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| Acute coronary syndrome: emergency medical care at the prehospital stage. Examination of a patient with ox at the prehospital stage. Absolute contraindications for TLT |
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ACS treatment at the prehospital stage: modern understanding Prof. Tereshchenko S. N. Institute of Clinical Cardiology. A. L. Myasnikova. RKNPK Russian Cardiology Research and Production Complex
ACUTE CORONARY SYNDROME: EMERGENCY CARE AT THE PRE-HOSPITAL I... GENERAL CONCEPTS Definition. Acute coronary syndrome (ACS) is a group of clinical signs or symptoms that make it highly likely to suspect myocardial infarction (MI) or unstable angina pectoris (NS) at the first contact with the patient. ACS includes conditions caused by acute ischemic changes in the myocardium: NA (new-onset or progressive), MI without ST-segment elevation (STEMI), and ST-segment elevation MI (STEMI). At the prehospital stage of emergency medical care (ED EMC), differential diagnosis between NS and ST-IBM is not performed. Since at the early stage of diagnosis (including in the hospital) it is not always possible to differentiate between NA and MI, as well as other diseases with a similar clinic, it is advisable to single out "probable ACS" as a preliminary diagnosis in case of urgent hospitalization of the patient, and "presumptive ACS" , as a secondary diagnosis if another disease is a more likely cause of treatment, but ACS has not yet been excluded. It should be noted that overdiagnosis of ACS at the prehospital stage is less of a mistake than underestimating the patient's condition. In one third of cases of ACS, it can be atypical. To assess the clinical situation, E. Braunwald (1989) proposed to subdivide unstable angina pectoris according to the severity of clinical manifestations and the conditions for the onset of seizures as follows (table). Classification of unstable angina pectoris (according to E. Braunwald, 1989) Etiology and pathogenesis. Possible causes of an acute decrease in coronary blood flow may be a prolonged spasm of the coronary vessels, a sharp increase in myocardial oxygen demand, thrombotic changes against the background of stenosing sclerosis of the coronary arteries and damage to atherosclerotic plaque, as well as hemorrhage into the plaque and detachment of the arterial intima. The formation of occlusion of the coronary artery leads to an insufficient supply of oxygen to the myocardium, followed by the formation of necrosis of the heart muscle. Moreover, the longer the period of ischemia lasts, the larger the area and depth of necrosis. After 4-6 hours of ischemia, the zone of necrosis of the heart muscle practically corresponds to the area of \u200b\u200bblood supply to the affected vessel. POINT OF VIEW TREATMENT OF ACUTE CORONARY SYNDROME WITH ST-SEGMENT RISE IN THE PREHOSPITAL STAGE OF MEDICAL CARE S. N. Tereshchenko *, I. V. Zhirov Russian Cardiology Research and Production Complex. 121552 Moscow, 3rd Cherepkovskaya st., 15a Treatment of acute coronary syndrome with B7 segment elevation at the prehospital stage of medical care S. N. Tereshchenko *, I. V. Zhirov Russian Cardiology Research and Production Complex, 121552 Moscow, 3rd Cherepkovskaya st., 15a The issues of organization of medical care at the prehospital stage in patients with acute coronary syndrome (ACS) and elevation of the BT segment are discussed. An algorithm for the diagnosis and provision of emergency care for a patient with ACS and elevation of the BT segment at the prehospital stage is presented. The necessary examination methods, medications and their doses are indicated. The importance of reperfusion therapy as a key aspect of the treatment of patients in this group is emphasized. The advantages and disadvantages of each of the reperfusion therapy methods and the algorithm for their selection are discussed. Key words: acute coronary syndrome, myocardial infarction, prehospital stage, thrombolytic therapy. RFK 2010; 6 (3): 363-369 Treatment of the acute coronary syndrome with ST segment elevation at the pre-hospital care S.N. Tereshchenko *, I.V Zhirov Russian Cardiology Research and Production Complex. Tretya Cherepkovskaya ul. 15a, Moscow, 121552 Russia Details of pre-hospital medical care organization in patients with acute coronary syndrome (ACS) with ST segment elevation are discussed. The algorithm of pre-hospital diagnostics and emergency cardiac care to these patients is presented. The necessary methods of examination, drugs and their dosages are specified. The importance of reperfusion as a key approach to ACS patients treatment is emphasized. Advantages and disadvantages of reperfusion therapeutic methods and algorithm of their choice are presented. Key words: acute coronary syndrome, myocardial infarction, pre-hospital cardiac care, thrombolytic therapy. Rational Pharmacother. Card. 2010; 6 (3): 363-369 Introduction The term acute coronary syndrome (ACS) with a persistent elevation of the 5T segment on the ECG means any group of clinical signs against the background of existing elevations of the BT segment with an amplitude of\u003e 1 mm on the ECG for at least 20 minutes, allowing to suspect a coronary catastrophe. It should be noted right away that the term ACS is not a diagnosis. The establishment of ACS enables the specialist to recognize the presence of a coronary catastrophe, requires a clear set of diagnostic and treatment techniques and dictates the need for hospitalization of the patient in a specialized hospital. Tereshchenko Sergey Nikolaevich, Doctor of Medical Sciences, Professor, Head of the Department of Myocardial Diseases and Heart Failure, RKNPK, Head. Department of Emergency Medicine, Moscow State University of Medicine and Dentistry, Chairman of the Emergency Cardiology Section of VNOK Zhirov Igor Vitalievich, Doctor of Medical Sciences, Art. n. from. of the same department, scientific secretary of the emergency cardiology section of VNOK Along with damage to an atherosclerotic plaque with subsequent intracoronary thrombosis, ACS can be caused by a sharp increase in myocardial oxygen demand (cocaine intoxication, thyroid pathology, anemia), coronary vasospasm, and more rare causes (for example, dissection of coronary arteries in pregnant women). At the same time, more than 95% of ACS with persistent elevation of the BT segment are associated precisely with the processes of violation of the integrity of the plaque membrane. Issues of organization of medical care at the prehospital stage in patients with ACS and ST-segment elevation It is known that almost 50% of unfavorable outcomes in various forms of ACS occur in the first hours of the disease. Thus, a competent scheme of examination and treatment of a patient in the early stages of ACS is the cornerstone of the success of therapy. Patient treatment is a single process, starting at the prehospital stage and continuing in hospital. For this, ambulance teams and hospitals, where patients with ACS are admitted, should work according to a single algorithm based on common principles of diagnosis and treatment, and a common understanding of tactical issues. In this regard, the previously used two-stage system of medical care delivery (line brigade - specialized brigade) led to an unjustified delay in the provision of appropriate medical care. Any team, having made this diagnosis, having determined the indications and contraindications for the appropriate treatment, should stop the pain attack, begin antithrombotic treatment, including the administration of thrombolytics (if primary angioplasty is not planned), and if complications develop - heart rhythm disturbances or acute heart failure - the necessary therapy , including measures for cardiopulmonary resuscitation. At the prehospital stage, the specialist needs to solve several practical problems at once - this is the provision of emergency care, the assessment of the risk of complications and their prevention, the hospitalization of the patient in the target hospital. All this is carried out in conditions of lack of time and labor, in stressful conditions. Accordingly, clear diagnostic and treatment algorithms are required, as well as the appropriate equipment of the team (Table 1). It must be remembered that even a suspicion of the presence of ACS is an absolute indication for hospitalization of a patient in a hospital. Examination of a patient with ACS and ST-segment elevation at the prehospital stage There is no doubt that a complete examination of a patient with this diagnosis at the prehospital stage is difficult for objective reasons. At the same time, the proposed algorithm is practically feasible, it is necessary to develop the correct treatment tactics, as well as to prepare the patient for therapy at the hospital stage (Table 2). Prehospital ST-segment elevation ACS treatment We consider it expedient to reflect the treatment algorithm in the sequence that occurs most often at the prehospital stage. Anesthesia Anesthesia is an integral part of the complex therapy of ACS, not only for ethical reasons, but also due to excessive sympathetic activation during nociceptive disruption. Table 1. A sample of equipment for an ambulance team to provide care to patients with ACS with ST-segment elevation 1. Portable electrocardiograph with autonomous power supply 2. Portable device for electro-pulse therapy with autonomous power supply and the ability to monitor cardiac activity 3. Set for cardiopulmonary resuscitation (CPR) including a device for manual mechanical ventilation 4. Equipment for infusion therapy including infusion pumps and perfusers 5. Set for the installation of an intravenous catheter 6. Cardioscope 7. Pacemaker 8. System for remote ECG transmission 9. Mobile communication system 11. Medicines required for basic therapy of acute myocardial infarction Table 2. Preliminary algorithm diagnostic manipulations at the prehospital stage in a patient with ACS and elevation of the BT segment 1. Determination of NPV, heart rate, blood pressure, blood saturation 02 2. Registration of ECG in 12 leads 3. Monitoring of the ECG at the entire stage of treatment and transportation of the patient 4. Preparing for eventual defibrillation and CPR 5. Providing intravenous access 6. Short sighting history, physical examination NPV - frequency of respiratory movements, HR - heart rate dredging. This leads to increased vasoconstriction, increased myocardial oxygen demand, and increased load on the heart. If the use of aerosolized forms of nitrates is ineffective, immediate intravenous administration of morphine hydrochloride 2-4 mg + 2-8 mg every 5-15 minutes or 4-8 mg + 2 mg every 5 minutes or 3-5 mg until pain relief is recommended. With systolic blood pressure (BP) above 90 mm Hg. an intravenous infusion of nitroglycerin should be started at a dose of 20-200 mcg / minute. In the case of severe anxiety, European authors consider the intravenous administration of small doses of benzodiazepines to be indicated, but in most cases the use of opioid analgesics allows satisfactory results. Respiratory support Along with anesthesia, all patients with ACS require respiratory support. Inhalation of humidified oxygen at a rate of 2-4 l / min is associated with a decrease in myocardial oxygen demand and the severity of clinical symptoms. In some cases, non-invasive mask ventilation is recommended, especially in the mode of positive end-expiratory pressure (PEEP). This ventilation mode is especially indicated in the presence of heart failure; it is associated with hemodynamic unloading of the pulmonary circulation and correction of hypoxemia. Non-invasive mask ventilation also reduces the need for tracheal intubation and mechanical ventilation, which is important, since mechanical ventilation itself can adversely change hemodynamic parameters in a patient with ACS. Acetylsalicylic acid, non-steroidal anti-inflammatory drugs, COX-2 inhibitors Absolutely all patients with ACS should take a loading dose of acetylsalicylic acid (ASA) - 160-325 mg of non-enteric forms under the tongue as early as possible. An acceptable alternative is the use of intravenous ASA (250-500 mg) and ASA in the form of rectal suppositories. Contraindications to the use of a loading dose are active gastrointestinal bleeding, known hypersensitivity to ASA, thrombocytopenia, severe hepatic failure. The use of non-steroidal anti-inflammatory drugs (NSAIDs) and selective COX-2 inhibitors leads to an increased risk of death, recurrence of ACS, myocardial rupture and other complications. If ACS occurs, all drugs from the groups of NSAIDs and COX-2 inhibitors should be canceled. In the future, for an indefinitely long time, all patients should receive low doses of ASA (75-160 mg) every day. Clopidogrel The addition of clopidogrel to ASA at the prehospital stage significantly improves clinical outcomes, reduces morbidity and mortality in patients with ACS. The dosage of clopidogrel differs depending on the type of ACS and the type of treatment (Table 3). In the future, the dosage of clopidogrel is 75 mg. The duration of dual antiplatelet therapy (ASA plus clopidogrel) also differs depending on the type of ACS and the approach to treatment (invasive / non-invasive) and is 4-52 weeks (at least 4 weeks, ideally 1 year). Table 3. Loading doses of clopidogrel (by, with changes) Various clinical scenarios Loading dose Primary PCI is definitely possible At least 300 mg, preferably 600 mg Thrombolytic therapy Under 75 75 years and older (unless primary TBA is planned) Without reperfusion therapy Up to 75 years 300 mg 75 years and older 75 mg ST-segment elevation ACS reperfusion therapy The significance of reperfusion therapy in the case of a patient with ACS with elevation of the BT segment is difficult to overestimate. The Russian guidelines for the diagnosis and treatment of patients with acute myocardial infarction with elevation of the BT segment (BMI) on the ECG indicate that the mainstay of treatment for acute myocardial infarction is the restoration of coronary blood flow - coronary reperfusion. The destruction of the thrombus and the restoration of myocardial perfusion lead to a limitation of the extent of its damage and, ultimately, to an improvement in the short and long term prognosis. Therefore, all patients with IMpBT should be promptly examined to clarify the indications and contraindications for the restoration of coronary blood flow. To assess the importance of an early start of reperfusion therapy, the concept of "golden hour" was introduced: its implementation in the first 2-4 hours can completely restore blood flow in the ischemic zone and lead to the development of the so-called "interrupted" or "aborted" myocardial infarction. Until now, there are two methods of reperfusion therapy - interventional intervention (PCI) or thrombolytic therapy (TLT). It should be noted that these two methods of reperfusion can be effectively combined with each other, which led to the emergence of the term “pharmacoinvasive reperfusion strategy” (Figure). Thus, the choice of the initial reperfusion method is the most important at the prehospital stage. Below are the criteria for its selection (by, as amended): An invasive strategy is preferred if: There is a 24-hour angiographic laboratory and an experienced researcher performing at least 75 primary PCI per year, and the time from the first contact with medical personnel to balloon inflation in the CA does not exceed 90 minutes; the patient has severe complications of myocardial infarction: cardiogenic 300 mg 75 mg Invasive coronary artery recanalization "Primary" PCI Rescue PCI "Facilitated" PCI 1 1 Fibrinolytic Fibrinolytic No non-invasive signs of myocardial reperfusion Transportation to an "experienced" invasive center Drawing. Reperfusion therapy options (adapted by S.N. Tereshchenko) shock, acute heart failure, life-threatening arrhythmias; There are contraindications to thrombolytic therapy (TLT): high risk of bleeding and hemorrhagic stroke; Late hospitalization of the patient: duration of symptoms of IMPT\u003e 3 hours; There are doubts about the diagnosis of myocardial infarction or it is assumed that the mechanism of cessation of blood flow through the coronary artery is different from thrombotic occlusion. Accordingly, the choice in favor of TLT occurs if: The duration of myocardial infarction is not more than 3 hours; PCI is impossible (there is no available angiographic laboratory or the laboratory is busy, there are problems with vascular access, there is no way to deliver the patient to the angiographic laboratory, or the skill of using Table 4. Contraindications to TLT investigator); PCI cannot be performed within 90 minutes after the first contact with medical personnel, and also when the expected delay time between the first balloon inflation in the CA and the onset of TLT exceeds 60 minutes. According to numerous studies, the initiation of reperfusion therapy early in treatment can significantly improve clinical outcomes of the disease. In this regard, the cornerstone of successful therapy is the possibility of prehospital TLT. Conducting TLT at the prehospital stage entails a significant improvement in prognosis and clinical outcomes for the patient. Indications for TLT are: The time from the onset of an anginal attack does not exceed 1 2 hours; Absolute contraindications Previous hemorrhagic stroke or CMD of unknown etiology Ischemic stroke in the last 3 months Brain tumor, primary and metastatic Suspected aortic dissection Presence of signs of bleeding or hemorrhagic diathesis (excluding menstruation) Significant closed head injuries in the past 3 months Changes in the structure of cerebral vessels, such as arteriovenous malformation, arterial aneurysms Relative contraindications History of persistent, high, poorly controlled hypertension AH - at the time of hospitalization - BP sis. \u003e 180 mm Hg, diast. \u003e 110 mm Hg) Ischemic stroke more than 3 months old Dementia or intracranial pathology not listed in the "Absolute Contraindications" Traumatic or prolonged (more than 10 minutes) cardiopulmonary resuscitation or surgery, transferred within the last 3 weeks Recent (within the previous 2-4 weeks) internal bleeding Puncture of a vessel that cannot be pressed For streptokinase - administration of streptokinase more than 5 days ago or known allergy to it Pregnancy Exacerbation of peptic ulcer Taking indirect anticoagulants (the higher the INR, the higher the risk of bleeding) Table 5. Scheme of using various thrombolytic agents Alteplase Intravenous 1 mg / kg body weight (but not more than 100 mg): bolus 15 mg; subsequent infusion of 0.75 mg / kg of body weight in 30 minutes (but not more than 50 mg), then 0.5 mg / kg (but not more than 35 mg) in 60 minutes (total duration of infusion 1.5 hours) Prourokinase Intravenous: bolus 2,000,000 IU followed by 4,000,000 IU infusion over 30-60 minutes Streptokinase Intravenous infusion 1,500,000 IU over 30-60 minutes) Tenecteplase Intravenous bolus: 30 mg by weight<60 кг, 35 мг при 60-70 кг, 40 мг при 70-80 кг; 45 мг при 80-90 кг и 50 мг при массе тела >90 kg Table 6. Characteristics of the "ideal" drug for thrombolytic therapy (with additions and corrections by the authors) On the ECG, there is an increase in the BT segment\u003e 0.1 tM in at least 2 consecutive chest leads or in 2 leads from the extremities or blockade of LBPH appears; The introduction of thrombolytics is justified at the same time with ECG signs of a true posterior MI (high R waves in the right precordial leads and depression of the BT segment in leads V1-V4 with an upward T wave). Contraindications to TLT are presented in Table 4. The issue of a possible modification of the TLT algorithm at the prehospital stage is quite relevant. This topic is the subject of rather heated discussions. The most generally accepted point of view is that TLT at the prehospital stage should be limited to the first 6 hours after the onset of clinical symptoms, and the existing relative contraindications should be considered absolute. Conducting TLT at the prehospital stage is facilitated by the creation of special questionnaires, the filling of which allows the specialist to more accurately decide the question of the possibility / impossibility of TLT in each specific case. The developed questionnaires are based on the indication of indications and contraindications for TLT, while any doubt or negative answer speaks in favor of abandoning prehospital TLT. Table 7. Comparative effectiveness and safety of tenecteplase and alteplase (based on the results of the ASSENT-2 study with additions and corrections by the authors) Alteplaza, n \u003d 8488 Tenekteplaza, p n \u003d 8461 Death for 30 days 6.18% 6.165 NA Nosocomial VChK 0.94% D N% t, 9 0, Intrahospital massive bleeding 5.94% 4.66% 0.0002 Blood transfusion 5.49% 4.25% 0.0002 the nutritional stage of medical care and developed at FGU RKNPK Rosmedtechnologii is presented in Appendix 1. Currently, four drugs are registered in the Russian Federation for TLT in ACS with an elevated BT segment. Table 5 provides information on the doses and methods of administration of various thrombolytics. Requirements for an “ideal” thrombolytic drug are shown in Table 6. In our opinion, for TLT at the prehospital stage, the most significant are the efficacy, safety and ease of use of the drug. In this regard, the most promising is the use of tenecteplase, a genetically modified form of human tissue plasminogen activator, at the prehospital stage. Tenecteplase is not inferior to tissue plasminogen activator (alteplase) in its effectiveness, but surpasses it in its safety (Table 7). At the same time, in the group of greatest risk (women, the elderly, body weight less than 60 kg) against the background of the introduction of tenecteplase, a 57% decrease in the risk of stroke was observed. The extremely simple dose selection based on body weight, the simplicity of TLT with tenecteplase - intravenous bolus administration of 6-10 ml of the drug - is an additional clinical advantage in conditions of lack of time, working hands and increasing Fast onset of action High efficiency within 60-90 minutes with improved blood flow (grade 3 on the T1M1 scale) Low incidence of side effects (especially bleeding and stroke) Low re-occlusion rate Ease of administration (bolus versus continuous infusion) Simple dosing regimen Good long-term forecast Saving resources (financial, labor, budget) Table 8. Indications and contraindications for the appointment of intravenous beta-blockers in patients with ACS at the prehospital stage Indications Contraindications Tachycardia - heart failure Recurrent ischemia - AV conduction disorders Tachyarrhythmias - severe broncho-obstructive pulmonary disease Arterial hypertension - an increased risk of developing cardiogenic shock stress associated with prehospital care. A prerequisite before TLT is the ability to monitor the patient's condition and the ability to timely identify and correct possible complications. Antithrombotic therapy Heparins They are a standard link in anticoagulant therapy in patients with ACS. The introduction of unfractionated heparin is recommended to start with an intravenous bolus (no more than 5000 U for ACS without an increase in the BT segment and 4000 IU for ACS with an increase in the BT segment) with a further transition to intravenous infusion at a rate of 1000 U / hour and control of an activated partial thromboplast. stein time every 3-4 hours. The use of low molecular weight heparins avoids laboratory control and facilitates the heparin therapy regimen. Among the representatives of the group, enoxaparin is the most studied. It has been shown that the combined use of enoxaparin and thrombolytic therapy is associated with additional clinical benefits for the patient. In addition, if anticoagulant therapy is expected to be carried out for more than 48 hours, then the use of unfractionated heparin is associated with a high risk of thrombocytopenia formation. Enoxaparin for a non-invasive treatment strategy for ACS is used according to the following scheme: intravenous bolus of 30 mg, then subcutaneously at a dose of 1 mg / kg 2 times a day; ki until the 8th day of illness. The first 2 doses for subcutaneous administration should not exceed 100 mg. In persons over 75 years of age, the initial intravenous dose is not administered, and the maintenance dose is reduced to 0.75 mg / kg (the first 2 doses should not exceed 75 mg). When creatinine clearance is less than 30 ml / min, the drug is administered subcutaneously at a dose of 1 mg / kg once a day. With an invasive approach to the treatment of ACS for the introduction of enoxaparin, it is necessary to remember the following: if no more than 8 hours have passed after a subcutaneous injection of 1 mg / kg, additional administration is not required. If this period is 8-12 hours, then immediately before the procedure, enoxaparin should be administered intravenously at a dose of 0.3 mg / kg. Fondaparinux The Scottish national guidelines for the treatment of ACS provide instructions on the need for immediate administration of fondaparinux after the establishment of electrocardiological signs of ACS: patients with ACS with elevation of the BT segment who will not receive reperfusion therapy should receive fondaparinux immediately. These recommendations, however, do not speak directly about the need for administration at the prehospital stage, but only paraphrase the words of the instructions, which indicate: the recommended dose is 2.5 mg once a day. The first dose is administered intravenously, all subsequent doses are administered subcutaneously. Treatment should begin as early as possible after diagnosis and continue for 8 days or until the patient is discharged. Table 9. Doses of beta-blockers when used in patients with ACS at the prehospital stage Drug Dose Metoprolol succinate IV, 5 mg 2-3 times with an interval of at least 2 minutes; first ingestion 15 minutes after intravenous administration Propranolol 0.1 mg / kg IV for 2-3 doses at intervals of at least 2-3 minutes; first ingestion 4 hours after intravenous administration Esmolol IV infusion at an initial dose of 0.05-0.1 mg / kg / min, followed by a gradual increase in the dose by 0.05 mg / kg / min every 10-15 minutes until an effect or dose of 0.3 mg / kg / min is achieved; for a more rapid onset of the effect, an initial administration of 0.5 mg / kg for 2-5 minutes is possible. Esmolol is usually discontinued after a second dose of an oral β-blocker, if proper heart rate and blood pressure have been maintained during their combined use Application. Decision checklist by the medical and paramedic team of the emergency medical service on conducting a patient with acute coronary syndrome (ACS) TLT Check and mark each of the indicators in the table. If all the boxes in the "Yes" column are marked and none in the "No" column, then the patient is shown thrombolytic therapy. If there is even one unmarked box in the "Yes" column, TLT therapy should not be carried out and the checklist can be stopped "Well no" The patient is oriented, can communicate Pain syndrome characteristic of ACS and / or its equivalents lasting at least 15-20 minutes, but not more than 12 hours After the disappearance of pain syndrome characteristic of ACS and / or its equivalents, no more than 3 hours have passed. registration of ECG in 12 leads The doctor / paramedic of the EMS has experience in assessing changes in the BT segment and blockade of the bundle of His bundle on the ECG (test only in the absence of a remote ECG evaluation by a specialist) There is an elevation of the BT segment by 1 mm or more in two or more adjacent ECG leads or a blockade of the left bundle branch was registered, which the patient did not have before. The doctor / paramedic of the EMS has experience in TLT. Transportation of the patient to the hospital will take more than 30 minutes. medical recommendations of the in-patient cardioreanimatologist in real time During the transportation of the patient, it is possible to continuously monitor the ECG (at least in one lead), intravenous infusion (a catheter is installed in the cubital vein) and urgent use of a defibrillator Age over 35 years for men and over 40 years for women Systolic blood pressure does not exceed 180 mm Hg Diastolic blood pressure does not exceed 110 mm Hg. The difference in systolic blood pressure levels measured on the right and left hand does not exceed 15 mm Hg. Art. The history does not indicate a stroke or the presence of other organic (structural) brain pathology.There are no clinical signs of bleeding of any localization (including gastrointestinal and urogenital) or manifestations of hemorrhagic syndrome. The submitted medical documents do not contain data on the patient's long-term (more than 10 minutes ) cardiopulmonary resuscitation or the presence of internal bleeding in the last 2 weeks; the patient and his relatives confirm this In the submitted medical documents, there is no data on the transferred for the last 3 months. surgery (including on the eyes using a laser) or serious injury with hematomas and / or bleeding, the patient confirms this The submitted medical documents do not contain data on the presence of pregnancy or the terminal stage of any disease and the survey and examination data confirm this The submitted medical documents do not contain data on the presence of jaundice, hepatitis, renal failure in the patient, and the data from the survey and examination of the patient confirm this. : TLT patient ____________________________________________________ (full name) SHOWN CONTRAINDICATED (circle necessary, cross out unnecessary) The sheet was filled out by: Doctor / paramedic (circle the required) __________________________ (full name) Date _________________ Time _____________ Signature ___ The checklist is transferred with the patient to the hospital and filed in the medical history Time of initiation of antithrombotic therapy in a patient with ACS It should be emphasized that the earlier antithrombotic treatment of a patient with ACS is started, the greater the likelihood of a successful clinical outcome. That is why the use of antiplatelet agents (aspirin, clopidogrel) and anticoagulants should be started already at the pre-hospital stage. Other medicines Beta-blockers In order to reduce myocardial oxygen demand in ACS, it is necessary to prescribe beta-adrenergic blockers. At the prehospital stage, it is advisable to use intravenous forms of beta-blockers both for the speed of the onset of the clinical effect, and for the possibility of a rapid decrease in the effect in case of possible side effects (Tables 8, 9). ACE inhibitors During the first 24 hours after the development of ACS, it is advisable to use drugs from the group of blockers of the activity of the renin-angiotensin system - ACE inhibitors or angiotensin receptor antagonists. However, the initiation of such therapy is recommended after the patient is admitted to the hospital. Conclusion The pre-hospital stage of providing medical care to patients with ACS and elevation of the 5T segment is the foundation for successful treatment and a favorable patient prognosis. Training of specialists in medical diagnostic algorithms will reduce cardiovascular morbidity and mortality in the Russian Federation. Literature 1. Diagnostics and treatment of patients with acute myocardial infarction with ST segment elevation ECG. V. Oganov R.G., Mamedov M.N., editors. National clinical guidelines. M .: MEDI Expo; 2009. 2. Van de Werf F, Bax J., Betriu A. et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 2008; 29 (23): 2909-45. 3. Dudek D., Rakowski T, Dziewierz A. et al. PCI after lytic therapy: when and how? Eur Heart J Suppl 2008; 10 (suppl J): J15-J20. 4. Scottish Intercollegiate Guidelines Network. Acute coronary syndromes. A national clinical guideline. Available on http://www.sign.ac.uk/pdf/sign93.pdf. 5. Chazov E.I., Boytsov S.A., Ipatov P.V. Large-scale task. Improvement of ACS treatment technology as the most important mechanism for reducing cardiovascular mortality in the Russian Federation. Modern medical technologies 2008; (1): 35-8. Acute coronary syndrome (abbreviated as ACS for simplicity) is a working diagnosis used by emergency and ambulance doctors. In fact, it combines two diseases - unstable angina pectoris and true myocardial infarction. We recommend reading:Causes of Acute Coronary Syndrome
The second mechanism is complete detachment of the plaque and blockage of the coronary arteries by it. In this case, the blood flow completely stops and the phenomena of ischemia and later necrosis are rapidly increasing in the heart muscle. Myocardial infarction develops. The third mechanism is the onset of a powerful spasm of the coronary arteries under the influence of catecholamines released in response to stress. The process arising from the intake of certain drugs with a vasoconstrictor effect is similar to it. Symptoms of the disease
The main clinical symptom of ACS is pain behind the sternum, varied both in intensity and sensation. It can be squeezing, pressing, burning - these are the most typical forms of pain. Stress, physical exertion, emotional stress, the intake of certain medications and narcotic substances (amphetamines, cocaine) provoke an attack of ischemia. Often it is not localized only behind the sternum, but gives it to various regions of the body - the neck, left arm, scapula, back, lower jaw. Situations are possible when pain is felt exclusively in the upper abdomen, simulating the clinical picture, for example, of acute pancreatitis. In this case, instrumental and laboratory studies contribute to the diagnosis. Nevertheless, the abdominal form of myocardial ischemia is still the most difficult to diagnose.
The second most common symptom is shortness of breath. Its occurrence is associated with a decrease in the functions of the heart for pumping blood. The appearance of this clinical sign indicates a high likelihood of life-threatening acute heart failure with pulmonary edema. The third symptom is the occurrence of various arrhythmias. Sometimes, cardiac arrhythmias are the only symptom of impending myocardial infarction, which can be painless. In this case, there is also a high risk of developing fatal complications in the form of cardiac arrest or cardiogenic shock, with the subsequent death of the patient. How is ACS detected
An ambulance doctor or general practitioner suspects ACS based on:
However, the main diagnostic criterion is the duration of chest pain. If the pain syndrome lasts more than 20 minutes, the patient is given a preliminary diagnosis of ACS. Depending on the ECG signs, it can be supplemented with information about the presence or absence of the ST segment elevation. Emergency care for acute coronary syndromeThe patient's chances of survival are the higher, the sooner he is provided with emergency care in acute coronary syndrome. Even if ACS subsequently develops into myocardial infarction, timely medical intervention will limit the area of \u200b\u200bnecrosis and reduce the consequences of the disease. WHO proposes the following algorithm for emergency interventions:
In addition to these measures, actions are taken to eliminate complications such as arrhythmias, impending or existing pulmonary edema, cardiogenic shock, etc. After stabilization of the patient's condition, he is urgently hospitalized in a hospital where there are conditions for thrombolysis (destruction of a blood clot), and in the absence of such a medical institution within the reach - to any hospital with an intensive care unit or intensive care unit. It should be remembered that the life of the patient depends on the timely provision of emergency care at the prehospital stage. World practice shows that most deaths from myocardial infarction occur before the arrival of specialized medical teams. For this reason, any patient with coronary artery disease should be trained both in recognizing the first signs of acute coronary syndrome and in self-help tactics at the onset of an attack.
Acute coronary syndrome Chest pain Acute coronary syndrome No ST elevation No troponin Unstable angina ST elevation MV SK MI with ST elevation One cause of disease but other clinical manifestations and other treatment strategies Troponin positon MI without ST elevation
Intracoronary thrombosis changes in the geometry of the plaque distal embolization local spasm Pathogenesis of acute coronary syndrome Emergence / worsening of myocardial ischemia Symptoms of exacerbation of coronary artery disease (acute coronary syndrome) Spasm of the coronary artery at the site of stenosis without visible stenosis of oxygen delivery to the myocardium in case of significant stenosis Ruptured wound atrial myocardium with significant stenosis
The main tasks facing the first examination Providing emergency care Assessment of the alleged cause of chest pain (ischemic or non-ischemic) Assessment of the immediate risk of life-threatening conditions Determination of the indication and place of hospitalization.
MULTICENTER RESEARCH OF CHEST PAIN% Stabbing pain in the chest Pain with lesions of the pleura Pain on palpation ACUTE MYOCARDIAL ISCHEMIA WAS DETECTED AT…. Lee T., Cook E., et al. 1985
DOCTOR'S TACTICS FOR ACS IN THE PREHOSITIONAL STAGE Initial assessment of patients with chest pain. Differential diagnosis. Indication for hospitalization and transportation. Pre-hospital assessment of the risk of death and development of AMI in patients with ACS without ST-segment elevation.
Acute risk of adverse outcomes in ACS without ST (assessed by follow-up) High Low recurrent angina dynamic ST segment displacements (more common, the worse the prognosis) early postinfarction angina cardiac troponins (the higher, the worse the prognosis) diabetes mellitus hemodynamic instability severe arrhythmias during follow-up ischemia does not resume no ST segment depressions no markers of myocardial necrosis normal level of cardiac troponin when measured twice with an interval of at least 6 hours Risk stratification in ACS without ST Eur Heart J 2002; 23:
DOCTOR'S TACTICS FOR ACS IN THE PREHOSITIONAL STAGE Initial assessment of patients with chest pain. Differential diagnosis. Indication for hospitalization and transportation. Pre-hospital assessment of the risk of death and MI in patients with ACS. Treatment of CSCs at the prehospital stage.
90 If ineffective, after 5 minutes Morphine (especially with agitation, acute heart failure) IV 2-4 mg + 2-8 mg every 5-15 minutes or 4-8 mg + 2 mg every "title \u003d" (! LANG : Providing emergency care Anesthesia Nitroglycerin 0.4 mg p / i or spray for systolic blood pressure\u003e 90 If ineffective, after 5 minutes Morphine (especially with agitation, acute heart failure) IV 2-4 mg + 2-8 mg every 5- 15 min or 4-8 mg + 2 mg every" class="link_thumb"> 18 !} Providing emergency care Anesthesia Nitroglycerin 0.4 mg p / i or spray for systolic blood pressure\u003e 90 If ineffective, after 5 minutes Morphine (especially with agitation, acute heart failure) IV 2-4 mg mg every 5-15 minutes or 4- 8 mg + 2 mg every 5 minutes or 3-5 mg until pain relief IV nitroglycerin with blood pressure\u003e 90 mm Hg, if there is pain, acute pulmonary congestion, high blood pressure Nitroglycerin 0.4 mg p / i or spray with SBP\u003e 90 With ineffectiveness "03" 90 If ineffective, after 5 minutes Morphine (especially with agitation, acute heart failure) IV 2-4 mg + 2-8 mg every 5-15 minutes or 4-8 mg + 2 mg every "\u003e 90 If ineffective, after 5 min Morphine (especially with agitation, acute heart failure) IV 2-4 mg + 2-8 mg every 5-15 minutes or 4-8 mg + 2 mg every 5 minutes or 3-5 mg until pain relief B \\ into nitroglycerin with blood pressure\u003e 90 mm Hg, if there is pain, acute congestion in the lungs, high blood pressure Nitroglycerin 0.4 mg p / i or spray with blood pressure\u003e 90 With ineffectiveness "03" "\u003e 90 With ineffectiveness, after 5 minutes Morphine (especially with agitation, acute heart failure) IV 2-4 mg + 2-8 mg every 5-15 minutes or 4-8 mg + 2 mg every "title \u003d" (! LANG: Emergency care Pain relief Nitroglycerin 0, 4 mg p / i or spray for systolic blood pressure\u003e 90 If ineffective, after 5 minutes Morphine (especially with agitation, acute heart failure) IV 2-4 mg + 2-8 mg every 5-15 minutes or 4-8 mg + 2 mg every"> title="Emergency care Anesthesia Nitroglycerin 0.4 mg p / i or spray for systolic blood pressure\u003e 90 If ineffective, after 5 min Morphine (especially with agitation, acute heart failure) IV 2-4 mg + 2-8 mg every 5-15 min or 4-8 mg + 2 mg every"> !}
12.5 6.4 5.3 2.0 Influence of aspirin and heparin on the sum of deaths and myocardial infarction in ACS without ST Meta-analysis of conducted studies p \u003d 0.0005 Aspirin 5 days-2 years Heparin 1 week No treatment% n \u003d 2488 n \u003d 2629
Factors influencing the choice of antithrombotic treatment for ACS without persistent ST The nature of myocardial ischemia and time after the last episode Risk of poor outcome (MI, death) in the near future Approach to patient management invasive conservative Clinical judgment on the presence of ongoing intracoronary thrombosis Risk of bleeding Renal function
Initial Dose Long-term use Class European Society of Cardiology, ACS without ST (2002) with clopidogrel I (A) I (A) American College of Cardiology and Heart Association, ACS without ST (2002) I (A) I (A) Russian recommendations, ACS without ST (2004), then (150) - European Society of Cardiology, antiplatelet agents (2004) I (A) I (A) American College of Thoracic Physicians (2004) I (A) I ( A) Eur Heart J 2002; 23: Circulation 2002; 106: Chest 2004; 126: 513S-548S. Eur Heart J 2004; 25: Cardiology 2004, supplement. Aspirin for ACS without ST. Modern guidelines
Heparin in ACS without persistent ST on ECG for pain IV infusion of UFH SC injections of LMWH High risk of thrombotic complications ST troponin ... No signs of high risk of thrombotic complications no ST normal troponin (twice with an interval of\u003e 6 hours) Observation 6-12 hours Introduction from 2 to 8 days (according to the doctor's decision) Cancellation of heparin 6 hours "\u003e 6 hours) Observation 6-12 hours Introduction from 2 to 8 days (by the doctor's decision) Cancellation of heparin"\u003e 6 hours "title \u003d" (! LANG: Heparin for ACS without persistent ST on ECG 48-72 hours from pain I / V infusion of UFH SC injections of LMWH High risk of thrombotic complications ST troponin ... No evidence of high risk of thrombotic complications No ST normal troponin (twice with an interval of\u003e 6 h"> title="Heparin in ACS without persistent ST on ECG 48-72 h of pain IV infusion of UFH SC injections of LMWH High risk of thrombotic complications ST troponin ... No evidence of high risk of thrombotic complications no ST normal troponin (twice with an interval of\u003e 6 h"> !} Circulation 2003; 107: 966–72 0.00 0.02 0.04 0.06 0.08 0.10 0.12 0, Months 9.3% 11.4% C-s death, MI, stroke, severe ischemia Aspirin Hours after randomization Aspirin + clopidogrel risk 34% p \u003d 0.003 Risk of event Heparin in 92%, of which LMWH 54% Clopidogrel addition in ACS without ST CURE study (n \u003d 12 562)
Clopidogrel in addition to aspirin for non-ST ACS Current guidelines Duration Class European Society of Cardiology (2002) minimum 9 months possibly 12 months I (B) I (B) American College of Cardiology and Heart Association (2002) minimum 1 month to 9 month I (A) I (B) I (A) I (B) Russian guidelines (2004) about 1 year - American College of Thoracic Physicians (2004) 9-12 months I (A) I (A) European Cardiology society, PCI (2005) 9-12 months I (B) I (B) Clopidogrel (loading dose 300 mg, then 75 mg / day) as early as possible Eur Heart J 2002; 23: Circulation 2002; 106: Chest 2004; 126: 513S-548S. Cardiology 2004, supplement. Eur Heart J 2005; 26:
Clinical variants of MI% status anginosus status asthmaticus status gastralgicus arrhythmic cerebral asymptomatic, 6 10.5 6.7 14.3 - 2.9 616 people 105 people A.L. Syrkin.
The clinical picture of ACS; - the appearance of pathological Q waves on the ECG; - ECG changes, indicating the appearance of myocardial ischemia: the occurrence of elevation or depression of the ST segment, blockade of LPH; Necessary and sufficient signs for the diagnosis of AMI One of the following criteria is sufficient for the diagnosis of AMI:
50% of deaths from STEMI occur in the first 1.5-2 hours from the onset of an anginal attack, and most of these patients die before the arrival of the emergency team. Therefore, the greatest efforts should be made so that first aid is provided to the patient as early as possible, and so that the volume of this aid is optimal.
A two-stage system, when, upon suspicion of MI, the linear ambulance team calls upon itself a "specialized" one, which actually begins treatment and transports the patient to the hospital, leads to an unjustified loss of time. Each ambulance team (including the paramedic) must be ready for active treatment STEMI patient Organization of EMS work in AMI Treatment of a STEMI patient is a single process that begins at the prehospital stage and continues in the hospital. For this, the ambulance teams and hospitals where ACS patients are admitted must work according to a single algorithm based on common principles of diagnosis, treatment and a common understanding of tactical issues.
Any ambulance team, having diagnosed ACS, having determined the indications and contraindications for appropriate treatment, should stop the pain attack, begin antithrombotic treatment, including the administration of thrombolytics (if invasive restoration of coronary artery patency is not planned), and with the development of complications, cardiac arrhythmias or acute cardiac insufficiency - the necessary therapy, including measures for cardiopulmonary resuscitation, Emergency care teams in each locality should have clear instructions to which hospitals to transport patients with STEMI or suspected STEMI Doctors of these hospitals, if necessary, provide emergency medical services with appropriate advice.
1. Portable ECG with autonomous power supply; 2. Portable device for EIT with autonomous power supply with heart rate control; 3. Set for cardiopulmonary resuscitation, including a manual ventilator; 4. Equipment for infusion therapy, including infusomats and perfusers; 5. Set for the installation of an IV catheter; 6. Cardioscope; 7. Pacemaker; 8. System for remote ECG transmission; 9. Mobile communication system; 10. Suction; 11. Medicines required for basic therapy of AMI The linear EMS team must be equipped with the necessary equipment
Each ambulance team (including the paramedic) must be ready to actively treat the patient with STEMI Treatment of uncomplicated STEMI at the prehospital stage Basic therapy. 1. Eliminate pain syndrome. 2. Chew a tablet containing 250 mg ASA. 3. Take 300 mg of clopidogrel by mouth. 4. Start IV infusion of NG, primarily with persistent angina pectoris, AH, AHF. 5. Start treatment with b-blockers. Preferably the initial intravenous administration, especially with ischemia, which persists after intravenous administration of narcotic analgesics or recurs, hypertension, tachycardia or tachyarrhythmia, without HF. It is supposed to perform primary TBA. Loading dose of clopidogrel mg.
90 If ineffective, after 5 minutes Morphine (especially with agitation, acute heart failure) IV 2-4 mg + 2-8 mg every 5-15 minutes or 4-8 mg + 2 mg every "title \u003d" (! LANG : Providing emergency care Anesthesia Nitroglycerin 0.4 mg p / i or spray for systolic blood pressure\u003e 90 If ineffective, after 5 minutes Morphine (especially with agitation, acute heart failure) IV 2-4 mg + 2-8 mg every 5- 15 min or 4-8 mg + 2 mg every" class="link_thumb"> 38 !} Providing emergency care Anesthesia Nitroglycerin 0.4 mg p / i or spray for systolic blood pressure\u003e 90 If ineffective, after 5 minutes Morphine (especially with agitation, acute heart failure) IV 2-4 mg mg every 5-15 minutes or 4- 8 mg + 2 mg every 5 minutes or 3-5 mg until pain relief IV nitroglycerin with blood pressure\u003e 90 mm Hg, if there is pain, acute pulmonary congestion, high blood pressure Nitroglycerin 0.4 mg p / i or spray with SBP\u003e 90 With ineffectiveness "03" 90 If ineffective, after 5 minutes Morphine (especially with agitation, acute heart failure) IV 2-4 mg + 2-8 mg every 5-15 minutes or 4-8 mg + 2 mg every "\u003e 90 If ineffective, after 5 min Morphine (especially with agitation, acute heart failure) IV 2-4 mg + 2-8 mg every 5-15 minutes or 4-8 mg + 2 mg every 5 minutes or 3-5 mg until pain relief B \\ into nitroglycerin with blood pressure\u003e 90 mm Hg, if there is pain, acute congestion in the lungs, high blood pressure Nitroglycerin 0.4 mg p / i or spray with blood pressure\u003e 90 With ineffectiveness "03" "\u003e 90 With ineffectiveness, after 5 minutes Morphine (especially with agitation, acute heart failure) IV 2-4 mg + 2-8 mg every 5-15 minutes or 4-8 mg + 2 mg every "title \u003d" (! LANG: Emergency care Pain relief Nitroglycerin 0, 4 mg p / i or spray for systolic blood pressure\u003e 90 If ineffective, after 5 minutes Morphine (especially with agitation, acute heart failure) IV 2-4 mg + 2-8 mg every 5-15 minutes or 4-8 mg + 2 mg every"> title="Emergency care Anesthesia Nitroglycerin 0.4 mg p / i or spray for systolic blood pressure\u003e 90 If ineffective, after 5 min Morphine (especially with agitation, acute heart failure) IV 2-4 mg + 2-8 mg every 5-15 min or 4-8 mg + 2 mg every"> !} Possible complications when using morphine Severe hypotension. A horizontal position combined with raising the legs (if there is no pulmonary edema). If ineffective, IV - 0.9% NaCl solution or other plasma expanders. In rare cases, pressor drugs. Severe bradycardia in combination with hypotension; eliminated by atropine (intravenously 0.5-1.0 mg). Nausea, vomiting; eliminated by phenothiazine derivatives, in particular, metoclopramide (intravenously 5-10 mg). Severe respiratory depression; eliminated by naloxone (intravenously 0.1-0.2 mg, if necessary again after 15 minutes), however, the analgesic effect of the drug also decreases.
Nitrates in acute myocardial infarction Indications for the use of nitrates myocardial ischemia acute pulmonary congestion the need to control blood pressure p / i (spray) 0.4 mg up to 3 times every 5 minutes i / v infusion (5-200 BP by 10% in normotonics, up to 30% with hypertension) inside while maintaining ischemia SBP 30 mm Hg below baseline heart rate 100 suspected right ventricular infarction
Lancet 1995; 345: Nitrates in early MI Meta-analysis (n \u003d 81,908) 9 small, by mouth 11 small, i.v. GISSI-3 ISIS-4 All studies Nitrate Risk control 5.5% p \u003d 0.03
Prehospital triple antiplatelet therapy On-TIME 2 trial data Prehospital IH IIb / IIIa tirofiban (25 μg / kg bolus followed by 0.15 μg / kg / min infusion for 18 hours) or placebo in addition to aspirin (500 mg intravenously), clopidogrel (600 mg orally) and intravenous bolus (5000 IU) UFH p \u003d 0.043 p \u003d 0.051 p \u003d 0.581
Restoration of coronary perfusion The mainstay of treatment for acute MI is restoration of coronary blood flow — coronary reperfusion. The destruction of the thrombus and the restoration of myocardial perfusion lead to a limitation of the extent of its damage and, ultimately, to an improvement in the short and long term prognosis. Therefore, all STEMI patients should be promptly evaluated to clarify the indications and contraindications for the restoration of coronary blood flow. Russian recommendations. Diagnostics and treatment of patients with acute myocardial infarction with ST segment elevation ECG, VNOK
Efficiency of TLT in MI, depending on the time of initiation of treatment 65 * Lives saved per 1000 treated 37 * 29 * 18 * 0-1 h 1-2 h 2-3 h 3-6 h Lancet 1996; 348: Death in the first 35 days 26 * h Time from the onset of symptoms to the administration of a fibrinolytic n \u003d * p
The emergence of pain Decision to call an ambulance Arrival to the hospital Arrival in the emergency room Diagnosis SK PTCA Metallize at the prehospital stage Prehospital thrombolysis: gain in time \u003d saving the myocardium Actilize Metallize in the emergency room "Early thrombolysis" strategy ambulance Ambulance arriving Diagnosis
USIC 2000: Reducing Mortality in Prehospital Thrombolysis Danchin et al. Circulation 2004; 110: 1909 - Mortality (%) Dogosp. TLTL in hospital PCI Without reperfusion therapy
Choice of strategy WEST survey, n \u003d 304% EHJ, 2006; 27,
VIENNA STEMI REGISTRY: Change in reperfusion strategy VIENNA 2003/2004 VIENNA 2002 Kalla et al. Circulation 2006; 113: 2398 - Patients (%) PCI Without reperfusion Thrombolysis
Kalla et al. Circulation 2006; 113: 2398-2405. VIENNA STEMI REGISTRY: Time from disease onset to treatment with different THROMBOLYSIS PCI strategies 0-2 h 2-6 h Patients (%) 6-12 h
Years Eagle et al. 2007, Submitted GRACE REGISTRY Reperfusion therapy No reperfusion PCI only TLT only Patients (%)
Prehospital treatment of uncomplicated STEMI Prehospital thrombolytic therapy. It is carried out in the presence of indications and the absence of contraindications. When using streptokinase at the discretion of the physician, direct-acting anticoagulants can be used as concomitant therapy. If the use of anticoagulants is preferred, UFH, enoxaparin, or fondaparinux may be chosen. When using fibrin-specific thrombolytics, enoxaparin or UFH should be used. Reperfusion therapy is not expected. The decision on the advisability of using direct anticoagulants may be postponed until admission to the hospital. Russian recommendations. Diagnostics and treatment of patients with acute myocardial infarction with ST segment elevation ECG, VNOK
Indications for TLT If the time from the onset of an anginal attack does not exceed 12 hours, and the ECG shows an elevation of the ST segment of 0.1 mV, at least in 2 consecutive chest leads or in 2 leads from the extremities, or a blockade of LPH appears. The introduction of thrombolytics is justified at the same time with ECG signs of true posterior MI (high R waves in the right precordial leads and depression of the ST segment in leads V1-V4 with an upward T wave). Russian recommendations. Diagnostics and treatment of patients with acute myocardial infarction with ST segment elevation ECG, VNOK
Contraindications for TLT Absolute contraindications for TLT Previous hemorrhagic stroke or CCD of unknown etiology; ischemic stroke, suffered within the last 3 months; brain tumor, primary and metastatic; suspicion of aortic dissection; the presence of signs of bleeding or hemorrhagic diathesis (with the exception of menstruation); significant closed head injuries in the last 3 months; changes in the structure of cerebral vessels, for example, arteriovenous malformation, arterial aneurysms Russian recommendations. Diagnostics and treatment of patients with acute myocardial infarction with ST segment elevation ECG, VNOK
Checklist for making a decision by the medical and paramedic team of the ambulance service to perform TLT for a patient with acute coronary syndrome (ACS) Check and mark each of the indicators in the table. If all the boxes in the "Yes" column are marked and none in the "No" column, then the patient is shown thrombolytic therapy. If there is even one unmarked box in the “Yes” column, TLT therapy should not be performed and the checklist can be stopped. "Yes" "No" The patient is oriented, can communicate Pain syndrome characteristic of ACS and / or its equivalents lasting at least min., But no more than 12 hours After the disappearance of pain syndrome characteristic of ACS and / or its equivalents, no more than 3 hours have passed. high-quality ECG registration in 12 leads The EMS doctor / paramedic has experience in assessing ST segment changes and bundle branch blockade on an ECG (test only in the absence of a remote ECG evaluation by a specialist) There is a ST segment elevation by 1 mm or more in two or more adjacent ECG leads or a blockade of the left bundle branch was registered, which the patient did not have before. The doctor / paramedic of the EMS has experience in performing TLT. Transportation of the patient to the hospital will take more than 30 minutes. ECG monitoring (at least one lead), intravenous infusion th (a catheter is installed in the cubital vein) and urgent use of a defibrillator
CONCLUSION: TLT to the patient _____________________________ (full name) SHOWN CONTRAINDICATED (circle the necessary, cross out the unnecessary) The sheet was filled out by: Doctor / paramedic (circle the necessary) _________________________ (full name) Date ____________ Time _________ Signature _____________ The checklist is transferred with the patient to the hospital history and is filed 35 years for men and over 40 for women Systolic blood pressure does not exceed 180 mm Hg. Art. Diastolic blood pressure does not exceed 110 mm Hg. Art. The difference in systolic blood pressure levels measured on the right and left hand does not exceed 15 mm Hg. Art. The history does not indicate a stroke or the presence of other organic (structural) brain pathology.There are no clinical signs of bleeding of any localization (including gastrointestinal and urogenital) or manifestations of hemorrhagic syndrome. ) cardiopulmonary resuscitation or the presence of internal bleeding in the last 2 weeks; the patient and his relatives confirm this. In the submitted medical documents there is no data on the transferred over the last 3 months. surgery (including on the eyes using a laser) or serious injury with hematomas and / or bleeding, the patient confirms this The submitted medical documents do not contain data on the presence of pregnancy or the terminal stage of any disease and the survey and examination data confirm this The submitted medical documents do not contain data on the presence of jaundice, hepatitis, renal failure in the patient, and the data from the survey and examination of the patient confirm this.
Thrombolytic drugs Alleplaza Intravenous 1 mg / kg body weight (but not more than 100 mg): bolus 15 mg; subsequent infusion of 0.75 mg / kg of body weight in 30 minutes (but not more than 50 mg), then 0.5 mg / kg (but not more than 35 mg) in 60 minutes (total duration of infusion 1.5 hours). Purolaza Intravenous: bolus of ME followed by infusion of ME for min. Streptokinase Intravenous infusion (IU per minute). Tenecteplase Intravenous bolus: 30 mg at a weight of 90 kg. Russian recommendations. Diagnostics and treatment of patients with acute myocardial infarction with ST segment elevation ECG, VNOK
Evolution of thrombolysis First generation Second generation Third generation Streptokinase allergenic not selective to fibrin Continuous intravenous infusion Actilise "gold standard" fibrin selectivity not allergenic Metalysis Equivalent to Alteplase High fibrin specificity Single bolus 5-10 seconds
Meta-analysis of studies with early intravenous administration of beta-blockers in MI (n \u003d 52 411) Lancet 2005; 366:% -22% -15% Death Recurrent MI VF and other causes of cardiac arrest
IV% 50% BETA-BLOCKERS: APPLICATION IN PATIENTS WITH ACS IN 59 RUSSIAN CENTERS GRACE register data (years) N \u200b\u200b\u003d 2806 C ST –50.3% Without ST - 49.7% C ST Without ST 0% IV 4.3% 100 % 50% 0% Previous 7 days First 24 hours. During the period of hospitalization Recommended. at discharge
Beta-blockers in STEMI Drug Dose Treatment on the 1st day of the disease Metoprolol IV 5 mg 2-3 times with an interval of at least 2 min; First oral administration 15 minutes after intravenous administration. Propronolol V / in 0.1 mg / kg for 2-3 doses at intervals of at least 2-3 minutes; First oral administration 4 hours after intravenous administration. Esmolol IV infusion at an initial dose of 0.05-0.1 mg / kg / min, followed by a gradual increase in the dose by 0.05 mg / kg / min every 10-15 minutes until an effect or dose of 0.3 mg / kg is achieved. min; for a more rapid onset of the effect, an initial administration of 0.5 mg / kg for 2–5 minutes is possible. Emolol is usually canceled after the second dose of an oral β-blocker, if during their combined use the correct heart rate and blood pressure were maintained.
5) Negative T on baseline ECG (%) 3,451,730,49 (0.12-2.11) "title \u003d" scale (! LANG: GKB 29 (n \u003d 58) Other centers (n \u003d 1917) Odds ratio (confidence interval) Time from onset of symptoms before hospitalization (hours) 5,482.83 ST elevations on baseline ECG (%) 86,293.82.45 (1.13-\u003e 5) Negative T on baseline ECG (%) 3,451,730.49 (0.12-2.11) Scale" class="link_thumb"> 68 !} HKB 29 (n \u003d 58) Other centers (n \u003d 1917) Odds ratio (confidence interval) Time from symptom onset to hospitalization (hours) 5,482,83 ST elevations on baseline ECG (%) 86,293,82.45 (1.13-\u003e 5) Negative T on baseline ECG (%) 3,451,730,49 () GRACE scale: proportion of patients at risk of death \u003d 10% 10,319,42.08 () Killip class I-II (%) 93.193,10.99 () III (%) 5,173, () IV (%) 02, () OKS P ST Data on admission to the hospital RUSSIAN REGISTER OF ACUTE CORONARY SYNDROMES (RECORD) 5) Negative T on baseline ECG (%) 3,451,730.49 (0.12-2.11) Scale "\u003e 5) Negative T on baseline ECG (%) 3,451,730.49 (0.12-2.11) GRACE scale: proportion of patients at risk of death \u003d 10% 10,319,42.08 (0.89-4.88) Killip class I-II (%) 93.193,10.99 (0.35-2.78) III (%) 5,173,860.74 (0.23-2.41) IV (%) 02,741.81 (0.25-13.3) OKS P ST Data on admission to the hospital RUSSIAN REGISTER OF ACUTE CORONARY SYNDROMES (RECORD) "\u003e 5) Negative T on the baseline ECG (%) 3,451,730,49 (0.12-2.11) Scale" title \u003d "(! LANG: GKB 29 (n \u003d 58) Other centers (n \u003d 1917) Odds ratio (confidence interval) Time from symptom onset to hospitalization (hours) 5,482.83 ST elevations on baseline ECG (%) 86,293.82.45 (1.13-\u003e 5) Negative T on baseline ECG (%) 3,451,730 , 49 (0.12-2.11) Scale"> title="HKB 29 (n \u003d 58) Other centers (n \u003d 1917) Odds ratio (confidence interval) Time from symptom onset to hospitalization (hours) 5,482,83 ST elevations on baseline ECG (%) 86,293,82.45 (1.13-\u003e 5) Negative T on the initial ECG (%) 3,451,730,49 (0.12-2.11) Scale"> !} 5 Anticoagulants (%) 81,094,03.69 (1.86-\u003e 5) LMWH (%) 062,4 "title \u003d" (! LANG: GKB 29 (n \u003d 58) Other centers (n \u003d 1917) Odds ratio (confidence interval) Primary reperfusion (%) 27.675.7 Primary PCI (%) 047.9 TLT: Streptokinase (%) 24.15.00.17 (0.09-0.31) T-PA (%) 3.522.8\u003e 5 Anticoagulants (%) 81.094.03.69 (1.86-\u003e 5) LMWH (%) 062.4" class="link_thumb"> 69 !} HKB 29 (n \u003d 58) Other centers (n \u003d 1917) Odds ratio (confidence interval) Primary reperfusion (%) 27.675.7 Primary PCI (%) 047.9 TLT: Streptokinase (%) 24.15.00.17 () T-PA (%) 3.522.8\u003e 5 Anticoagulants (%) 81.094.03.69 (1.86-\u003e 5) LMWH (%) 062.4 UFH (%) 10050.5 Fondaparinux (%) 00.1 Bivalirudin (%) 00 , 1 ACS P ST Primary reperfusion therapy and anticoagulant treatment RUSSIAN REGISTER OF ACUTE CORONARY SYNDROMES (RECORD) 5 Anticoagulants (%) 81.094.03.69 (1.86-\u003e 5) LMWH (%) 062.4 "\u003e 5 Anticoagulants (%) 81.094.03.69 (1.86-\u003e 5) LMWH (%) 062.4 UFH (%) 10050, 5 Fondaparinux (%) 00.1 Bivalirudin (%) 00.1 ACS P ST Primary reperfusion therapy and anticoagulant treatment RUSSIAN REGISTER OF ACUTE CORONARY SYNDROMES (RECORD) "\u003e 5 Anticoagulants (%) 81.094.03.69) (1.86-\u003e 5 %) 062.4 "title \u003d" (! LANG: GKB 29 (n \u003d 58) Other centers (n \u003d 1917) Odds ratio (confidence interval) Primary reperfusion (%) 27.675.7 Primary PCI (%) 047.9 TLT: Streptokinase (%) 24,15,00.17 (0.09-0.31) T-PA (%) 3,522,8\u003e 5 Anticoagulants (%) 81,094,03.69 (1.86-\u003e 5) LMWH (%) 062,4"> title="HKB 29 (n \u003d 58) Other centers (n \u003d 1917) Odds ratio (confidence interval) Primary reperfusion (%) 27.675.7 Primary PCI (%) 047.9 TLT: Streptokinase (%) 24.15.00.17 (0.09 -0.31) T-PA (%) 3.522.8\u003e 5 Anticoagulants (%) 81.094.03.69 (1.86-\u003e 5) LMWH (%) 062.4"> !} Practical approaches in the treatment of AMI Within minutes NPV, heart rate, blood pressure, O 2 saturation ECG monitoring Readiness for defibrillation and CPR Providing IV access 12-lead ECG Short aiming history, physical examination Emergency treatment morphine 2-4 mg in / in until the effect of O l / min to saturate O 2\u003e 90% aspirin (if not given earlier): chew 250 mg, in suppositories 300 mg or in / in 500 mg clopidogrel 300 mg, age 90, if there is pain, acute congestion in the lungs, high blood pressure solution to the issue of TLT !!! 90% aspirin (if not given earlier): chew 250 mg, in suppositories 300 mg or intravenous 500 mg clopidogrel 300 mg, age 90, if there is pain, acute congestion in the lungs, high blood pressure the decision on TLT !!! " \u003e |
Acute coronary syndrome One cause of disease but other clinical manifestations and other treatment strategies Retrosternal pain Acute coronary syndrome No ST elevation No troponin Unstable angina ST elevation Troponin position MV SK MI without ST elevation ST elevation MI
Pathogenesis of acute coronary syndrome Rupture of a vulnerable atherosclerotic plaque intracoronary thrombosis change in the geometry of the plaque distal embolization local spasm Spasm of the coronary artery at the site of stenosis without visible stenosis of myocardial oxygen demand with significant stenosis of oxygen delivery to the myocardium in case of significant stenosis Development / aggravation of acute symptoms coronary syndrome)
Treatment goals for acute coronary syndrome Improve mortality prognosis, frequency of MI complications Eliminate symptoms and syndromes pain HF arrhythmias ...
The main tasks facing the first examination § Providing emergency care § Assessment of the presumptive cause of chest pain (ischemic or non-ischemic) § Assessment of the immediate risk of developing life-threatening conditions § Determining the indication and place of hospitalization.
Physician's tactics for ACS at the prehospital stage. § Initial assessment of patients with chest pain. Differential diagnosis.
Differential diagnosis of chest pain is not only a clinical, but also an organizational problem solved in the diagnostic departments for patients with chest pain
DOCTOR'S TACTICS IN ACS AT THE PREHOSPITAL STAGE § Initial assessment of patients with chest pain. Differential diagnosis. §Indication to hospitalization and transportation.
The slightest suspicion (probable ACS) regarding the ischemic genesis of chest pain, even in the absence of characteristic electrocardiographic changes, should be the reason for the immediate transportation of the patient to the hospital.
DOCTOR'S TACTICS IN ACS AT THE PREHOSPITAL STAGE § Initial assessment of patients with chest pain. Differential diagnosis. §Indication to hospitalization and transportation. §Prehospital assessment of the risk of death and development of AMI in patients with ACS without ST-segment elevation.
Risk stratification in ACS without ST Acute risk of adverse outcomes in ACS without ST (assessed by follow-up) High recurrent angina dynamic displacements of the ST segment (the more common, the worse the prognosis) Low during follow-up ischemia does not recur no ST segment depression early postinfarction angina is not markers myocardial necrosis cardiac troponins (the higher, the worse the prognosis) normal cardiac troponin levels when measured twice with an interval of at least 6 hours diabetes mellitus hemodynamic instability severe arrhythmias Eur Heart J 2002; 23: 1809 -40
DOCTOR'S TACTICS IN ACS AT THE PREHOSPITAL STAGE § Initial assessment of patients with chest pain. Differential diagnosis. § Indication for hospitalization and transportation. §Pre-hospital assessment of the risk of death and MI in patients with ACS. § Treatment of USC at the prehospital stage.
Providing emergency care Anesthesia Nitroglycerin 0.4 mg p / i or spray with. BP\u003e 90 If ineffective, after 5 minutes Nitroglycerin 0.4 mg p / I or spray with. BP\u003e 90 With ineffectiveness "03" Morphine (especially with excitement, acute heart failure) IV 2 -4 mg + 2 -8 mg every 5 -15 minutes or 4 -8 mg + 2 mg every 5 minutes or 3 - 5 mg before pain relief IV nitroglycerin with blood pressure\u003e 90 mm Hg, if there is pain, acute pulmonary congestion, high blood pressure
The basic principles of treatment of patients with ACS without ST-segment elevation at the prehospital stage §Adequate pain relief §Antithrombotic therapy.
Influence of aspirin and heparin on the sum of deaths and myocardial infarction in ACS without ST Meta-analysis of conducted studies% p \u003d 0, 0005 12, 5 6, 4 5, 3 2, 0 n \u003d 2488 No treatment www. acc. org n \u003d 2629 Aspirin 5 days-2 years Heparin 1 week
Factors influencing the choice of antithrombotic treatment for ACS without persistent ST The nature of myocardial ischemia and the time of the last episode Risk of adverse outcome (MI, death) in the near future Approach to patient management invasive conservative Risk of bleeding Renal function Clinical judgment about the presence of ongoing intracoronary thrombosis
Aspirin for ACS without ST. Current recommendations Initial dose European Society of Cardiology, ACS without ST (2002) Long-term use 75 -150 ≤ 100 with clopidogrel Class I (A) American College of Cardiology and Heart Association, ACS without ST (2002) 162 -325 75 - 160 I (A) Russian recommendations, ACS without ST (2004) 250 -500 75 -325, then 75 -160 (150) - European Society of Cardiology, antiplatelet agents (2004) 160 -300 75 -100 I (A ) American College of Thoracic Physicians (2004) 160 -325 75 -162 I (A) Eur Heart J 2002; 23: 809 -40. Circulation 2002; 106: 893 -1900. Chest 2004; 126: 513 S-548 S. Eur Heart J 2004; 25: 166 -81. Cardiology 2004, supplement.
Heparin in ACS without persistent ST on ECG 48 -72 h from pain IV infusion of UFH SC injections of LMWH Observation 6-12 hours High risk of thrombotic complications No evidence of high risk of thrombotic complications ST troponin ... no ST normal troponin (twice with an interval \u003e 6 hours) Administration from 2 to 8 days (by doctor's decision) Cancellation of heparin
Clopidogrel addition in ACS without ST CURE study (n \u003d 12 562) C-c death, MI, stroke, severe ischemia risk 34% р \u003d 0, 003 11, 4% 0, 14 Risk of event 0, 12 Heparin in 92%, of which LMWH 54% Aspirin 0, 10 9, 3% 0, 08 Aspirin + clopidogrel 0, 06 0, 04 Hours after randomization 0, 02 0, 00 0 Circulation 2003; 107: 966 - 72 3 6 9 12 Months
Manifestations of myocardial ischemia Severe pain behind the sternum, constricting, pressing Perspiration, clammy cold sweat Nausea, vomiting Shortness of breath Weakness, collapse
Clinical variants of MI% 65, 6 status anginosus 89 status asthmaticus 7 10, 5 status gastralgicus 1 6, 7 arrhythmic 2 14, 3 cerebral 1 - asymptomatic - 2, 9 616 people 105 people Syrkin A.L.
Necessary and sufficient signs for the diagnosis of AMI One of the following criteria is sufficient for the diagnosis of AMI: - clinical picture of ACS; - the appearance of pathological Q waves on the ECG; - ECG changes, indicating the appearance of myocardial ischemia: the occurrence of elevation or depression of the ST segment, blockade of LPH;
50% of deaths from UTI. ST occurs in the first 1, 5-2 hours from the onset of an anginal attack and most of these patients die before the arrival of the ambulance team. Therefore, the greatest efforts should be made so that first aid is provided to the patient as early as possible, and so that the volume of this aid is optimal.
Organization of EMS work in AMI Treatment of a UTI patient. ST is a single process that begins in the prehospital phase and continues in the hospital. For this, the ambulance teams and hospitals, where patients with ACS are admitted, must work according to a single algorithm based on common principles of diagnosis, treatment and a common understanding of tactical issues § Two-stage system, when, upon suspicion of MI, the linear ambulance team calls on itself a "specialized" which actually begins treatment and transports the patient to the hospital, leads to an unjustified loss of time §Each ambulance team (including the paramedic) must be ready to carry out active treatment of the patient with UTI. ST
Organization of EMS work in AMI § Any EMS team, having diagnosed ACS, having determined the indications and contraindications for appropriate treatment, should stop the pain attack, begin antithrombotic treatment, including the administration of thrombolytics (if invasive restoration of coronary artery patency is not planned), and if complications develop - cardiac arrhythmias or acute heart failure - the necessary therapy, including measures for cardiopulmonary resuscitation § Emergency medical service teams in each locality should have clear instructions to which hospitals it is necessary to transport UTI patients. ST or suspected UTI. ST § Doctors of these hospitals provide emergency medical services with appropriate advice if necessary
It is necessary to transport the patient as soon as possible to the nearest specialized institution, where the diagnosis will be clarified and treatment will continue
Linear ambulance team should be equipped with the necessary equipment 1. Portable ECG with autonomous power supply; 2. Portable device for EIT with autonomous power supply with heart rate control; 3. Kit for cardiopulmonary resuscitation, including a device for manual ventilation; 4. Equipment for infusion therapy, including infusion pumps and perfusers; 5. Set for the installation of an IV catheter; 6. Cardioscope; 7. Pacemaker; 8. System for remote ECG transmission; 9. Mobile communication system; 10. Suction; 11. Medicines required for basic therapy of AMI
Treatment of uncomplicated UTI. ST at the prehospital stage Each ambulance team (including the paramedic) must be ready to actively treat the patient with UTI. ST Basic therapy. 1. Eliminate pain syndrome. 2. Chew a tablet containing 250 mg ASA. 3. Take 300 mg of clopidogrel by mouth. 4. Start IV infusion of NG, primarily with persisting angina pectoris, AH, AHF. 5. Start treatment with b-blockers. Preferably the initial intravenous administration, especially with ischemia, which persists after intravenous administration of narcotic analgesics or recurs, hypertension, tachycardia or tachyarrhythmia, without HF. It is supposed to perform primary TBA. The loading dose of clopidogrel is 600 mg.
Oxygen therapy In all cases 2 l / min through nasal catheters in the first 6 hours § At saturation of arterial blood O § persistence of myocardial ischemia § congestion in the lungs 2-4 (4-8) l / min through nasal catheters 2
Nitrates in acute myocardial infarction Indications for the use of nitrates § myocardial ischemia § acute congestion in the lungs § need for blood pressure control No contraindications § p. BP 30 mm Hg below baseline § HR 100 § Suspected right ventricular MI §
Prehospital triple antiplatelet therapy Data from the On-TIME 2 trial Prehospital IH IIb / IIIa tirofiban (bolus 25 μg / kg followed by 0.15 μg / kg / min infusion for 18 hours) or placebo in addition to aspirin (500 mg IV), clopidogrel (600 mg PO) and IV bolus (5000 IU) UFH p \u003d 0.043 p \u003d 0.051 p \u003d 0.581
Restoration of coronary perfusion The mainstay of treatment for acute MI is the restoration of coronary blood flow - coronary reperfusion. The destruction of the thrombus and the restoration of myocardial perfusion lead to a limitation of the extent of its damage and, ultimately, to an improvement in the short and long term prognosis. Therefore, all patients with UTI. ST should be examined without delay to clarify the indications and contraindications for the restoration of coronary blood flow. Russian recommendations. Diagnostics and treatment of patients with acute myocardial infarction with ST-segment elevation ECG. 2007 VNOK
Thrombolytic therapy in patients with AMI in 2008 according to 12 regions 2008
Prehospital thrombolysis: gain in time \u003d saving the myocardium Decision to call an ambulance Ambulance arrival Arrival to hospital Occurrence of pain Diagnosis Clearance in the emergency room Actilize SK today PTCA Metallize in ICU tomorrow Occurrence of pain The decision to call an ambulance in Metalysis at Arrival Arrival in the emergency room Early thrombolysis strategy
Prehospital thrombolysis for ST MI
USIC 2000 Register: Reducing Mortality in Prehospital Thrombolysis Mortality (%) 15 12. 2 10 5 8. 0 6. 7 3. 3 0 Dogosp. TL TL in hospital Without PCI of reperfusion therapy Danchin et al. Circulation 2004; 110: 1909-1915.
VIENNA STEMI REGISTRY: Change in reperfusion strategy Thrombolysis Without reperfusion PCI 60 60 50 50 Patients (%) 40 34 26.7 30 20 16 13.4 10 0 VIENNA 2002 VIENNA 2003/2004 Kalla et al. Circulation 2006; 113: 2398-2405.
VIENNA STEMI REGISTRY: Time from disease onset to treatment with different strategies 0 -2 h 100 90 19.5 6 -12 h 2 -6 h 5.1 80 44.4 Patients (%) 70 60 50 65.9 40 30 20 10 50.5 14.6 0 PCI THROMBOLYSIS Kalla et al. Circulation 2006; 113: 2398-2405.
GRACE REGISTRY Reperfusion therapy No reperfusion PCI only 50 48 Patients (%) 43 40 40 41 36 32 30 35 33 33 31 30 25 20 10 TLT only 35 32 26 19 13 15 0 1999 2000 2001 2002 Years 2003 2004 Eagle et al. 2007, Submitted
Treatment of uncomplicated UTI. ST at the prehospital stage Thrombolytic therapy at the prehospital stage. It is carried out in the presence of indications and the absence of contraindications. When using streptokinase, at the discretion of the physician, direct-acting anticoagulants can be used as concomitant therapy. If the use of anticoagulants is preferred, UFH, enoxaparin, or fondaparinux may be chosen. When using fibrin-specific thrombolytics, enoxaparin or UFH should be used. Reperfusion therapy is not expected. The decision on the advisability of using direct anticoagulants may be postponed until admission to the hospital. Russian recommendations. Diagnostics and treatment of patients with acute myocardial infarction with ST-segment elevation ECG. 2007 VNOK
Indications for TLT If the time from the onset of an anginal attack does not exceed 12 hours, and the ECG shows an increase in the ST segment ≥ 0, 1 m. V, in at least 2 consecutive chest leads or 2 limb leads, or blockade of LBR appears. The introduction of thrombolytics is justified at the same time in ECG signs of true posterior MI (high R waves in the right precordial leads and depression of the ST segment in leads V 1 -V 4 \u200b\u200bwith an upward T wave). Russian recommendations. Diagnostics and treatment of patients with acute myocardial infarction with ST-segment elevation ECG. 2007 VNOK
Contraindications for TLT Absolute contraindications for TLT § Previous hemorrhagic stroke or CCD of unknown etiology; § ischemic stroke, suffered within the last 3 months; § brain tumor, primary and metastatic; § suspicion of aortic dissection; § the presence of signs of bleeding or hemorrhagic diathesis (with the exception of menstruation); § significant closed head injuries in the last 3 months; § changes in the structure of cerebral vessels, for example, arteriovenous malformation, arterial aneurysms Russian recommendations. Diagnostics and treatment of patients with acute myocardial infarction with ST-segment elevation ECG. 2007 VNOK
Checklist for making a decision by the medical and paramedic team of the ambulance service to perform TLT for a patient with acute coronary syndrome (ACS) Check and mark each of the indicators in the table. If all the boxes in the "Yes" column are marked and none in the "No" column, then the patient is shown thrombolytic therapy. If there is even one unmarked box in the “Yes” column, TLT therapy should not be performed and the checklist can be stopped. "Yes" The patient is oriented, can communicate Pain syndrome characteristic of ACS and / or its equivalents lasting at least 15-20 minutes. , but not more than 12 hours After the disappearance of the pain syndrome characteristic of ACS and / or its equivalents, no more than 3 hours have passed.Qualitative registration of ECG in 12 leads was performed.The doctor / paramedic of the EMS has experience in assessing changes in the ST segment and blockade of the bundle of His bundle on the ECG (test only in the absence of a remote ECG evaluation by a specialist) There is a ST segment elevation of 1 mm or more in two or more adjacent ECG leads or a left bundle branch block is registered, which the patient did not have before. The doctor / paramedic of the EMS has experience in TLT. the hospital will take more than 30 minutes. It is possible to receive medical recommendations from a cardioreanimatologist of the hospital in real time. During the transportation of the patient, it is possible to continuously monitor the ECG (at least in one lead), intravenous infusions (in "No"
Age over 35 for men and over 40 for women Systolic blood pressure does not exceed 180 mm Hg. Art. Diastolic blood pressure does not exceed 110 mm Hg. Art. The difference in systolic blood pressure levels measured on the right and left hand does not exceed 15 mm Hg. Art. The history does not indicate a stroke or the presence of other organic (structural) brain pathology.There are no clinical signs of bleeding of any localization (including gastrointestinal and urogenital) or manifestations of hemorrhagic syndrome. The submitted medical documents do not contain data on the patient's long-term (more than 10 minutes) ) cardiopulmonary resuscitation or the presence of internal bleeding in the last 2 weeks; the patient and his relatives confirm this. In the submitted medical documents there is no data on the transferred over the last 3 months. surgery (including on the eyes using a laser) or serious injury with hematomas and / or bleeding, the patient confirms this The submitted medical documents do not contain data on the presence of pregnancy or the terminal stage of any disease and the survey and examination data confirm this The submitted medical documents do not contain data on the presence of jaundice, hepatitis, renal failure and data from the patient's survey and examination CONCLUSION: TLT is CONTRAINDICATED for the patient _______________ (full name) SHOWN (circle necessary, cross out unnecessary) The sheet was filled in: Doctor / paramedic (circle the necessary ) _____________ (full name) Date ______ Time _____ Signature _______ The checklist is sent with the patient to the hospital and filed into the medical history
Thrombolytic drugs Intravenous 1 mg / kg body weight (but not more than 100 mg): bolus 15 mg; subsequent infusion of 0.75 mg / kg of body weight in 30 minutes (but not more than 50 mg), then 0.5 mg / kg (but not more than 35 mg) in 60 minutes (total duration of infusion is 1.5 hours). Intravenous: bolus 2,000,000 IU and Purolaza followed by 4,000,000 IU infusion over 30-60 minutes. Streptokinase Intravenous infusion of 1,500,000 IU over 30-60 minutes). Tenecteplase Intravenous bolus: 30 mg at a weight of 90 kg. segment ST ECG. 2007 VNOK Alleplaza
Evolution of thrombolysis First generation Streptokinase allergenic, non-selective to fibrin Second generation Third generation Metalize Equivalent to Alteplase Actilize High "gold standard" fibrin selectivity Fibrin-specific non-allergenic Long-term intravenous infusion Single bolus 5-10 seconds
Reducing the relative risk Meta-analysis of studies with early IV administration of beta-blockers in MI (n \u003d 52 411) 0 -5 -10 -15 -20 -13%
BETA-BLOCKERS: APPLICATION IN ACS PATIENTS IN 59 RUSSIAN CENTERS GRACE register data (2000-1) 100% N \u003d 2806 C ST - 50.3% Without ST - 49.7% 1 Prev. 7 days 3 During hospitalization 2 First 24 hours. 4 Recommended at discharge 100% Without ST C ST 55.6 54.3 50.7 50% 54 50% 20. 2 0% 4.3% 2.9 I / O 60.3 54.5 12.2 0% 1 2 3 4 I / O 1 2 3 4 www. cardiosite. ru
Intravenous administration of beta-blockers in acute myocardial infarction From the first hours / day To eliminate symptoms § persistence of ischemia § tachycardia without heart failure § tachyarrhythmia § blood pressure All without contraindications § the appropriateness of intravenous infarction is discussed § if there are no contraindications
Beta-blockers for UTI. ST Drug Dose Treatment on the 1st day of the disease Metoprolol IV, 5 mg 2-3 times with an interval of at least 2 minutes; First oral administration 15 minutes after intravenous administration. Propronolol V / in 0.1 mg / kg for 2-3 doses at intervals of at least 2-3 minutes; First oral administration 4 hours after intravenous administration. Esmolol IV infusion at an initial dose of 0.05-0.1 mg / kg / min, followed by a gradual increase in the dose by 0.05 mg / kg / min every 10-15 minutes until an effect or dose of 0.3 mg / kg is achieved / min; for a more rapid appearance of the effect, the initial administration of 0.5 mg / kg is possible for 2–5 minutes. Emolol is usually canceled after the second dose of an oral β-blocker, if the correct heart rate and blood pressure were maintained during their combined use.
ACS P ST Data at admission to hospital Odds ratio (confidence interval) HKB # 29 (n \u003d 58) Other centers (n \u003d 1917) Time from symptom onset to hospitalization (hours) 5, 48 2, 83 ST elevations on baseline ECG (%) 86, 2 93, 8 2.45 (1.13 -\u003e 5) Negative T on baseline ECG (%) 3.45 1.73 0.79 (0.12 -2. 11) GRACE scale: proportion patients at risk of death \u003d 10% 10.3 19.4 2.08 (0.89 -4.88) Killip class I-II (%) 93.193.1 0.999 (0.35 -2.78 ) III (%) 5, 17 3, 86 0.74 (0.23 -2.41) IV (%) 02, 74 1.81 (0.25 -13.3) RUSSIAN REGISTER OF ACUTE CORONARY SYNDROMES (RECORD )
ACS P ST Primary reperfusion therapy and anticoagulant treatment Odds ratio (confidence interval) GKB # 29 (n \u003d 58) Other centers (n \u003d 1917) 27, 6 75, 7 0 47, 9 Streptokinase (%) 24, 1 5, 0 0.17 (0.09 -0. 31) T-PA (%) 3, 5 22, 8\u003e 5 81, 0 94, 0 3.69 (1.86 -\u003e 5) LMWH (%) 0 62 , 4 UFH (%) 100 50.5 Fondaparinux (%) 0 0, 1 Bivalirudin (%) 0 0, 1 Primary reperfusion (%) Primary PCI (%) TLT: Anticoagulants (%) RUSSIAN REGISTER OF ACUTE CORONARY SYNDROMES (RECORD)
Practical approaches in the treatment of AMI Within 10 - 15 minutes Emergency treatment § morphine 2-4 mg i.v. to effect § NPV, heart rate, blood pressure, O 2 saturation ECG monitoring Readiness for defibrillation and CPR Providing IV access ECG at 12 -th leads Short sighting history, physical examination §O 2 4-8 L / min for O 2 saturation\u003e 90% § § § Aspirin (if not given earlier): § § Clopidogrel 300 mg, chew 250 mg, 300 mg in suppository or intravenous 500 mg, age 90, if there is pain, acute congestion in the lungs, high blood pressure § solution of the issue of TLT !!!
The main cause of ACS was and remains atherosclerosis. Plaque deposits on the walls of the coronary arteries narrow the effective vascular lumen. Partial destruction of the plaque capsule provokes parietal thrombus formation, which further impedes blood flow to the heart muscle. A decrease in the capacity of the coronary artery by more than 75% leads to the appearance of symptoms of myocardial ischemia. According to this mechanism, unstable angina pectoris develops more often - a more favorable form of ACS.
Doctors of the prehospital stage are extremely limited in diagnostic tools for acute coronary syndrome. Therefore, they are not required to make an accurate diagnosis. The main thing is to correctly interpret the data available at the time of the examination and deliver the patient to the nearest medical center for the final detection of the disease, observation and treatment.
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