PREHOSPITAL DIAGNOSIS AND MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION Dr Abdul Raqib bin Abd Ghani MBBS(Mal), MRCP(UK) Cardiology Clinical Specialist Serdang Hospital, MALAYSIA Greetings from MALAYSIA! CONTRAINDICATIONS TO THROMBOLYSIS Absolute contraindications • previous Intracranial haemorrhage • Known structural cerebrovascular lesion (eg, arteriovenous malformation) • Known malignant intracranial neoplasm (primary or metastatic) • Ischemic stroke within mo, except for acute ischemic stroke within h • Suspected aortic dissection • Active bleeding or bleeding diathesis (excluding menses) • Severe closed-head or facial trauma within mo J Am Coll Cardiol Relative contraindications History of chronic, severe, poorly controlled hypertension Severe uncontrolled hypertension on presentation (SBP ≥180 mm Hg or DBP ≥110 mm Hg) History of ischemic stroke more than mo previously, dementia, or known intracranial pathology not included in contraindications Traumatic or prolonged (>10 min) CPR or major surgery (5 d previously) or previous allergic reaction to these agents Pregnancy Active peptic ulcer Current use of anticoagulants: the higher the INR, the higher the risk of bleeding     427 patients, 21 to 85 years of age, with STEMI within h of symptom onset and 90-min ECG criteria (50% ST-segment resolution) for failed thrombolysis Patients were randomly assigned to rescue PCI (n 144), repeat thrombolysis (n 142), or conservative therapy (n 141) R-PCI was done within 5-10 hours after the onset of symptoms The mean time for pain-torescue PCI was 414 minutes (6.5hours) The rate of event-free survival within 6/12: 84.6% with rescue PCI, 70.1 % receiving conservative therapy, 68.7 % repeat thrombolysis (overall P = 0.004) Composite primary end point at months : 31.0% (repeat thrombolysis), 29.8% (conservative) and 15.3% (rescue PCI) p 3 hours and less than 12 hours • STEMI > 12hours but < 24 hours with on going ischemia • Patient must able to be lie flat, on oxygen therapy or intubated/ventilated prior to transfer • **Cardiogenic shock • Exclusion criteria (transfer not safe) • • • • • • • • SBP < 80 mmHg > inotropes Cardiorespiratory arrest (more than minutes) Mechanical failure Poor EF/global hypokinesia Age > 75 Multiple co morbids (DM/HPT/ESRF/previous CVA with disability) Recurrent VF/VT Contraindications for transfer • Patient not giving consent for PCI • Non Malaysians • Poor social support • Vagabond • Possible non-compliance • IVDU etc thank you for your kind attention ... conservative therapy (n 141) R-PCI was done within 5-10 hours after the onset of symptoms The mean time for pain-torescue PCI was 414 minutes (6.5hours) The rate of event-free survival within 6/12: