The 30 min. infusion !!!

1. The 30 min. infusion !!!

2. Management of Acute MI:Evidence based approach Dr. Prasant Kr. Sahoo Consultant Cardiologist Kalinga Hospital Bhubaneswar

3. Pathophysiology of AMI

4. Unstable Angina / NSTEMI

5. ST Elevation MI

6. Acute Coronary Syndromes ACUTE CORONARY SYNDROME No ST Elevation ST Elevation NSTEMI NQMI QwMI Myocardial Infarction Unstable Angina

7. Progression of necrosis post AMI

9. Consequences of AMI

10. Key concepts in MI management • Early diagnosis • Early reperfusion • Management of complications

11. Steps to diagnosis • Clinical evaluation • ECG • Cardiac enzymes • Echocardiographic evaluation • Coronary angiogram

12. Symptoms of Acute MI • Steady, squeezing pressure or burning pain in the centre of the chest that lasts two minutes or more • Pain that radiates from the centre of the chest down one (usually left) or both arms and to shoulders, neck, jaw or back • Dizziness, light-headedness or fainting • Nausea or vomiting • “A sense of anxiety or impending doom”

13. 33% of AMI do not present with chest pain

14. How helpful is the ECG ?

15. 40 % cases of AMI , ECG is inconclusive

16. The MI iceberg

17. ST Elevation Ant. MI

18. ST elevation Inf. MI

19. Non ST elevation MI

20. Chest pain without ECG changes IS HE INFARCTING ?

21. Enzymatic diagnosis of AMI

22. How an Echo helps ? • RWMA • EF • Complications

23. Coronary patency following AMI

24. Desmond Julian:the concept of ICCU( 1961)

25. Pillars of the ICCU concept • Continuous ECG monitoring & arrhythmia alarms • CPR & external defibrillation • Clustering of MI patients where personnel, drugs & equipment are available • Trained nurses to initiate resuscitation

26. Pradigm for treatment of AMI

28. Non STEMI ( Non Q ) LMWH GPII b IIIa inhibitors STEMI (Transmural) Thrombolysis Angioplasty Treatment for ACS

29. Clinical approach to AMI

30. Aim of revascularisation Coronary recanalization • Prompt • Complete • Sustained

31. Success of recanalization over time

32. Coronary patency & mortality

33. Golden Hour Term used in emergency medicine which refers to the first sixty minutes after an accident or the onset of acuteillness. The victim's chances of survival are greatest if he or she can be transported to a hospital within the Golden Hour.

34. The ‘Golden hour’ ('Boersma et al 1996')

35. Reducing delay is our major challenge • Delay in context : • Delay thrombolysis by 1 hour = 21 deaths/1000 patients in one month (and probably as many again die in 2 years) • Rawles 1998

36. How to establish reperfusion • Thrombolysis • Coronary Angioplasty ( PTCA)

38. AAC/AHA Guidelines for Thrombolysis • All patients who have symptoms suggesting AMI • Within 12 hours of onset of symptoms • ECG changes of AMI (STEMI, new BBB) • No contraindications

39. Thrombolysis : What to give ? • Streptokinase : 1.5MU in 100 ml. 5% Dextrose/ 0.9% saline over 60 mins. • tPA : 15 mg bolus , followed by 50mg over 60 mins.& residual 35 mg over 30 mins. • Reteplase : 10 IU bolus, then 10 IU after 30 mins. • Tenecteplase : 30-50mg IV bolus • Door-to-needle time – 30 min

40. Problems with thrombolysis • Only 30 % pts.recieve it • Patency rate 66% (Tenecteplase) 63% (Reteplase) ; 54% (tPA); ! 30% (STK) • 30% reocclude in 3 months • Not for haemodynamically unstable pts. • Residual stenosis

41. Nightmares in thrombolysis

42. Trials of STK on AMI

43. Which thrombolytic is best ?

44. GUSTO trial : Patency

45. Effect of Thrombolysis on Mortality

46. Does thrombolysis play a role in NSTEMI ( TIMI IIIb)

47. Time to ThrombolysisInt J Cardiol 1995; 49: 33-37 EMIP MITI GREAT Benefit Gradient 23 / 1000 / Hour

48. Can we give prehospital thrombolysis ?

49. 2008 guidelines ACC/AHA • The use of prehospital 12-lead electrocardiography is encouraged to increase the efficiency of care for STEMI.

50. Rationale of prehospital thrombolysis