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  #1  
Old 09-10-2011
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Heart Acute Coronary Syndrome; best next step

55 old male with history of long standing HTN, presented to the ER with sever chest pain, squeezing in nature, developed at rest & radiating to the neck, symptoms started 6 Hrs ago. EKG showed ST segment elevation > 1 mm in 2 contiguous leads. What is best next step in the management of this patient?
1. CK MB & Troponin.
2. T-PA.
3. Morphine, O2 & heparin.
4. Angioplasty.
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  #2  
Old 09-10-2011
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angioplasty if available
otherwise tpa
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Old 09-10-2011
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That is correct samstar.
The main point here, we do not need to get cardiac enzymes to confirm the diagnosis of MI.
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Old 09-10-2011
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This a summary for the management of ACS, please feel free to contribute:
Initial management:
Put the patient on continuous cardiac monitoring.
O2, aspirin, BB.
Nitroglycerin & morphine as indicated.
Patient within 12 Hrs of symptoms:
Emergency reperfusion therapy : Indication of Emergency Reperfusion Therapy is 1. Elevated ST segment > 1 mm in 2 contiguous leads. 2. New Lt Bundle Branch Block.
PCI –if available- superior to thromblysis.
The greatest benefit from PCI is anterior infarction & new LBBB.
Late presentation > 12 Hrs after symptoms:
Reperfusion therapy is not indicated if the patient is stable.
Elective catheterization.
CABG is indicated in 1. Lt main or 3 vessels disease. 2. Cardiogenic shock in spite of angioplasty.
Antiplatelet therapy: Aspirin: Lower mortality. Give aspirin first, if they ask you aspirin or thrombolytic first say aspirin. Unless contraindicated.
Clopidogrel: if aspirin is not tolerated or in case of stent.
Glycoprotein 2a/3b inhibitors are not useful in ST elevated MI, unless the patient is for angioplasty.
Emergency CABG: 1. Failed angioplasty. 2. Persistent or recurrent ischemia refractory to medical therapy.
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Old 09-10-2011
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Quote:
Originally Posted by ag2011n View Post
This a summary for the management of ACS, please feel free to contribute:
Initial management:
Put the patient on continuous cardiac monitoring.
O2, aspirin, BB.
Nitroglycerin & morphine as indicated.
Patient within 12 Hrs of symptoms:
Emergency reperfusion therapy : Indication of Emergency Reperfusion Therapy is 1. Elevated ST segment > 1 mm in 2 contiguous leads. 2. New Lt Bundle Branch Block.
PCI –if available- superior to thromblysis.
The greatest benefit from PCI is anterior infarction & new LBBB.
Late presentation > 12 Hrs after symptoms:
Reperfusion therapy is not indicated if the patient is stable.
Elective catheterization.
CABG is indicated in 1. Lt main or 3 vessels disease. 2. Cardiogenic shock in spite of angioplasty.
Antiplatelet therapy: Aspirin: Lower mortality. Give aspirin first, if they ask you aspirin or thrombolytic first say aspirin. Unless contraindicated.
Clopidogrel: if aspirin is not tolerated or in case of stent.
Glycoprotein 2a/3b inhibitors are not useful in ST elevated MI, unless the patient is for angioplasty.
Emergency CABG: 1. Failed angioplasty. 2. Persistent or recurrent ischemia refractory to medical therapy.
Agree with everything u said, but have a confusion about
ur 2nd indication of routine CABG i.e cardiogenic shock....

do u mean congestive heart failure or actually cardiogenic shock???
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Old 09-10-2011
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Hi aasiaafzal, I mean low blood pressure, in spite of every effort still the heart is not pumping well.
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Quote:
Originally Posted by ag2011n View Post
Hi aasiaafzal, I mean low blood pressure, in spite of every effort still the heart is not pumping well.

i dont think such a major surgery can be performed, if a pt is in shock or hypotensive....

True we do it in acute MI pts, when left main disease or critical triple vessel disease,or if stenting fails,or ischemia n pain persists but they r not in shock i think...because here our purpose is to restore coronary circulation before ischemia changes into infarction....whereas same pt if in shock, must be resuscitated first....

though this is my personal opinion, no reference...plz send me the refernce or the link of what u r saying....i donot want to waste much time googling it...thx...
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If the patient is not improving after angioplasty, and full medical intervention, they need to do CABG, to save the patient life, because the heart is not getting enough blood supply yet. This according to Conrad Fischer Kaplan videos.
Thanks
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Quote:
Originally Posted by ag2011n View Post
If the patient is not improving after angioplasty, and full medical intervention, they need to do CABG, to save the patient life, because the heart is not getting enough blood supply yet. This according to Conrad Fischer Kaplan videos.
Thanks
not improving after angio is totally different than cardiogenic shock..!!!

angio failure or no improvement after angio means that u attempted angio but u reaslised that anatomically stenting is not possible..,pt is still having reversible ischemia so u go for CABG

whereas MI pt in shock is different...i just wanted to confirm if we go for CABG in this scenario as well...??i dont think so....
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Quote:
Originally Posted by aasiaafzal View Post
i dont think such a major surgery can be performed, if a pt is in shock or hypotensive....

True we do it in acute MI pts, when left main disease or critical triple vessel disease,or if stenting fails,or ischemia n pain persists but they r not in shock i think...because here our purpose is to restore coronary circulation before ischemia changes into infarction....whereas same pt if in shock, must be resuscitated first....

though this is my personal opinion, no reference...plz send me the refernce or the link of what u r saying....i donot want to waste much time googling it...thx...
I don't think its the right example to give but i would still proceed to make my point clear.

You need optimal lung function of a patient to perform any surgery but lets say we have a pt needing a lung transplant. We can never optimize his respiratory function enough to call him fit for surgery. So for this procedure his pulmonary function becomes irrelevant.

And in our case, the patient is still having ischemia despite angioplasty attempt. So only option left is to go for CABG to deliver oxygen to the dying heart.The earlier we do it, the better.
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Last edited by step1an; 09-10-2011 at 01:31 PM.
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  #11  
Old 09-10-2011
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I think step1an explanation is really good, but still let us see if other fellows have different opinion.
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I understand your point aasiaafzal, your are correct in this scenario, CABG is not indicated, it will be indicated, if after angioplasty, the patient cardiac function is not getting better and as a marker of that he has low blood pressure.
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yes both of u r right...CABG is done even if a pt is in cardiogenic shock...!!
http://cardiology.jwatch.org/cgi/con...ll/2005/1104/4
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