Ossigeno, morfina, nitrati ed ASA nell`IMA. Tutti, nessuno, qualcuno?

Ossigeno,
morfina,
nitrati ed ASA
nell’IMA.
Tutti, nessuno,
qualcuno?
mario cavazza
MU & PS
AOU di Bologna
Morfina
ASA
Nitrati
acronimo ben noto………
Ossigeno
Initial treatment of acute
coronary syndromes.
Is there a future for MONA
acronym after the 2010
guidelines?
administer ASA
and consider
oxygen, nitroglycerin and morphine
if needed
In CRUSADE registry, morphine
administration in patients with STEMI
was associated with increased rates of
mortality and MI. It is unclear,
however, whether this association
reflects harmful effects of morphine
or another, unmeasured, treatment
effect
Hyperoxia caused by inhalation of high
flow O2, may induce constriction of
the coronary resistance vessels in
patients
with
CAD
and
also
exacerbate reperfusion injury to
ischaemic myocardium.
Nitrates remain part of MONA as a
means for the control of ischaemic
symptoms while aspirin is supported
by the strongest evidence for an
improvement in patient outcomes.
Divinum opus
est sedare
dolorem !
Relief of pain is of paramount importance, not
only for humane reasons but because the pain
is associated with sympathetic activation that
causes vasoconstriction and increases the
workload of the heart.
Non si tratta
il “sintomo” dolore
ma la “causa” del dolore
Steele C.
Severe angina pectoris relieved by oxygen
inhalations.
BMJ. 1900;2:1568.
Oxygen (by mask or nasal prongs) should be
administered to those who are breathless,
hypoxic, or who have heart failure.
Whether oxygen should be systematically
administered to patients without heart failure
or dyspnoea is at best uncertain.
Supplemental oxygen for arterial
oxygen saturation <90% or
respiratory distress.
Supplemental oxygen should be initiated if
the patient has breathlessness, hypoxaemia,
and signs of heart failure or shock. There is
relatively limited evidence from clinical
studies to support the routine use of oxygen
therapy in ACS.
Myocardial infarction and ACS
Most patients with acute coronary artery
syndromes are not hypoxaemic and the benefits
/ harms of oxygen therapy are unknown in such
cases
Grade D
It is suggested that in patients with acute
myocardial infarction who are hypoxemic, oxygen
is indicated to maintain arterial oxygen saturation
from 94% to 96%.
Sufficient evidence now exists that hyperoxia
has the potential to induce unfavorable
hemodynamicand metabolic changes and should be
avoided.
Routine oxygen therapy in acute MI settings is a
common practice.
Whereas hypoxaemic patients undoubtedly benefit
from oxygen insufflation, the level of evidence
for this practice in normoxaemic patients is
insufficient to determine its efficacy and safety.
Further, there is evidence that this therapy is
ineffective and hazardous
There
is
no
conclusive
evidence
from
randomised controlled trials to support the
routine use of inhaled oxygen in people with
AMI. A definitive randomised controlled trial is
urgently required, given the mismatch between
trial evidence suggestive of possible harm from
routine oxygen use and recommendations for its
use in clinical practice guidelines.
Meccanismo:
•Riduzione preload e LVED volume con riduzione
MVO2.
•Coronarodilatazione ? Circoli collaterali?
•NO di routine
•IV in acuto se ipertensione / scompenso
•“cave” sildenafil, ipotensione e sospetto
IMA destro !
•Da valutare in acuto per il controllo dei
sintomi anginosi
Pochi studi piccoli e osservazionali,
non RCT
Uso “physiopatology” e “experience
based”
Dosaggio da titolare su:
Riduzione sintomi ( dolore /
dispnea)
Effetti collaterali ( ipotensione e
cefalea)
Class I
1. Patients with continuing ischemic pain
should receive sublingual NTG (0.3 mg0.4 mg) every 5 minutes / 3 doses.
(LOE: C)
2. Intravenous nitroglycerin is indicated
for the treatment of persistent
ischemia, heart failure (HF), or
hypertension. (LOE: B)
Probability of death or MI
0.25
Placebo
0.20
Risk ratio after 1 year 0.52
95% Cl 0.37–0.72 (P=0.0001)
0.15
0.10
ASA 75 mg
0.05
0.00
0
3
6
Months
Wallentin et al, JACC 1991
9
12
Class I
Aspirin 162 to 325 mg should be given before primary
PCI (LOE: B)
A loading dose of a P2Y12 receptor inhibitor should be
given as early as possible or at time of primary PCI to
patients with STEMI.
a. Clopidogrel 600 mg76,81,82 (LOE : B); or
b. Prasugrel 60 mg83 (LOE: B); or
c. Ticagrelor 180 mg.84 (LOE: B)
Class III
Prasugrel should not be administered to patients with a
history of prior stroke or transient ischemic
attack (LOE: B)
Hammm et al
For NSTE-ACS patients undergoing PCI with stenting:
Prasugrel 60 mg loading dose then 10 mg/day
Intra-hospital
transfer
Out-ofhospital EMS
ER
ASA
Appraisal of thrombotic and bleeding risks – aspirin unless bleeding risk prohibitive
↑ thrombotic risk ↓ thrombotic risk
↑ bleeding risk
↑ bleeding risk
Clopidogrel or
Ticagrelor
Wait-and-see
↓ thrombotic risk ↑ thrombotic risk
↓ bleeding risk
↓ bleeding risk
Wait-and-see
Coronary angiography
una ipotesi
( Biondi Zoccai , 2011)
Prasugrel or
Ticagrelor
TACCUINO
MORFINA (CAVEATS !!)
ASA
CONCORDA IL RESTO CON I
CARDIOLOGI DI RIFERIMENTO
NITRATI SE SCOMPENSO
(CAVEATS !!)
O2 SE IPOSSIA ( CAVEATS !!)
The time of PCT publication to
meaningful uptake of class IA ACS
therapies into clinical practice took a
median of 16 years. This significant
time lag indicates systemic barriers to
the translation of therapeutics into
routine clinical practice.