Management of Acute Myocardial Infarction.PPTVIP

Management of Acute Myocardial Infarction Minimal Acceptable vs Optimal Care Background Suspicious chest pain: extremely common cause of ER visits Acute MI: the most costly cardiac cause of ER visits 5-10% of acute MI patients are missed because of errors in symptom interpretation or missed ECG diagnosis Many patients do not receive proven inexpensive effective therapy Clinical proceedings of a suspected MI Symptom evaluation Pain characteristics Heart failure, syncope Contraindication to SK Physical examination ECG Quick Interpretation correct Lab work-up Basic [Sugar. CRT. K. CK if no ST elevation] CXR Specific [Clinically guided] Disposal: Discharge Observation Admission Referral Relief of symptoms Pain Nausea Anxiety Aspirin Saves as many lives as SK ACE-I Low dose [Captopril 6.25] Not if SBP100 BB Thrombolysis SK TPA: SK sensitive or recent use Primary PCI: Who? Where? Should everybody with acute MI have: Statin? Clopedogrel? Platelet GP II b/III a inhibitor? Primary PCI? Timing of Statin Therapy Initiation After ACS in Recent Clinical Studies MIRACLStudy Outcome Measures Primary Death, Non-fatal MI, Cardiac arrest Worsening angina + evidence of myocardial ischemia. Secondary Stroke Revascularization. Worsening CHF Worsening angina without evidence of ischemia MIRACL: Primary Efficacy Measure MIRACL: COST-BENEFIT Absolute risk reduction for worsening angina: 2.2% NNT = 100/2.2 = 45.5 Cost of avoiding one worsening angina event = NNT x No of Days x Daily cost (Ignoring lab tests treating complications) = 45.5 x 120 X 36 = 196,364 LE GP II b/III a inhibitors for medically treated acute coronary syndromes GUSTO 4-ACS: Abciximab, no acute revascularization. No benefit at 30D (Simoons. Lancet 2001;357:1915) or 1Y (Ottervanger et al. CIRCULATION 2003;107:437) GRAPE pilot: abciximab for acute MI: TIMI 3 flow in 20% (van der Merkhof et al. JACC 1999;33:1528) PRISM: Tirofiban reduced total mortality compared to heparin alone. Tirofiban in ACS: 1.5% ARR o