Time is Muscle: Understanding Heart Attack
Hendri Susilo, dr., Sp.JP.
Universitas Airlangga Teaching Hospital
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▪ Chest pain accounts for ± 7.6 million annual visits to ER in the US
▪ Making chest pain the 2nd most common complaint.
▪ Patients present with a spectrum of signs and symptoms reflecting the many
potential etiologies of chest pain.
▪ Diseases of the heart, aorta, lungs, esophagus, stomach, mediastinum, pleura,
and abdominal viscera may all cause chest discomfort.
▪ Clinicians in the ED focus on the immediate recognition and exclusion of life-
threatening causes of chest pain.
▪ Patients with life-threatening etiologies for chest pain may appear deceptively
well, manifesting neither vital sign nor physical examination abnormalities.
https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf. 2
CASE ILUSTRATION
▪ A 60 years old man, heavy smoker, came to the ER with
6 hours onset of typical chest pain (VAS 7/10)
▪ Vital sign
▪ BP 119/71 mmHg, HR 80 bpm, RR 20, axillar temp 370C, SpO2
98%
▪ Physical exam within normal limits
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✓Onset of pain (eg, abrupt or gradual)
✓Provocation (which activities provoke pain; which alleviate pain)
✓Quality of pain (eg, sharp, squeezing, pleuritic)
✓Radiation (eg, shoulder, jaw, back)
✓Site of pain (eg, substernal, chest wall, back, diffuse, localized)
✓Timing (eg, constant or episodic, duration of episodes, when pain began)
Risk factors: male sex, age over 55 years, family history of CAD, DM,
hypercholesterolemia, hypertension, and tobacco use.
<10 minutes of patient
presentation inthe ED
Patients with normal or nonspecific ECGs have a 1-5% incidence of AMI and a 4-23%
incidence of UA. The ECG can be repeated if the initial ECG is not diagnostic but the
patient remains symptomatic and there remains high clinical suspicion for AMI.
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RV infarction is diagnosed based on the following findings:
•There is an inferior STEMI with ST elevation in lead III > lead II
•V1 is isoelectric while V2 is significantly depressed
•There is ST elevation throughout the right-sided leads V3R-V6R
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QUESTION?...
1. We have to confirm the diagnosis with serum marker to
establish the diagnosis… (T/F)
2. At the moment your diagnosis is?
a. Unstable Angina
b. Non STEMI
c. STEMI
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10 minutes
No need to
wait the result
Eur Heart J, Volume 42, Issue 14, 7 April 2021, Pages 1289–1367, https://doi.org/10.1093/eurheartj/ehaa575
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▪ DUAL ANTIPLATELETS: Aspirin 300-325 mg plus ?
▪ Prasugrel 60 mg loading, then 10 mg od
▪ Ticagrelor 180 mg loading, then 90 bid mg
▪ Clopidogrel 600 mg loading then 75 mg od
▪ NITRATE (avoid in RV infarct)
▪ BETA-BLOCKER (if not contraindicated)
▪ STATIN
▪ THROMBOLYTIC vs PPCI (gold standard)
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DIAGNOSTIC CORONARY ANGIOGRAPHY
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PRIMARY PCI PROSEDURE
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• Hipotensi
• NE mulai 50 nano
• Brdikardi
• SA 1 mg
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PRE POST
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VT pulse konvesi spontan menjadi sinus takikardi
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ACUTE CORONARY SYNDROME
ST Elevation Non ST Elevation
SIMILAR INITIAL TREATMENT
URGENT REPERFUSION RISK STRATIFICATION
Invasively Medically
Primary PCI Fibrinolysis
managed managed
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Pathophysiology of Acute Coronary Syndromes
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PATHOGENESIS Biomarker Release
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Characteristics of Chest Pain in Myocardial Ischemia
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• Angina occurring at rest and usually prolonged
Rest angina >20 min occurring within a week of presentation
New-onset • Angina of at least CCSC III severity with onset
angina within 2 months of initial presentation
Increasing • Previously diagnosed angina that is distinctly more frequent,
longer in duration or lower in threshold (i.e., increased by at
angina least one CCSC class within 2 months of initial presentation
to at least CCSC III severity)
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Principal causes of chest pain
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DIAGNOSIS
Target:
ECG ≤10 minutes from
First Medical Contact
- ST-Elevation in minimal
two contagious lead
J-point + 0,04 Sec
≥0,1mV
- In lead V2-V3 :
Baseline ≥0,2 mV in male ≥40 y.o
≥0,25 mV in male<40 y.o
≥0,15 mV in female
ESC Guidelines, 2012
MANAGEMENT
Early diagnosis
Reperfusion therapy ASAP
Optimal secondary prevention
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EMERGENCY ROOM
OXYGENATION
Indicated in patient with hypoxia (Sa02 <90%), dyspnea, and heart failure
INTRAVENOUS OPIOID
• Morphine 4-8 mg i.v
• Relieve pain and anxiety
• Adverse reaction: Hypotension, respiratory depression, and vomiting
ASPIRIN
• Aspirin oral (chewable) or i.v should be given in STEMI
• Loading dose 300-325 mg , maintenance dose 75-100 mg od
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EMERGENCY ROOM
P2Y12 RECEPTOR BLOCKER
• Ticagrelor & Prasugrel are preferable and recommended in patients
who planned for Primary PCI
• Loading dose Ticagrelor 180 mg or Prasugrel 60 mg
• Loading dose Clopidogrel 600 mg (Primary PCI) or 300 mg (Fibrinolysis)
NITRATE
• Short acting nitrates (Nitroglyserin 0,4 mg or ISDN 5 mg S.L) is recommended
• Should not be given in : RV infarction is suspected, hypotension, still in effect of
sildenafil/viagra, aorta stenosis, & HOCM
BETA BLOCKERS
• Reduce myocardial oxygen demand and incident of lethal arrhythmia
• Should not be given in: acute heart failure (Killip >2), significant AV Block,
hypotension (SBP<90mmHg) and bradycardia (<60bpm)
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REPERFUSION THERAPY STRATEGY
Primary PCI Fibrinolysis
VS
Eur Heart J, Volume 39, Issue 2, 07 January 2018, Pages 119–177, https://doi.org/10.1093/eurheartj/ehx393
The content of this slide may be subject to copyright: please see the slide notes for details.
Eur Heart J, Volume 39, Issue 2, 07 January 2018, Pages 119–177, https://doi.org/10.1093/eurheartj/ehx393
The content of this slide may be subject to copyright: please see the slide notes for details.
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• Acute emergency care is very important, the key point of STEMI
management is reperfusion therapy
• Determining the appropriate reperfusion therapy strategy is highly
depend on the clinical setting and resource availability in each
medical center
• Time to perform reperfusion is the most important variable to get
a better outcomes
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