Download ESC guidelines about Acute Coronary Syndrom

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
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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 antiarrhythmic 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, V4r
Troponine (if pain > 6h)
ACS with ST elevation
ACS without ST elevation
First medical treatment
ASPEGIC 250mg IV
PLAVIX 600mg loading dose (8 tab. 75mg)
Heparine 70UI/Kg IV loading dose
Morphine 0.05mg/Kg IV first dose
Atorvastatine 80mg
First medical treatment
ASPEGIC 250mg IV
PLAVIX 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 >120
ISOKET IV if persistent chest pain (TA > 120)
Morphine bolus IV If severe pain
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
Improvement?
Chest pain relieved or decreased
Patient stable (pulse, pressure)
Next ECG stable or improved
YES
Transfert to an Hospital
with cathlab & cardiologic
intensive care
Hospitalazation in USC/ICU
Agreement of cardiologist
Refer to cardiologist