12 hours
ace inhibitors within 24 hours
aspirin
lipid lowering drugs
warfarin
ongoing management
education and coucelling
bed rest 24-48 hours
continue ECG monitoring
check serum potassium and magnesium
early mobilisation to full activity over 7-12 days
light diet
sedation
beta blocker - atenolol or metoprolol
anticoagulation
ACE inhibitors for left ventricular failure and to prevent remodelling
monitor psychological issues
indications for coronary angiography
development of angina
strongly positive exercise test
consider after use f of streptokinase
complications of STEMI
acute left ventricular failure
caardiogenic shock
pericarditis
post-AMI syndrome
left ventricular aneurysm
right ventricular infarction
ventricular septal rupture and mitral valve papillary rupture
cardiac arrythmias
anxiety and depression
signs of acute left ventricular failure
basal crackles, extra (third or forth) heart sounds, x-ray changes
cariogenic shock
required early specialist management which may include
- adrenaline - titrated to BP
- treat hypotension with inotropes
- intra-aortic balloon pump
- urgent angiography +/- angioplasty/surgery
pericarditis signs
occurs in the first few days after AMI (usually anterior AMI), with onset of sharp pain
pericardial friction rub
post AMI syndrome also called
Dressler syndrome
post-AMI syndrome features
this occurs weeks or months later, usually around 6 weeks
pericarditis, fever, pericardial effusion (an autoimmune response)
