Reperfusion therapy
(Additional)

Indication

• STEMI - ST elevation on their ECG (1mm in 2 contigous limb leads, 2mm in 2 contiguous chest leads)
• LBBB (left bundle branch block)
• Angina and/or associated symptoms for >20minutes

AND symptoms commenced within the last 12 hours.

If haemodynamically unstable --> aggressive management (may include angiogram+/- angioplasty +/- stent)

If ST depression, but elevated serum markers --> early (4-48hrs) invasive procedure.

Thrombolytic therapy

e.g. alteplase, reteplase, tenecteplase, streptokinase

If percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) are not immediately available, and emergency reperfusion therapy is needed, then start (with heparin as soon as possible).

Contraindications

• Active bleeding
• Uncontrolled severe hypertension (>200/110)
• Recent (<1 month) surgery
• Hx of haemorrhagic stroke
• Hx of ischaemic stroke in the past year
• Prior use of anticoagulants, INR>2.0
• Prolonged CPR
• Pregnancy
• Diabetic retinopathy

Emergency invasive procedure

(STEMI and LBBB patients only)

Coronary angiography

   +

Either PCI OR CABG.

(Should be done immediately as an emergency procedure.)

Streptokinase protocol

1.5 million units of streptokinase in 100mL N.S. ---> given in 45-60mins.

ECG at the start, finish, 1hour, 3 hour, 6 hour, 12 hour post-infusion.

Monitor for allergic/anaphylactic reaction and hypotension.

Stop infusion if SBP<70. Restart when SBP>70.

Half the rate if SBP between 70-80

GTN infusion protocol

50mg in 10mL, diluted to 50mL ---> 1mg in 1mL.

0.3mL/hr=300mcg/hr=5mcg/min

Start infusion at 0.3mL/hr (i.e. 5mcg/min).

Adjust infusion by 0.3mL/hr increments every 5 minutes, depending on the pain and BP.

Things to revise/add later: side-effects of streptokinase. indications for GTN infusion

Bibliography: