Cập nhật về chẩn đoán và xử trí cấp cứu nhồi máu cơ tim cấp trước viện

PREHOSPITAL DIAGNOSIS AND MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION Dr Abdul Raqib bin Abd Ghani MBBSMal, MRCPUK Cardiology Clinical Specialist Serdang Hospital, MALAYSIA... CONTRAINDICA

PREHOSPITAL DIAGNOSIS AND MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION

Dr Abdul Raqib bin Abd Ghani MBBS(Mal), MRCP(UK) Cardiology Clinical Specialist Serdang Hospital, MALAYSIA

Greetings from MALAYSIA!

CONTRAINDICATIONS TO

THROMBOLYSIS

Absolute contraindications

• previous Intracranial haemorrhage

• Known structural cerebrovascular lesion (eg, arteriovenous

malformation)

• Known malignant intracranial neoplasm (primary or metastatic)

• Ischemic stroke within 3 mo, except for acute ischemic stroke within 3 h

• Suspected aortic dissection

• Active bleeding or bleeding diathesis (excluding menses)

• Severe closed-head or facial trauma within 3 mo

J Am Coll Cardiol

Relative contraindications

History of chronic, severe, poorly controlled hypertension

Severe uncontrolled hypertension on presentation (SBP ≥180 mm Hg or DBP ≥110 mm Hg) History of ischemic stroke more than 3 mo previously, dementia, or known intracranial

pathology not included in contraindications

Traumatic or prolonged (>10 min) CPR or major surgery (<3 wk previously)

Recent (within 2-4 wk) internal bleeding

Non compressible vascular punctures

For streptokinase: previous exposure (>5 d previously) or previous allergic reaction to these agents

Pregnancy

Active peptic ulcer

Current use of anticoagulants: the higher the INR, the higher the risk of bleeding

•Primary PCI is the preferred strategy to treat patients with acute STEMI

•Delays in performing PCI are common when patients present to emergency medical services or non PCI

capable centres

•The delay in transfer for primary PCI increases the

rates of morbidity and mortality

• randomised multicentre trial, intention to treat analysis

• n=840 patients, patients presenting within 6hrs of a STEMI, initially managed by mobile emergency care units

• assigned to

• prehospital fibrinolysis (with accelerated alteplase)

• primary angioplasty

• all were transfered to centres with access to emergency angioplasty

• primary endpoint: composite of death, non fatal reinfarction, or non disabling stroke at 30 days

 427 patients, 21 to 85 years of age, with STEMI within 6 h of symptom onset and 90-min ECG criteria (50% ST-segment resolution) for failed thrombolysis Patients were randomly assigned to rescue PCI (n 144), repeat thrombolysis (n 142), or conservative therapy (n 141)

 R-PCI was done within 5-10 hours after the onset of symptoms The mean time for rescue PCI was 414 minutes (6.5hours)

pain-to- The rate of event-free survival within 6/12: 84.6% with rescue PCI, 70.1 % receiving conservative therapy, 68.7 % repeat thrombolysis (overall P = 0.004)

 Composite primary end point at 6 months : 31.0% (repeat thrombolysis), 29.8% (conservative) and 15.3% (rescue PCI) p <0.01

NEJM 2005;353:2758-68

142 patients

ng Hospit

Indications for transfer

• STEMI < 3 hours with extensive right, extensive anterior, anterior and/or in

**cardiogenic shock, stent thrombosis ,OR thrombolytic therapy

contraindicated

• STEMI >3 hours and less than 12 hours

• STEMI > 12hours but < 24 hours with on going ischemia

• Patient must able to be lie flat, on oxygen therapy or intubated/ventilated prior

thank you for your kind attention