C h a p t e r 3 Acute Myocardial Infarction - Management in First 3 Hours

Size: px
Start display at page:

Download "C h a p t e r 3 Acute Myocardial Infarction - Management in First 3 Hours"

Transcription

1 C h a p t e r 3 Acute Myocardial Infarction - Management in First 3 Hours AB Mehta 1 BP Shivdasani 2 1 Director of Cardiology, Jaslok Hospital, Mumbai. 2 Clinical Associate, Jaslok Hospital, Mumbai. Introduction 50% of deaths due to Acute Myocardial Infarction (AMI) occur within one hour of symptom onset. 1 Therefore, rapid diagnosis and management is vital to reduce mortality. Out of Hospital Sudden Cardiac Arrest Majority are the result of fatal arrhythmias that can be treated with emergency Cardio-Pulmonary Resuscitation, defibrillation and prompt Advanced Cardiac Life Support. This requires patient education regarding symptoms, availability of trained Emergency medical services and rapid transport to a fully equipped cardiac hospital. 2,11 Recognition and Management Most patients seek medical care after 2 hours of symptom onset and even wait 12 hours or more. Pharmacologic therapy beyond 12 hours may offer little benefit. 2 Thus, prompt treatment is essential. Components of Delay to Treatment and Goals 3 1. Patient related (failure to recognize problem and delay in seeking help). Goal 15 minutes. 2. Pre hospital evaluation, treatment and transport time. Goal 30 minutes. 3. Diagnosis and initiation of treatment in hospital. Goal door to needle time for thrombolysis 30 minutes. 4. Time to reperfusion door to balloon time 90 minutes. High Risk Patients Include those with tachycardia ( 100 bpm), hypotension ( 100 mmhg), pulmonary edema (rales > one half way up) and shock. They should be managed in a tertiary hospital with early thrombolysis or Percutaneous Coronary Intervention(PCI). 4 Pre Hospital Thrombolysis A meta-analysis of trials showed a 17% relative improvement in outcome 5. However, it is administered only if transport time is >90 minutes or if a trained physician is present in the ambulance CME 2004

2 Diagnosis of AMI 1. History of Ischaemic type chest discomfort (lasting >20 minutes): Presentation in 70 to 80% of patients Changes in serially obtained ECG: ST segment elevation has sensitivity of 46% and specificity of 91% for diagnosing AMI 7. Mortality increases with number of leads showing ST elevation. 3. Rise and fall of cardiac markers: Elevated cardiac specific troponins ctni or ctnt identify patients who are at increase risk of death and those who benefit from treatment with GPII b/iiia inhibitors 8. Myoglobin may be detected after two hours of MI. CK-MB2 >1U/L or ratio of CK- MB2 to CK-MB1 of 1.5 has improved accuracy of diagnosing AMI within 1 st 6 hours.9 Routine Measures Oxygen Given to patients with overt pulmonary congestion, desaturation (SaO 2 <90%) and routinely to all patients with uncomplicated MI during 1 st 3 hours 11. It limits myocardial injury 10, reduces ST segment elevation and hypoxia due to excess lung water. Nitroglycerine (NTG) Given for 1 st hours in patients with AMI + CHF, large anterior MI, persistent ischaemia or hypertension 11. It should be avoided in patients with hypotension (SBP < 100 mm Hg), bradycardia (<50 bpm) 12, tachycardia or RV infarct 11. Pre hospital sublingual NTG 5 mg every 5 minutes upto 3 doses. In hospital it is given as an infusion. Analgesia IV Morphine 4-8 mg relieves anxiety without causing myocardial depression. It reduces pain induced sympathetic activation which causes vasoconstriction and increased cardiac workload 11. Alternatively, pentazocine or buprenorphine may be used. Aspirin mg of soluble Aspirin immediately after onset of symptoms. ISIS-2 study showed that Aspirin alone in AMI resulted in 35-day mortality reduction of 23%. When combined with Streptokinase (STK), mortality reduction was 42% 13. It reduces coronary re-occlusion and recurrent Ischaemic events after fibrinolysis 14. The tablet may be chewed or swallowed with equal benefit. Aspirin suppositories or intravenous form may be used in patients with severe nausea and vomiting or upper GI disorders. Other Anti-platelet Agents Clopidogrel, ticlopidine or dipyridamole are used if patient is allergic to aspirin or has aspirin resistence. Loading dose of 300mg clopidogrel or 500mg ticlopidine is given if PCI is contemplated. Atropine Recommended in patients with: 1) sinus bradycardia with low cardiac output and peripheral hypoperfusion. 2) acute inferior MI with type 1 second or third degree A-V block with hypotension, ischaemic discomfort or ventricular arrhythmia. 3) sustained bradycardia and hypotension after NTG. 4) ventricular asystole. Dose: 0.5 to 1mg I.V repeated every 3-5 minutes upto 2.5mg (0.04mg/kg). 11 Beta-blocker Analysis of 28 trials reveals absolute mortality reduction at 7 days from 4.3% to 3.7% 15. It should be used in setting of tachycardia (without CHF), hypertension or pain unresponsive to opiods or NTG. 11 ACE Inhibitors Given to patients with CHF or impaired LVEF in early phase.gissi-3 16 and ISIS-4 17 have shown that it reduces mortality at 4-6 weeks. Acute Myocardial Infarction - Management in First 3 Hours 21

3 Table 1 : Golden hour benefit period for thrombolysis: Time to lysis in hours Lives saved/thousand (FTT Collaborative Group. Lancet 1994; 343: ) Table 2 : Comparative Efficacy STK Anistreplase Alteplase Reteplase Dose 1.5MU in min 30 mg in 5min 100mg in 90 min 10 u twice over 20 min 90min patency (%) TIMI-3 flow % Thrombolytic Therapy An overview of 9 trials have shown an 18% proportional reduction in 35-day mortality with thrombolytic therapy (9.6% fibrinolysis v/s 11.5% control). 18 Comparative Thrombolytic Efficacy The GISSI-2 19 and ISIS-3 20 studies showed that mortality rates at 4 to 5 weeks were similar. GISSI- 2: tissue plasminogen activator (tpa) 8.9% and STK 8.5%. ISIS-3: alteplase 10.3%, STK 10.6% and anistreplase 10.5%. Limitations of Thrombolysis 1)Reduced efficacy: GUSTO-1 study showed that TIMI grade 3 flow is seen in 32% with STK and 54% with tpa with corresponding mortality of 7.4% and 6.3%. 21 2)Reocclusion: Ohman et al in the TAMI study 22 showed post fibrinolysis re-occlusion rate of 12.4%.3) Re-infarction: occurs in 3-5%. 4) Recurrent ischaemia: in upto 34%. 5) No Tissue flow: occurs in about 30%. Thus, effective tissue flow is achieved in only about 25% of patients. 23 Adjunctive Anti-thrombotic Therapy Heparin: Does not improve clot lysis but enhances coronary patency after rtpa. 24 Low molecular weight heparin: In the ASSENT-3 trial, enoxaparin(30mg i.v bolus and 1mg/kg every 12 hours) for 7 days plus tenecteplase reduced in-hospital re-infarction or refractory ischaemia compared to heparin. 25 Direct thrombin inhibitors: Hirudin, bivalirudin and argatroban have not shown clear benefit over heparin following fibrinolysis. Combination therapy: fibrinolysis + GpIIb/IIIa Inhibitors Pooled analysis of TIMI-14 26, SPEED 27 and INRO-AMI 28 trials showed an improvement in TIMI Grade 3 flow from 56% with lytic therapy to 64% in patients with combination therapy (8% improvement with 0.4% mortality reduction). Percutaneous Coronary Interventions (PCI) Includes primary PCI, PCI + Pharmacologic reperfusion therapy-facilitated PCI and Rescue PCI after failed trombolysis. Primary PCI The DANAMI-2 investigators 29 found that routine transfer to a tertiary care hospital for primary PCI 22 CME 2004

4 is superior to in-hospital thrombolysis. A significant reduction in combined end point of death, reinfarction and stroke at 30 days was seen in primary PCI group (14.2% to 8.5%, p< 0.002). Primary PCI results in higher patency, less re-occlusion, improved LVEF and better clinical outcome. 30 It is indicated in patients ineligible for fibrinolytic therapy and treatment of choice in cardiogenic shock. 30 Facilitated PCI The SPEED trial 31 showed that PCI after combination therapy increased rate of TIMI 3 flow from 47% to 87%. In TIMI study, those who received half dose alteplase and abciximab and early PCI had greater ST segment resolution compared to those with only combination therapy (57% v/s 24%) or with only fibrinolysis + PCI (54% v/s 8%). Rescue PCI Trials have shown clinical benefit if infarct related artery is recanalized by PTCA after failed thrombolysis.33 Role of IABP Used in patients with hemodynamic instability, persistent ischaemia or refractory arrhythmia often in conjunction with PCI. CABG It is performed when Angiography reveals unfavourable anatomy for PCI, failed PTCA or mechanical complications like VSD, papillary muscle rupture with MR or cardiac rupture. 30 Conclusion Successful management of AMI during the first 3 hours depends on early diagnosis, rapid triage and optimum combination of pharmacologic reperfusion and PCI. References 1. Herlitz J, Blohm M, Hartford M, et al. Delay time in suspected acute myocardial infarction and the importance of its modification. Clin. Cardiol 1989; 12: National Heart, Lung and blood Institute: Rapid identification and treatment of acute myocardial infarction. National Institutes of Health; 1993 & 1994: NIH publication Nos & Cannon CP, Antman EM, Walls R, Braunwald E: Time as an adjunctive agent to thrombolytic therapy. J Thromb Thrombol. 1994; 1: Weaver WD, Cerqueira M, Hallstrom AP, et al. Pre hospital initiated vs hospital initiated Thrombolytic therapy. The Myocardial Infarction Triage and Intervention Trial. JAMA 1993 ; 270: The European Myocardial Infarction Project Group. Pre-hospital thrombolytic therapy in patients with suspected acute myocardial infarction. NEJM 1993; 329: Kannel W. Prevalence and clinical aspects of unrecognized myocardial infarction and sudden death. Circulation 1987; 75 (suppl II): II-4-II Rude RE, Poole WK, Muller JE, et al. Electrocardiography and clinical criteria for recognition of acute myocardial infarction based on analysis of 3697 pts. Am J Cardiol 1983; 52: Ohman EM, Armstrong PW, Christenson RH, et al. Cardiac Troponin T levels for risk stratification in acute myocardial ischaemia. GUSTO IIA investigators. NEJM 1996; 335: Puleo PR, Meyer D, Wathen C, et al. Use of a rapid assay of subforms of creatine Kinase MB to diagnose or rule out acute myocardial infarction. NEJM 1994; 331: Maroko PR, Radvany P, Braunwald E, Reduction of infarct size by oxygen inhalation following acute coronary occlusion. Circulation 1975; 52: Ryan et al. ACC/AHA guidelines on Management of Acute Myocardial Infarction 1999 update. J Am Coll Cardiol 1999; Sept 1: Come PC, Pitt B. Nitroglycerine induced severe hypotension and bradycardia in patients with AMI. Circulation 1976; 54: ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised Trial of IV STK, oral aspirin, both or neither among cases of suspected AMI. Lancet 1988; 2: Acute Myocardial Infarction - Management in First 3 Hours 23

5 14. Roux S, Christeller S, Ludin E. Effects of aspirin on coronary re-occlusion and recurrent ischaemia after thrombolysis a meta-analysis. J Am Coll Cardiol 1992; 19: Yusuf S, Lessem J, Jha P, et al. Primary and secondary prevention of myocardial infarction & strokes. An update of randomly allocated controlled trials. J Hypertens 1993; 11(suppl.4); GISSI-3: Effects of lisinopril and transdermal glyceryl-trinitrate singly and together on 6 week mortality and ventricular function after AMI. Lancet 1994; 343 : ISIS-4: A randomized factorial trial asscessing oral captopril, mono-nitrate and IV magnesium in 58,050 patients with suspected AMI. Lancet 1995; 345: Fibrinolytic Therapy Trials (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected AMI. Overview of early mortality and major morbidity results from all randomized trials of more than 1000 patients. Lancet 1994; 343: The International Study Group. In-hospital mortality and clinical course of patients with suspected AMI randomized between alteplase and STK with or without heparin. Lancet 1990; 336: ISIS-3 Collaborative Group. A randomized comparison of STK vs tpa vs anistreplase and of aspirin plus heparin vs aspirin alone. Lancet 1992; 339: GUSTO Angiographic Investigators. The effects of tpa, STK or both on coronary artery patency, ventricular function and survival after AMI. NEJM 1993; 329: Ohman EM, Califf RM, Topol EJ, et al. Consequences of re-occlusion after successful reperfusion therapy in AMI. TAMI Study Group. Circulation 1990; 82: Lincoff AM, Topol EJ. The illusion of reperfusion. Does anyone achieve optimal reperfusion during AMI. Circulation 1993; 87: Hsia J, Hamilton WP, et al. Heparin-Aspirin Reperfusion Trial (HART) Investigators. A comparison between heparin and low dose aspirin as adjunctive therapy with tpa for AMI. NEJM 1990; 323: The Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT) 3 Investigator. Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab or unfractionated heparin in AMI. Lancet 2001;358: Antman EM, Giugliano RP, Gibson CM, et al. Abciximab facilitates the rate and extend of thrombolysis. Results of the Thromboysis in Myocardial Infarction (TIMI) 14 Trial. Circulation 1999;99: Trial of abciximab with and without low dose reteplase for AMI. Strategies for Patency Enhancement in the Emergency Department ( SPEED ) Group. Circulation 2000; 101:2788/ Brener SJ, Zeymeru, Adgey A.A., et al. Eptifibatide and low dose tpa in AMI (INTRO-AMI) Trial. J Am Coll Cardiol 2002;39: Nielsen TT, Rasmussen K et al. A comparison of coronary angioplasty with Fibrinolytic therapy in AMI. The DANAMI II Study. NEJM 2003; 349: The task force on the management of AMI of the European Society of Cardiology. Eur Heart Journal 2003;24: Hermann HC, Moliterno DJ, et al. Facilitation of early PCI after reteplase with or without abciximab in AMI results from the SPEED (GUSTO 4 PILOT) trial. JACC 2000; 36: De Lemos JA, Gibson CM et al. Abciximab and early adjunctive PCI are associated with improved ST segment resolution after thrombolysis. TIMI 14 Trial. AHJ 2001; 141: Ellis SG, Da Silva ER, Heyndrickx G et al. Randomized comparison of rescue angioplasty with conservative management of patients with early failure of thrombolysis for AMI. Circulation 1994;90: CME 2004

DISCUSSION QUESTION - 1

DISCUSSION QUESTION - 1 CASE PRESENTATION 87 year old male No past history of diabetes, HTN, dyslipidemia or smoking Very active Medications: omeprazole for heart burn Admitted because of increasing retrosternal chest pressure

More information

Management of Acute Myocardial Infarction

Management of Acute Myocardial Infarction Management of Acute Myocardial Infarction Prof. Hossam Kandil Professor of Cardiology Cairo University ST Elevation Acute Myocardial Infarction Aims Of Management Emergency care (Pre-hospital) Early care

More information

Thrombolysis in Acute Myocardial Infarction

Thrombolysis in Acute Myocardial Infarction CHAPTER 70 Thrombolysis in Acute Myocardial Infarction J. S. Hiremath Introduction Reperfusion of the occluded coronary artery at the earliest is the most important aim of management of STEMI. Once a flow

More information

Acute coronary syndromes

Acute coronary syndromes Acute coronary syndromes 1 Acute coronary syndromes Acute coronary syndromes results primarily from diminished myocardial blood flow secondary to an occlusive or partially occlusive coronary artery thrombus.

More information

Acute Coronary Syndrome

Acute Coronary Syndrome Acute Coronary Syndrome Clinical Manifestation of CAD Silent Ischemia/asymptomatic Stable Angina Acute Coronary Syndrome (Non- STEMI/UA and STEMI) Arrhythmias Heart Failure Sudden Death Pain patterns with

More information

The restoration of coronary flow after an

The restoration of coronary flow after an Pharmacological Reperfusion in Acute Myicardial Infarction after ASSENT 3 and GUSTO V [81] DANIEL FERREIRA, MD, FESC Serviço de Cardiologia, Hospital Fernando Fonseca, Amadora, Portugal Rev Port Cardiol

More information

Current Advances and Best Practices in Acute STEMI Management A pharmacoinvasive approach

Current Advances and Best Practices in Acute STEMI Management A pharmacoinvasive approach Current Advances and Best Practices in Acute STEMI Management A pharmacoinvasive approach Frans Van de Werf, MD, PhD University Hospitals, Leuven, Belgium Frans Van de Werf: Disclosures Research grants

More information

ST-elevation myocardial infarctions (STEMIs)

ST-elevation myocardial infarctions (STEMIs) Guidelines for Treating STEMI: Case-Based Questions As many as 25% of eligible patients presenting with STEMI do not receive any form of reperfusion therapy. The ACC/AHA guidelines highlight steps to improve

More information

Acute myocardial infarction. Cardiovascular disorders. main/0202_new 02/03/06. Search date August 2004 Nicholas Danchin and Eric Durand

Acute myocardial infarction. Cardiovascular disorders. main/0202_new 02/03/06. Search date August 2004 Nicholas Danchin and Eric Durand main/0202_new 02/03/06 Acute myocardial infarction Search date August 2004 Nicholas Danchin and Eric Durand QUESTIONS Which treatments improve outcomes in acute myocardial infarction?...4 Which treatments

More information

2010 ACLS Guidelines. Primary goals of therapy for patients

2010 ACLS Guidelines. Primary goals of therapy for patients 2010 ACLS Guidelines Part 10: Acute Coronary Syndrome Present : 內科 R1 鍾伯欣 Supervisor: F1 吳亮廷 991110 Primary goals of therapy for patients of ACS Reduce the amount of myocardial necrosis that occurs in

More information

Cardiovascular Disorders Lecture 3 Coronar Artery Diseases

Cardiovascular Disorders Lecture 3 Coronar Artery Diseases Cardiovascular Disorders Lecture 3 Coronar Artery Diseases By Prof. El Sayed Abdel Fattah Eid Lecturer of Internal Medicine Delta University Coronary Heart Diseases It is the leading cause of death in

More information

The Strategic Reperfusion Early After STEMI study Implications for clinical practice

The Strategic Reperfusion Early After STEMI study Implications for clinical practice The Strategic Reperfusion Early After STEMI study Implications for clinical practice Robert C. Welsh, MD, FRCPC Associate Professor of Medicine Director, Adult Cardiac Catheterization and Interventional

More information

Facilitated Percutaneous Coronary Intervention in Acute Myocardial Infarction. Is it beneficial to patients?

Facilitated Percutaneous Coronary Intervention in Acute Myocardial Infarction. Is it beneficial to patients? Facilitated Percutaneous Coronary Intervention in Acute Myocardial Infarction Is it beneficial to patients? Seung-Jea Tahk, MD. PhD. Suwon, Korea Facilitated PCI.. background Degree of coronary flow at

More information

Acute Coronary Syndrome. Sonny Achtchi, DO

Acute Coronary Syndrome. Sonny Achtchi, DO Acute Coronary Syndrome Sonny Achtchi, DO Objectives Understand evidence based and practice based treatments for stabilization and initial management of ACS Become familiar with ACS risk stratification

More information

The First 12 Hours. ST-Segment Elevation AMI: Introduction. Definitions

The First 12 Hours. ST-Segment Elevation AMI: Introduction. Definitions ST-Segment Elevation AMI: The First 12 Hours Acute myocardial infarction (AMI) accounts for half of the deaths due to ischemic heart disease and is associated with significant use of resources. Because

More information

Role of platelet glycoprotein IIb/IIIa inhibitors in rescue percutaneous coronary interventions

Role of platelet glycoprotein IIb/IIIa inhibitors in rescue percutaneous coronary interventions Role of platelet glycoprotein IIb/IIIa inhibitors in rescue percutaneous coronary interventions Anna Sonia Petronio, Marco De Carlo, Roberta Rossini, Giovanni Amoroso, Ugo Limbruno, Nicola Ciabatti, Caterina

More information

When the learner has completed this module, she/he will be able to:

When the learner has completed this module, she/he will be able to: Thrombolytics and Myocardial Infarction WWW.RN.ORG Reviewed September 2017, Expires September 2019 Provider Information and Specifics available on our Website Unauthorized Distribution Prohibited 2017

More information

M/39 CC D. => peak CKMB (12 hr later) ng/ml T.chol/TG/HDL/LDL 180/150/48/102 mg/dl #

M/39 CC D. => peak CKMB (12 hr later) ng/ml T.chol/TG/HDL/LDL 180/150/48/102 mg/dl # Acute Coronary Syndrome - Case Review - Young-Guk Ko, MD Yonsei Cardiovascular Center Yonsei University College of Medicine Case 1 M/39 #4306212 CC D : Severe squeezing chest pain : 4 hours, aggravated

More information

The Window for Fibrinolysis. Frans Van de Werf, MD, PhD Leuven, Belgium

The Window for Fibrinolysis. Frans Van de Werf, MD, PhD Leuven, Belgium The Window for Fibrinolysis Frans Van de Werf, MD, PhD Leuven, Belgium ESC STEMI Guidelines : December 2008 Reperfusion Therapy: Fibrinolytic Therapy Recommendations Class LOE In the absence of contraindications

More information

2018 Acute Coronary Syndrome. Robert Bender, DO, FACOI, FACC Central Maine Heart and Vascular Institute

2018 Acute Coronary Syndrome. Robert Bender, DO, FACOI, FACC Central Maine Heart and Vascular Institute 2018 Acute Coronary Syndrome Robert Bender, DO, FACOI, FACC Central Maine Heart and Vascular Institute Definitions: Acute Myocardial Ischemia Unstable Angina Non-ST-Elevation MI (NSTEMI) }2/3 ST-Elevation

More information

Acute Coronary Syndromes

Acute Coronary Syndromes Overview Acute Coronary Syndromes Rabeea Aboufakher, MD, FACC, FSCAI Section Chief of Cardiology Altru Health System Grand Forks, ND Epidemiology Pathophysiology Clinical features and diagnosis STEMI management

More information

Myocardial Infarction In Dr.Yahya Kiwan

Myocardial Infarction In Dr.Yahya Kiwan Myocardial Infarction In 2007 Dr.Yahya Kiwan New Definition Of Acute Myocardial Infarction The term of myocardial infarction should be used when there is evidence of myocardial necrosis in a clinical setting

More information

ST ELEVATION MYOCARDIAL INFARCTION (STEMI) Gordon Kritzer, MD, FACC Virginia Mason Medical Center, Seattle

ST ELEVATION MYOCARDIAL INFARCTION (STEMI) Gordon Kritzer, MD, FACC Virginia Mason Medical Center, Seattle ST ELEVATION MYOCARDIAL INFARCTION (STEMI) Gordon Kritzer, MD, FACC Virginia Mason Medical Center, Seattle STEMI ACS and STEMI History and physical, differential diagnosis ECGs Initial Therapy and management

More information

Thrombolysis in Cardiology to whom? Professor Steen D. Kristensen, MD, DMSc, FESC Department of Cardiology

Thrombolysis in Cardiology to whom? Professor Steen D. Kristensen, MD, DMSc, FESC Department of Cardiology Thrombolysis in Cardiology to whom? Professor Steen D. Kristensen, MD, DMSc, FESC Department of Cardiology UNIVERSITY OF AARHUS 1 COI Speakers fee: Aspen, AZ, Bayer, BMS/Pfizer Departmental research grant:

More information

12/18/2009 Resting and Maxi Resting and Max mal Coronary Blood Flow 2

12/18/2009 Resting and Maxi Resting and Max mal Coronary Blood Flow 2 Coronary Artery Pathophysiology ACS / AMI LeRoy E. Rabbani, MD Director, Cardiac Inpatient Services Director, Cardiac Intensive Care Unit Professor of Clinical Medicine Major Determinants of Myocardial

More information

PRIMARY CORONARY ANGIOPLASTY VERSUS INTRAVENOUS THROMBOLYSIS FOR ACUTE MYOCARDIAL INFARCTION - A COMPARATIVE STUDY AT QUEEN ALIA HEART INSTITUTE

PRIMARY CORONARY ANGIOPLASTY VERSUS INTRAVENOUS THROMBOLYSIS FOR ACUTE MYOCARDIAL INFARCTION - A COMPARATIVE STUDY AT QUEEN ALIA HEART INSTITUTE PRIMARY CORONARY ANGIOPLASTY VERSUS INTRAVENOUS THROMBOLYSIS FOR ACUTE MYOCARDIAL INFARCTION - A COMPARATIVE STUDY AT QUEEN ALIA HEART INSTITUTE Walid Sawalha MD, MBBS (Lond), MRCP(UK)* ABSTRACT Objectives:

More information

Treatment of Acute Coronary Syndromes

Treatment of Acute Coronary Syndromes Treatment of Acute Coronary Syndromes UC SF Jeffrey Tabas, M.D. sf g h Associate Professor UCSF School of Medicine Emergency Services, San Francisco General Hospital Objectives Review the updated AHA/ACC

More information

Pre Hospital and Initial Management of Acute Coronary Syndrome

Pre Hospital and Initial Management of Acute Coronary Syndrome Pre Hospital and Initial Management of Acute Coronary Syndrome Dr. Muhammad Fadil, SpJP 3rd SymCARD 2013 Classification of ACS ESC Guidelines for the management of Acute Coronary Syndrome in patients without

More information

Reperfusion therapy for ST-segment elevation myocardial infarction: a review of the available treatment options in Kuwait

Reperfusion therapy for ST-segment elevation myocardial infarction: a review of the available treatment options in Kuwait Reperfusion therapy for ST-segment elevation myocardial infarction: a review of the available treatment options in Kuwait Mohammad Zubaid 1, Wafa A. Rashed 2, Mustafa Ridha 3 CME Acute myocardial infarction

More information

A Report From the Second National Registry of Myocardial Infarction (NRMI-2)

A Report From the Second National Registry of Myocardial Infarction (NRMI-2) 1240 JACC Vol. 31, No. 6 Clinical Experience With Primary Percutaneous Transluminal Coronary Angioplasty Compared With Alteplase (Recombinant Tissue-Type Plasminogen Activator) in Patients With Acute Myocardial

More information

Acute Coronary Syndrome

Acute Coronary Syndrome Acute Coronary Syndrome Vik Gongidi, DO FACOI, FACC Indian River Medical Center Vero Beach, FL Slides adapted from Robert Bender, DO, FACOI, FACC Definition: Acute Myocardial Ischemia Unstable Angina Non-ST-Elevation

More information

Improving the Outcomes of

Improving the Outcomes of Improving the Outcomes of STEMI Shelley Valaire, ACP; and Robert Welsh, MD, FRCPC Presented at the University of Alberta s 6th Annual Cardiology Update for General Practitioners and Internists, Edmonton,

More information

Patient Transfer. Mark de Belder The James Cook University Hospital Middlesbrough

Patient Transfer. Mark de Belder The James Cook University Hospital Middlesbrough Patient Transfer Mark de Belder The James Cook University Hospital Middlesbrough Current Management Strategies for ACS ACS No ST Elevation ST ST Elevation Elevation Early Invasive Early Conservative Fibrinolysis

More information

Medicine Dr. Omed Lecture 2 Stable and Unstable Angina

Medicine Dr. Omed Lecture 2 Stable and Unstable Angina Medicine Dr. Omed Lecture 2 Stable and Unstable Angina Risk stratification in stable angina. High Risk; *post infarct angina, *poor effort tolerance, *ischemia at low workload, *left main or three vessel

More information

Critics of Thrombolytics: Is Pre-Hospital Clot-busting Actually a Bad Thing? David Persse, MD Houston Fire Department EMS

Critics of Thrombolytics: Is Pre-Hospital Clot-busting Actually a Bad Thing? David Persse, MD Houston Fire Department EMS Critics of Thrombolytics: Is Pre-Hospital Clot-busting Actually a Bad Thing? David Persse, MD Houston Fire Department EMS STEMI Stuff New or Recurrent MI s in U.S.: 865,000 Acute STEMI s: 500,000 Sooner

More information

Management of acute myocardial infarction in patients presenting with ST-segment elevation

Management of acute myocardial infarction in patients presenting with ST-segment elevation European Heart Journal (2003) 24, 28 66 Task Force Report Management of acute myocardial infarction in patients presenting with ST-segment elevation The Task Force on the Management of Acute Myocardial

More information

ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI): DECREASING THE TIME TO TREATMENT IN THE ED

ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI): DECREASING THE TIME TO TREATMENT IN THE ED ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI): DECREASING THE TIME TO TREATMENT IN THE ED W. Brian Gibler, MD Professor and Chairman; Department of Emergency Medicine, University of Cincinnati College

More information

Acute myocardial infarction (AMI) and unstable angina

Acute myocardial infarction (AMI) and unstable angina Part 8: Stabilization of the Patient With Acute Coronary Syndromes Acute myocardial infarction (AMI) and unstable angina (UA) are part of a spectrum of clinical disease collectively identified as acute

More information

STREAM - ONE YEAR MORTALITY STRATEGIC REPERFUSION EARLY AFTER MYOCARDIAL INFARCTION. STREAM 1Y AHA 2013 P Sinnaeve

STREAM - ONE YEAR MORTALITY STRATEGIC REPERFUSION EARLY AFTER MYOCARDIAL INFARCTION. STREAM 1Y AHA 2013 P Sinnaeve STREAM - ONE YEAR MORTALITY STRATEGIC REPERFUSION EARLY AFTER MYOCARDIAL INFARCTION PCI Hospital Ambulance/ER STREAM design STEMI

More information

Management of ST-elevation myocardial infarction Update 2009 Late comers: which options?

Management of ST-elevation myocardial infarction Update 2009 Late comers: which options? European Society of Cardiology Annual Session 2009 Management of ST-elevation myocardial infarction Update 2009 Late comers: which options? Antonio Abbate, MD Assistant Professor of Medicine Virginia Commonwealth

More information

Update on the management of STEMI. Elliot Rapaport, M.D. San Francisco, CA December 14, 2007

Update on the management of STEMI. Elliot Rapaport, M.D. San Francisco, CA December 14, 2007 Update on the management of STEMI Elliot Rapaport, M.D. San Francisco, CA December 14, 2007 Universal MI Definition Committee 2007 Recommendations Type 1 Spontaneous MI associated with ischemia and due

More information

Post-Reteplase Evaluation of Clinical Safety & Efficacy in Indian Patients (Precise-In Study)

Post-Reteplase Evaluation of Clinical Safety & Efficacy in Indian Patients (Precise-In Study) 30 Post-Reteplase Evaluation of Clinical Safety & Efficacy in Indian Patients (Precise-In Study) RK Singh 1, A Trailokya 2, MM Naik 3 Original Article Abstract Background: ST elevated myocardial infarction

More information

Angina Luis Tulloch, MD 03/27/2012

Angina Luis Tulloch, MD 03/27/2012 Angina Luis Tulloch, MD 03/27/2012 Acute coronary syndromes ACS STE > 1 mm, new LBBB* Increased cardiac enzymes STEMI Yes Yes NSTEMI No Yes UA No No *Recognize Wellen s sign/syndrome, posterior wall MI,

More information

Cardiogenic Shock. Carlos Cafri,, MD

Cardiogenic Shock. Carlos Cafri,, MD Cardiogenic Shock Carlos Cafri,, MD SHOCK= Inadequate Tissue Mechanisms: Perfusion Inadequate oxygen delivery Release of inflammatory mediators Further microvascular changes, compromised blood flow and

More information

Platelet glycoprotein IIb/IIIa inhibition in acute coronary syndromes

Platelet glycoprotein IIb/IIIa inhibition in acute coronary syndromes European Heart Journal (00) 3, 1441 1448 doi:10.1053/euhj.00.3160, available online at http://www.idealibrary.com on Platelet glycoprotein IIb/IIIa inhibition in acute coronary syndromes Gradient of benefit

More information

Simon Horne 1 Clive Weston 2 * Tom Quinn 3 Anne Hicks 4 Lynne Walker 5 Ruoling Chen 6 John Birkhead 5

Simon Horne 1 Clive Weston 2 * Tom Quinn 3 Anne Hicks 4 Lynne Walker 5 Ruoling Chen 6 John Birkhead 5 The impact of pre-hospital thrombolytic treatment on re-infarction rates: analysis of the Myocardial Infarction National Audit Project (MINAP). Simon Horne 1 Clive Weston 2 * Tom Quinn 3 Anne Hicks 4 Lynne

More information

Prehospital management of acute ST-elevation myocardial infarction: A time for reappraisal in North America

Prehospital management of acute ST-elevation myocardial infarction: A time for reappraisal in North America Progress in Cardiology Prehospital management of acute ST-elevation myocardial infarction: A time for reappraisal in North America Robert C. Welsh, MD, a Joseph Ornato, MD, b and Paul W. Armstrong, MD

More information

Thrombolysis in acute myocardial infarction: analysis of studies comparing accelerated t-pa and streptokinase

Thrombolysis in acute myocardial infarction: analysis of studies comparing accelerated t-pa and streptokinase 3'Accid Emerg Med 1999;16:407-41 1 Thrombolysis in acute myocardial infarction: analysis of studies comparing accelerated t-pa and streptokinase Brendon J Smith 407 Department of Emergency Medicine, Sutherland

More information

Pharmaco-Invasive Approach for STEMI

Pharmaco-Invasive Approach for STEMI Pharmaco-Invasive Approach for STEMI Michael C. Kontos, MD Medical Director, Coronary Intensive Care Unit Director, Chest Pain Evaluation Center Associate Professor Departments of Internal Medicine (Cardiology),

More information

Medical Management of Acute Coronary Syndrome: The roles of a noncardiologist. Norbert Lingling D. Uy, MD Professor of Medicine UERMMMCI

Medical Management of Acute Coronary Syndrome: The roles of a noncardiologist. Norbert Lingling D. Uy, MD Professor of Medicine UERMMMCI Medical Management of Acute Coronary Syndrome: The roles of a noncardiologist physician Norbert Lingling D. Uy, MD Professor of Medicine UERMMMCI Outcome objectives of the discussion: At the end of the

More information

ST-segment Elevation Myocardial Infarction (STEMI): Optimal Antiplatelet and Anti-thrombotic Therapy in the Emergency Department

ST-segment Elevation Myocardial Infarction (STEMI): Optimal Antiplatelet and Anti-thrombotic Therapy in the Emergency Department ST-segment Elevation Myocardial Infarction (STEMI): Optimal Antiplatelet and Anti-thrombotic Therapy in the Emergency Department decision-making. They have become the cornerstone of many ED protocols for

More information

OUTCOME OF THROMBOLYTIC AND NON- THROMBOLYTIC THERAPY IN ACUTE MYOCARDIAL INFARCTION

OUTCOME OF THROMBOLYTIC AND NON- THROMBOLYTIC THERAPY IN ACUTE MYOCARDIAL INFARCTION OUTCOME OF THROMBOLYTIC AND NON- THROMBOLYTIC THERAPY IN ACUTE MYOCARDIAL INFARCTION FEROZ MEMON*, LIAQUAT CHEEMA**, NAND LAL RATHI***, RAJ KUMAR***, NAZIR AHMED MEMON**** OBJECTIVE: To compare morbidity,

More information

Continuing Medical Education Post-Test

Continuing Medical Education Post-Test Continuing Medical Education Post-Test Based on the information presented in this monograph, please choose one correct response for each of the following questions or statements. Record your answers on

More information

PCI Strategies After Fibrinolytic Therapy

PCI Strategies After Fibrinolytic Therapy PCI Strategies After Fibrinolytic Therapy How to choose the appropriate reperfusion strategy. BY MICHEL R. LE MAY, MD Survival in patients presenting with ST-segment elevation myocardial infarction (STEMI)

More information

Practitioner Education Course

Practitioner Education Course 2015 Practitioner Education Course ST Elevation Myocardial Infarction 2 Pathology Concept of vulnerable plaque Mild Atheroma Diagnosis IVUS OCT 3 Diagnosis This is based on : Clinical History ECG Changes.

More information

CHAPTER-I MYOCARDIAL INFARCTION

CHAPTER-I MYOCARDIAL INFARCTION CHAPTER-I MYOCARDIAL INFARCTION Definition A myocardial infarction, more commonly known as MI or acute myocardial infarction (AMI) or heart attack is a condition where there is interruption of blood supply

More information

Clinical Case. Management of ACS Based on ACC/AHA & ESC Guidelines. Clinical Case 4/22/12. UA/NSTEMI: Definition

Clinical Case. Management of ACS Based on ACC/AHA & ESC Guidelines. Clinical Case 4/22/12. UA/NSTEMI: Definition Clinical Case Management of ACS Based on ACC/AHA & ESC Guidelines Dr Badri Paudel Mr M 75M Poorly controlled diabetic Smoker Presented on Sat 7pm Intense burning in the retrosternal area Clinical Case

More information

Continuing Medical Education Post-Test

Continuing Medical Education Post-Test Continuing Medical Education Post-Test Based on the information presented in this monograph, please choose one correct response for each of the following questions or statements. Record your answers on

More information

Objectives. Treatment of ACS. Early Invasive Strategy. UA/NSTEMI General Concepts. UA/NSTEMI Initial Therapy/Antithrombotic

Objectives. Treatment of ACS. Early Invasive Strategy. UA/NSTEMI General Concepts. UA/NSTEMI Initial Therapy/Antithrombotic Objectives Treatment of ACS Michael P. Gulseth, Pharm. D., BCPS Pharmacotherapy II Spring 2006 Define early invasive strategy and what patients typically receive this approach Compare/contrast the medications

More information

Facilitated Percutaneous Coronary Intervention in STEMI Patients: Does It Work in Asian Patients?

Facilitated Percutaneous Coronary Intervention in STEMI Patients: Does It Work in Asian Patients? Editorial Comment Acta Cardiol Sin 2014;30:292 297 Facilitated Percutaneous Coronary Intervention in STEMI Patients: Does It Work in Asian Patients? Wei-Chun Huang, 1,2,3 Cheng-Hung Chiang 1,2 and Chun-Peng

More information

Pathophysiology of ACS

Pathophysiology of ACS Pathophysiology of ACS ~ 2.0 MM patients admitted to CCU or telemetry annually 0.6 MM ST-segment elevation MI 1.4 MM Non-ST-segment elevation ACS NSTEMI vs STEMI VANQWISH Boden et al N Engl J Med 1998;338:1785-1792

More information

EFFICACY OF THROMBOLYTIC THERAPY IN PRESERVING LEFT VENTRICULAR FUNCTION FOLLOWING ACUTE MYOCARDIAL INFARCTION

EFFICACY OF THROMBOLYTIC THERAPY IN PRESERVING LEFT VENTRICULAR FUNCTION FOLLOWING ACUTE MYOCARDIAL INFARCTION EFFICACY OF THROMBOLYTIC THERAPY IN PRESERVING LEFT VENTRICULAR FUNCTION FOLLOWING ACUTE MYOCARDIAL INFARCTION SUMMARY ABID AMIN KHAN, NOOR AHMED, MAIMOONA INAYAT This study is a prospective study to determine

More information

How to give thrombolysis in acute myocardial infarction

How to give thrombolysis in acute myocardial infarction Page 1 of 6 How to give thrombolysis in acute myocardial infarction Original article: Michael Tam In the major urban hospitals, there will be little place for thrombolysis in acute STEMI (STelevation myocardial

More information

AIMS: CHEST PAIN. Causes of chest pain. Causes of chest pain: Cardiac causes: Acute coronary syndromes pericarditis thoracic aortic dissection

AIMS: CHEST PAIN. Causes of chest pain. Causes of chest pain: Cardiac causes: Acute coronary syndromes pericarditis thoracic aortic dissection CHEST PAIN Dr Susan Hertzberg Emergency Department Prince of Wales Hospital AIMS: To identify causes of chest pain in patients presenting to the ED. To identify and risk stratify patients presenting with

More information

Long-Term Prognostic Value of ST-Segment Resolution in Patients Treated With Fibrinolysis or Primary Percutaneous Coronary Intervention

Long-Term Prognostic Value of ST-Segment Resolution in Patients Treated With Fibrinolysis or Primary Percutaneous Coronary Intervention Journal of the American College of Cardiology Vol. 54, No. 19, 2009 2009 by the American College of Cardiology Foundation ISSN 0735-1097/09/$36.00 Published by Elsevier Inc. doi:10.1016/j.jacc.2009.03.084

More information

ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

ST SEGMENT ELEVATION MYOCARDIAL INFARCTION ST SEGMENT ELEVATION MYOCARDIAL INFARCTION John Harrison, (1693-1776) H4 (1760) H1 (1737) H2 (1741) H3 (1759) In the wake of Harrison s success with H-4, legions of watch makers took up the special calling

More information

Update on Antithrombotic Therapy in Acute Coronary Syndrome

Update on Antithrombotic Therapy in Acute Coronary Syndrome Update on Antithrombotic Therapy in Acute Coronary Syndrome Laura Tsang November 13, 2006 Objectives: By the end of this session, you should understand: The role of antithrombotics in ACS Their mechanisms

More information

Mortality from ST-segment elevated acute

Mortality from ST-segment elevated acute Choosing Pharmacotherapy for Primary PCI in Acute Myocardial Infarction A review of the agents and strategies commonly used during percutaneous intervention for ST-segment elevated myocardial infarction.

More information

9/24/2013. Thrombolytics in 2013: Never Say Never. September 19 th, 2013 Scott M Lilly, MD PhD. Clinical Case

9/24/2013. Thrombolytics in 2013: Never Say Never. September 19 th, 2013 Scott M Lilly, MD PhD. Clinical Case September 19 th, 2013 Scott M Lilly, MD PhD Thrombolytics in 2013: Never Say Never Clinical Case 2 1 Evolution of STEMI Therapy The importance of absolute rest in bed for several days is clear James B

More information

Thrombolysis, adjunctive pharmacology and interventions

Thrombolysis, adjunctive pharmacology and interventions ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation ESC Annual Congress Munich, 2012 Thrombolysis, adjunctive pharmacology and interventions

More information

Diagnosis and Management of Acute Myocardial Infarction

Diagnosis and Management of Acute Myocardial Infarction Diagnosis and Management of Acute Myocardial Infarction Acute Myocardial Infarction (AMI) occurs as a result of prolonged myocardial ischemia Atherosclerosis leads to endothelial rupture or erosion that

More information

Cindy Stephens, MSN, ANP Kelly Walker, MS, ACNP Peter Cohn, MD, FACC

Cindy Stephens, MSN, ANP Kelly Walker, MS, ACNP Peter Cohn, MD, FACC Cindy Stephens, MSN, ANP Kelly Walker, MS, ACNP Peter Cohn, MD, FACC Define Acute Coronary syndromes Explain the Cause Assessment, diagnosis and therapy Reperfusion for STEMI Complications to look for

More information

Οξύ στεφανιαίο σύνδρομο και καρδιογενής καταπληξία. Επεμβατική προσέγγιση. Σωτήριος Πατσιλινάκος Κωνσταντοπούλειο Γ.Ν. Ν. Ιωνίας

Οξύ στεφανιαίο σύνδρομο και καρδιογενής καταπληξία. Επεμβατική προσέγγιση. Σωτήριος Πατσιλινάκος Κωνσταντοπούλειο Γ.Ν. Ν. Ιωνίας Οξύ στεφανιαίο σύνδρομο και καρδιογενής καταπληξία. Επεμβατική προσέγγιση Σωτήριος Πατσιλινάκος Κωνσταντοπούλειο Γ.Ν. Ν. Ιωνίας ACUTE HEART FAILURE AND CAD: ACS / LV ischaemic dysfunction Mechanical complications

More information

The Need for Rescue PCI after Failed Fibrinolysis: Who, When and Why.

The Need for Rescue PCI after Failed Fibrinolysis: Who, When and Why. Implementing the pharmacoinvasive strategy in STEMI The Need for Rescue PCI after Failed Fibrinolysis: Who, When and Why. 7:20-7:40 Robert C. Welsh, MD, FRCPC, FESC, FAHA, FACC Professor of Medicine Director,

More information

ORIGINAL ARTICLE. Rescue PCI Versus a Conservative Approach for Failed Fibrinolysis in Patients with STEMI

ORIGINAL ARTICLE. Rescue PCI Versus a Conservative Approach for Failed Fibrinolysis in Patients with STEMI Heart Mirror Journal From Affiliated Egyptian Universities and Cardiology Centers Vol. 6, No. 3, 2012 ISSN 1687-6652 ORIGINAL ARTICLE for Failed Fibrinolysis in Patients with STEMI Mohamed Salem, MD, PhD;

More information

ACC/AHA Guidelines for the Management of Patients With ST-Elevation Acute Myocardial Infarction- Focus Emergency Care

ACC/AHA Guidelines for the Management of Patients With ST-Elevation Acute Myocardial Infarction- Focus Emergency Care ACC/AHA Guidelines for the Management of Patients With ST-Elevation Acute Myocardial Infarction- Focus Emergency Care A Report of the American College of Cardiology/American Heart Association Task Force

More information

QUT Digital Repository:

QUT Digital Repository: QUT Digital Repository: http://eprints.qut.edu.au/ This is the author s version of this journal article. Published as: Doggrell, Sheila (2010) New drugs for the treatment of coronary artery syndromes.

More information

Acute Coronary Syndrome (ACS) is the consequence of

Acute Coronary Syndrome (ACS) is the consequence of Clinical Practice Pharmaco-invasive Therapy for STEMI; The Most Suitable STEMI Reperfusion Therapy for Transferred Patients in Thailand Pradub Sukhum, MD. 1 1 Division of Cardiovascular Medicine, Bangkok

More information

Adenosine. poison/drug induced. flushing, chest pain, transient asystole. Precautions: tachycardia. fibrillation, atrial flutter. Indications: or VT

Adenosine. poison/drug induced. flushing, chest pain, transient asystole. Precautions: tachycardia. fibrillation, atrial flutter. Indications: or VT Adenosine Indications: 1. Narrow complex PSVT 2. Does not convert atrial fibrillation, atrial flutter or VT 1. Side effects include flushing, chest pain, transient asystole 2. May deteriorate widecomplex

More information

OVERVIEW ACUTE CORONARY SYNDROME SYMPTOMS 9/30/14 TYPICAL WHAT IS ACUTE CORONARY SYNDROME? SYMPTOMS, IDENTIFICATION, MANAGEMENT

OVERVIEW ACUTE CORONARY SYNDROME SYMPTOMS 9/30/14 TYPICAL WHAT IS ACUTE CORONARY SYNDROME? SYMPTOMS, IDENTIFICATION, MANAGEMENT OVERVIEW ACUTE CORONARY SYNDROME SYMPTOMS, IDENTIFICATION, MANAGEMENT OCTOBER 7, 2014 PETE PERAUD, MD SYMPTOMS TYPICAL ATYPICAL IDENTIFICATION EKG CARDIAC BIOMARKERS STEMI VS NON-STEMI VS USA MANAGEMENT

More information

Inter-regional differences and outcome in unstable angina

Inter-regional differences and outcome in unstable angina European Heart Journal (2000) 21, 1433 1439 doi:10.1053/euhj.1999.1983, available online at http://www.idealibrary.com on Inter-regional differences and outcome in unstable angina Analysis of the International

More information

Objectives. Identify early signs and symptoms of Acute Coronary Syndrome Initiate proper protocol for ACS patient 10/2013 2

Objectives. Identify early signs and symptoms of Acute Coronary Syndrome Initiate proper protocol for ACS patient 10/2013 2 10/2013 1 Objectives Identify early signs and symptoms of Acute Coronary Syndrome Initiate proper protocol for ACS patient 10/2013 2 Purpose of this Education Module: Chest Pain Center Accreditation involves

More information

ST Elevation Myocardial Infarction (STEMI) Reperfusion Order Set

ST Elevation Myocardial Infarction (STEMI) Reperfusion Order Set Form Title Form Number CH-0454 2018, Alberta Health Services, CKCM This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. The license does not

More information

The role of thrombolytic drugs in the management of myocardial infarction

The role of thrombolytic drugs in the management of myocardial infarction European Heart Journal (1996) 17 (Supplement F), 9-15 The role of thrombolytic drugs in the management of myocardial infarction Comparative clinical trials W. D. Weaver MITI Coordinating Center, Seattle,

More information

Optimal antiplatelet and anticoagulant therapy for patients treated in STEMI network

Optimal antiplatelet and anticoagulant therapy for patients treated in STEMI network Torino 6 Joint meeting with Mayo Clinic Great Innovation in Cardiology 14-15 Ottobre 2010 Optimal antiplatelet and anticoagulant therapy for patients treated in STEMI network Diego Ardissino Ischemic vs

More information

Clinical Seminar. Which Diabetic Patient is a Candidate for Percutaneous Coronary Intervention - European Perspective

Clinical Seminar. Which Diabetic Patient is a Candidate for Percutaneous Coronary Intervention - European Perspective Clinical Seminar Which Diabetic Patient is a Candidate for Percutaneous Coronary Intervention - European Perspective Stephan Windecker Department of Cardiology Swiss Cardiovascular Center and Clinical

More information

Journal of the American College of Cardiology Vol. 39, No. 11, by the American College of Cardiology Foundation ISSN /02/$22.

Journal of the American College of Cardiology Vol. 39, No. 11, by the American College of Cardiology Foundation ISSN /02/$22. Journal of the American College of Cardiology Vol. 39, No. 11, 2002 2002 by the American College of Cardiology Foundation ISSN 0735-1097/02/$22.00 Published by Elsevier Science Inc. PII S0735-1097(02)01856-9

More information

Myocardial Oxygen Supply. Ischemic Heart Disease. Autoregulation. Epidemiology of IHD. Myocardial Ischemia. Myocardial Oxygen Supply

Myocardial Oxygen Supply. Ischemic Heart Disease. Autoregulation. Epidemiology of IHD. Myocardial Ischemia. Myocardial Oxygen Supply Myocardial Oxygen Supply Ischemic Heart Disease Paul P. Dobesh, Pharm.D., BCPS St. Louis College of Pharmacy Therapeutics I Coronary blood flow coronary perfusion pressure myocardial contraction collateral

More information

Appendix: ACC/AHA and ESC practice guidelines

Appendix: ACC/AHA and ESC practice guidelines Appendix: ACC/AHA and ESC practice guidelines Definitions for guideline recommendations and level of evidence Recommendation Class I Class IIa Class IIb Class III Level of evidence Level A Level B Level

More information

Intraaortic Balloon Counterpulsation- Supportive Data for a Role in Cardiogenic Shock ( Be Still My Friend )

Intraaortic Balloon Counterpulsation- Supportive Data for a Role in Cardiogenic Shock ( Be Still My Friend ) Intraaortic Balloon Counterpulsation- Supportive Data for a Role in Cardiogenic Shock ( Be Still My Friend ) Stephen G. Ellis, MD Section Head, Interventional Cardiology Professor of Medicine Cleveland

More information

Time delays in instituting thrombolysis in acute myocardial infarction - a Singapore perspective

Time delays in instituting thrombolysis in acute myocardial infarction - a Singapore perspective Hong Kong Journal of Emergency Medicine Time delays in instituting thrombolysis in acute myocardial infarction - a Singapore perspective M Tiru and SH Goh The reduction of mortality from acute myocardial

More information

M A Brouwer, N Clappers, F W A Verheugt

M A Brouwer, N Clappers, F W A Verheugt Coronary disease ADJUNCTIVE TREATMENT IN PATIENTS TREATED WITH THROMBOLYTIC THERAPY See end of article for authors affiliations Correspondence to: Professor F W A Verheugt, University Medical Center St

More information

The development of cardiogenic shock portends an extremely poor prognosis. Cardiogenic Shock: A Lethal Complication of Acute Myocardial Infarction

The development of cardiogenic shock portends an extremely poor prognosis. Cardiogenic Shock: A Lethal Complication of Acute Myocardial Infarction TREATMENT UPDATE Cardiogenic Shock: A Lethal Complication of Acute Myocardial Infarction David R. Holmes, Jr, MD Mayo Graduate School of Medicine, Mayo Clinic, Rochester, MN Cardiogenic shock is a serious

More information

MWLCEMS SYSTEM Continuing Education Packet Management of the Acute MI Patient

MWLCEMS SYSTEM Continuing Education Packet Management of the Acute MI Patient MWLCEMS SYSTEM Continuing Education Packet Management of the Acute MI Patient In this CE we will discuss the patient presenting with an acute ST-Elevation Myocardial Infarction (STEMI) Definition: Myocardial

More information

Journal of the American College of Cardiology Vol. 35, No. 4, by the American College of Cardiology ISSN /00/$20.

Journal of the American College of Cardiology Vol. 35, No. 4, by the American College of Cardiology ISSN /00/$20. Journal of the American College of Cardiology Vol. 35, No. 4, 2000 2000 by the American College of Cardiology ISSN 0735-1097/00/$20.00 Published by Elsevier Science Inc. PII S0735-1097(99)00643-9 Early

More information

ACS and Heart Failure

ACS and Heart Failure ACS and Heart Failure Jonathon Firnhaber, MD, FAAFP Associate Professor The Brody School of Medicine at East Carolina University Greenville, North Carolina Learning Objectives Establish the diagnosis and

More information

Journal of the American College of Cardiology Vol. 36, No. 5, by the American College of Cardiology ISSN /00/$20.

Journal of the American College of Cardiology Vol. 36, No. 5, by the American College of Cardiology ISSN /00/$20. Journal of the American College of Cardiology Vol. 36, No. 5, 2000 2000 by the American College of Cardiology ISSN 0735-1097/00/$20.00 Published by Elsevier Science Inc. PII S0735-1097(00)00923-2 Facilitation

More information

STEMI 2014 YAHYA KIWAN. Consultant Cardiologist Head Of Cardiology Belhoul Specialty Hospital

STEMI 2014 YAHYA KIWAN. Consultant Cardiologist Head Of Cardiology Belhoul Specialty Hospital STEMI 2014 YAHYA KIWAN Consultant Cardiologist Head Of Cardiology Belhoul Specialty Hospital Aspiration Thrombectomy Manual aspiration thrombectomy is reasonable for patients undergoing primary PCI. I

More information

Acute coronary syndrome (ACS) is a potentially

Acute coronary syndrome (ACS) is a potentially DIAGNOSING ACUTE CORONARY SYNDROME AND DETERMINING PATIENT RISK Edith A. Nutescu, PharmD* ABSTRACT Acute coronary syndrome is a form of coronary artery disease and has a broad range of clinical presentations.

More information

Results of Ischemic Heart Disease

Results of Ischemic Heart Disease Ischemic Heart Disease: Angina and Myocardial Infarction Ischemic heart disease; syndromes causing an imbalance between myocardial oxygen demand and supply (inadequate myocardial blood flow) related to

More information