CHEST PAIN

CHEST PAIN (EMS RESPONSE)

• Activate Cath Lab
• Aspirin 325mg Oxygen
• Oxygen
• 12 Lead EKG
• Manage Pain

ER (IMMEDIATE STEPS)

• Oxygen
• Aspirin
• Nitroglycerin
• Morphine
• 12 lead EKG
• CxR
• IV access, physical exam, vitals

ST ELEVATION MYOCARDIAL INFARCTION STEMI

Does the patient have chest pain?

• Is the duration < 12 hours (sometimes 12- 24 hour duration may also qualify)

Is there evidence of ST ELEVATION Myocardial Infarction?

• >1mm ST elevation in two contiguous leads

STEMI EKG definition : new ST elevation at the J point in 2 contiguous leads of 2mm or more in men or 1.5 mm in women in leads V2-V3 and/or 1 mm or more in other contiguous limb leads. (1mm= 0.1 mV)

STEMI equivalents :

• Posterior wall MI : ST depression in 2 or more precordial leads (V1-V4).
• Left main coronary artery occlusion, ST depression in at least 6 leads with coexistent ST elevation in lead aVR.
• New Left Bundle Branch Block

Our objective is :

• If patient can be taken to PCI and procedure started with in 90 minutes this would be ideal
• The next option is Fibrinolysis (Alteplase) which should be started within 30 minutes.

Meanwhile start Adjuvant therapies (Do NOT let this delay reperfusion therapy)

• Aspirin 320 mg (4 tablets of 80 mg) chewed, then Aspirin 80 mg daily
• If Aspirin allergy : Plavix 300 mg po initial dose, then 75 mg daily
• Sublingual Nitroglycerin 0.4 mg, may be repeated at 5 minute intervals x 3. This is THE initial treatment for MI pain.
• If Chest pain not relieved, give Morphine 2mg IV every 5-10 minutes until pain relief
• Metoprolol 5 mg IV over five minutes x 3 doses (If no 2nd or 3rd degree block or Asthma or COPD)
• Oxygen 4L/ NC keep O2sat >94%

Are there absolute contraindications to Fibrinolysis?

• Significant closed head/facial trauma within 3 months
• Ischemic stroke within 3 months(within 3 hours is ok)
• Intracranial or intraspinal surgery within 2 months
• Known history of intracranial hemorrhage (ICH)
• Known structural cerebral vascular lesion
• Known malignant intracranial neoplasm
• Suspected aortic dissection
• Active bleeding or bleeding diathesis (excluding menses)
• Severe uncontrolled hypertension that is not responding to meds in ER

Relative contraindications to Fibrinolysis

• Systolic blood pressure > 180 mm Hg or diastolic blood pressure > 110 mm Hg
• Prolonged CPR > 10 minutes or major surgery within 3 weeks
• History of prior ischemic stroke not within the last 3 months
• Internal bleeding within 4 weeks
• Noncompressible vascular punctures
• Dementia
• Pregnancy
• Active peptic ulcer
• Warfarin with INR >1.7

Alteplase dose:

• 15-mg IV bolus followed by
• 0.75 mg/kg (up to 50 mg) IV over 30 minutes
• 0.5 mg/kg (up to 35 mg) IV over 60 minutes.

The maximum total dose is 100 mg for patients weighing more than 67 kg.

After Alteplase patient is taken to PCI suite for angiography.

Unstable Angina / ST segment depression / T Wave Inversion or Positive Cardiac Markers:

• Monitored Bed Admission
• Adjuvant Measures
  • Intensive care monitoring for arrhythmias
  • Aspirin
  • Nitroglycerine 0.4mg Avoid if he has taken Viagra within 24 h or has large RV infarct
  • Heparin UFH or LMWH
  • GP IIb /IIIa inhibitor
  • Beta Blockers : Metoprolol 25 mg po q 12h
  • Monitoring
• Early Invasive intervention of any of these high risk features are present:
  • Refractory Chest Pain
  • Blood pressure unstable
  • Ventricular Tachycardia
  • Recurrent or persistent ST deviation
  • Signs and symptoms of Heart Failure
    • S3 gallop,
    • pulmonary edema,
    • worsening rales
    • new or worsening mitral regurgitation
  • High-risk findings on noninvasive stress testing
  • Depressed left ventricular function (EF < 40% on noninvasive study)

Low Risk Patients (Chest Pain with Non-diagnostic EKG)

Admit

Serial Cardiac Enzymes

Repeat EKGs

RIF: Abnormalities on noninvasive imaging and physiological testing

OR

IF: High risk features appear / Dynamic EKG changes / Elevated troponin

Adjuvant therapies

Monitored bed

Consider invasive therapies