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Treatment of Acute Coronary Syndrome with ST elevation ESC guidelines 2008

Treatment of Acute Coronary Syndrome with ST elevation ESC guidelines 2008. Dr. David Tran A&E dept. FVH 22/12/09. Initial diagnosis & early stratification . Chest pain or discomfort First ECG showing persistent ST elevation Elevated biomarkers of necrosis (2D echocardiography).

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Treatment of Acute Coronary Syndrome with ST elevation ESC guidelines 2008

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  1. Treatment of Acute Coronary Syndrome with ST elevationESC 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. Reperfusion strategies • 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 ACS without ST elevation • First medical treatment • ASPEGIC 250mg IV • PLAVIX300mg 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 • First medical treatment • ASPEGIC 250mg IV • PLAVIX 600mg loading dose (8 tab. 75mg) • Heparine70UI/Kg IV loading dose • Morphine 0.05mg/Kg IV first dose • Atorvastatine 80mg • Improvement? • Chest pain relieved or decreased • Patient stable (pulse, pressure) • Next ECG stable or improved • 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. NO YES • Hospitalazation in USC/ICU • Agreement of cardiologist • Refer to cardiologist Transfert to an Hospital with cathlab & cardiologic intensive care

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