Cardiovascular Critical Care I
STEMI
NSTEMI/ Unstable Angina
Goals of care
Reperfusion therapy as soon as possible
| • | Primary PCI preferred if it can be performed within 90 |
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min of first medical contact
| • | If primary PCI is not immediately available, and the |
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delay from hospital presentation to PCI is anticipated to
be >120 min; fibrinolytic should be administered within
30 min of presentation unless contraindications exist
| • | Surgical revascularization may be indicated, depending |
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on severity of CAD, complexity of anatomy, or
development of other complications
Prevent total occlusion of the vessel
| • | Decision and need for |
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revascularization (PCI or surgery)
vs. medical management should
be made on the basis of risk
stratification, symptom resolution,
and indicators of ongoing
myocardial damage/ischemia
CAD = coronary artery disease.
426; Circulation 2013;127:e362-425)
Predominant interventions on presentation/onset for stabilization – Any ACS
Morphine or other
narcotic analgesic
| • | Theoretical benefit of morphine was to treat pain and reduce myocardial and microvascular |
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damage by inducing vasodilation and mediate some degree of preload reduction, thereby
decreasing myocardial oxygen demand. However, morphine use has largely fallen out
of favor, and morphine should only be used for severe refractory chest pain despite
nitroglycerin
| • | Morphine is also an independent predictor of high residual platelet reactivity in ticagrelor/ |
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prasugrel use (may impair absorption because of delayed gastric emptying) (Am Heart J
2014;6:909-14)
| • | Morphine now carries a class IIb-B recommendation given that at least two large trials have |
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identified an association between morphine administration and risk of death (N Engl J Med
2014;371:1016-27; Am Heart J 2005;149:1043-9; J Am Coll Cardio. 2014;64:e139-228)
| • | Studies evaluating fentanyl in the population with ACS have also shown high |
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residual platelet reactivity. Given this risk, opioids should be avoided (Circulation.
2018;137(3):307-309)
Oxygen
| • | Can help attenuate anginal pain secondary to tissue hypoxia |
|---|---|
| • | Current evidence shows no benefit for supplemental oxygen (and potential harm) in patients |
with normal Sao2 (N Engl J Med 2017;13:1240-9; Circulation 2015;24:2143-50)
| • | Supplemental oxygen considered if Sao2 < 90%, respiratory distress, or other high-risk |
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features for hypoxemia