Treatment of Acute Coronary Syndrome with ST elevation

ESC guidelines 2008

Dr. David TranA&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)

Relief pain & anxiety

• Morphine 0.1mg/Kg loading dose followed by 2mg bolus

• Oxygen if breathless or desaturation

Reperfusion strategies

Reperfusion strategies

• PCI = invasive reperfusion

• Fibrinolysis = pharmacological reperfusion

Primary PCI strategy

• Time between first medical care & balloon < 90 min• Medical treatment: Aspirin, Clopidogrel and Heparin

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

Problems of bleeding complications after fibrinolyse

• Intracranial bleeding = 1%• Major non cerebral bleeding = 4-13%

Facilitated PCI ?

• No place for a prior fibrinolytic treatment before a planned PCI…

Anti-platelet co-therapies

• Aspirin 250mg

• Plavix 600mg (PCI)

or 300mg (fibrinolytic)

Antithrombin co-therapies• Unfractionated heparin iv bolus 100 UI/Kg• Enoxaparin iv bolus 30mg followed by s.c.

dose of 1mg/Kg/12h

Therapy without reperfusion strategy or view later (>12h)

• Aspirin• Plavix• Anti-thrombin agent (heparin or Enoxaparin)

Management of arrhythmias in acute phase of ACS

• Cardioversion

• Amiodarone

• Beta blocker

Recommended doses for anti-arrhythmic medications

Problem of betablockers

• Early use of iv beta-blockers has to be conterbalanced by the risk of cardiogenic shock

Problems of nitrates

• The routine use of nitrates in the initial phase of a STEMI is not recommended

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

Acute Coronary Syndrome (ACS)

ECG 12 derivations+/- V7,V8, V9, V3r, V4rTroponine (if pain > 6h)

ACS with ST elevation

First medical treatmentASPEGIC 250mg IVPLAVIX 600mg loading dose (8 tab. 75mg)Heparine 70UI/Kg IV loading doseMorphine 0.05mg/Kg IV first doseAtorvastatine 80mg

Primary PCI reperfusionContact Tam Duc Hospital for agreementTransfert the patient with SMUR Ideal timing < 45 min. between 1st ECG and arrival in cathlab.

ACS without ST elevation

First medical treatmentASPEGIC 250mg IVPLAVIX 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 >120ISOKET 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 decreasedPatient stable (pulse, pressure)Next ECG stable or improved

Hospitalazation in USC/ICUAgreement of cardiologistRefer to cardiologist

YES

NO