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120 Cards in this Set
- Front
- Back
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Objectives of lab testing |
To detect the type of MI Extent Site To Detect complications |
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What is the most important tool in initial triage of mi in someone suspected to have ACS |
ECG |
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What are the other lab tests used |
Cardiac biomarkers-troponin -early within 6h of arrival Complete blood count
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Initial management |
IV access O2 if SpO2 <90 Immediately aspirin chewable non enteric coated Pain-nitroglycerin S/L /spray Morphine/ benzodiazepine |
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Other drugs used in ACUTE MI |
STATIN |
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Who should receive immediate invasive treatment |
STEMI STEMI complicated with cardiac arrest after resuscitation NSTEMI with high risk within 24h |
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Place of therapeutic hypothermia in STEMI |
For comatose patients with |
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Place of initial defibrillation in those with MI |
Most deaths caused by MI occur early and are attributable to primary ventricular fibrillation (VF). Therefore, initial objectives are immediate ECG monitoring; electric cardioversion in cases of VF. |
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Other ways of treating VF |
pharmacologic reduction of excessive sympathoadrenal and vagal stimulation treatment of hemodynamically significant or symptomatic ventricular arrhythmias generally with amiodarone and lidocaine |
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Drugs used for fibrinolysis in MI |
tissue-type plasminogen activator (t-PA), aspirin, and heparin as guided by ECG findings within 90 mins |
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What is the use of early thrombolysis |
It has a better outcome |
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Goals of treatment for all ACS |
• Restoration of the balance between oxygen supply and demand to prevent further ischemia • Pain relief • Prevention and treatment of complications |
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What is the place of O2 in MI |
Continuous oxygen saturation monitoring by pulse oximetry is needed for all patients. Supplemental O2 indicated only for patients who are breathless hypoxic (oxygen saturation < 90% or PaO2< 60 mm Hg[70] ), or who present with heart failure |
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What is the mode of giving O2 |
Supplemental oxygen by a mask or nasal cannula |
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What is the only exception for aspirin use at presentation.
Patients with aspirin intolerance still should receive aspirin at presentation. |
Clear history of aspirin allergy |
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Aspirin type best to use |
Chewable aspirin is preferred, as this promotes rapid absorption into the bloodstream to achieve faster therapeutic levels. |
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What can be used to reduce cardiac pain |
Nitrates most often Oral--> IV IV Morphine if pain not relieved |
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How does nitrates reduce cardiac pain |
By reducing O2 demand by reducing cardiac work load |
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How do nitrates reduce cardiac work load |
They Are potent vasodilators. mainly relax the venous system. Systemic venodilation results in reduction of venous blood return to the heart (ie, reducing the ventricular preload); this will lead to reduction of the workload of the heart, less oxygen demand, and reduction in ischemic pain.
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How do nitrates reduce cardiac pain due to coronary ischaemia |
Nitrates are also the most commonly used agents to reduce cardiac chest pain related to ischemia via coronary vasodilation; |
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What is the mode of giving nitrates |
Nitrates are usually given as a 0.4 mg dose in a sublingual tablet, followed by close observation of the effect on chest pain and the hemodynamic response. If the initial dose is well tolerated, further nitrates can be administered |
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What are the commonest side effects of nitrates |
hypotension and headache. |
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When do we IV nitrates |
When chest pain persists or recurs, IV nitrates are indicated, usually started at a dose of 5 to 10 µg/min and gradually increased until relief of chest pain is achieved |
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Contraindications for nitrates use |
patients presenting with marked hypotension or bradycardia, or if there is suspicion of right ventricular infarction. |
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Which drug combination results in life threatening hypotension |
Special attention should be made in taking the history of whether concomitant use of phosphodiesterase (PDE) inhibitors (eg, sildenafil) has occurred within the last 24 to 72 hours. |
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What is used for pain refractory to nitrates |
IV Morphine 2-4 mg with top ups every 10 mins |
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When should we stop Morphine |
until the pain is relieved or intolerance is manifested by hypotension, vomiting, or depressed respiration. |
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What can be used in case of Morphine toxicity |
antagonist such as naloxone is used for reversal. |
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What are the parameters to be monitored |
BP AND PULSE PRESSURE Systolic BP should be maintained above 100and below 140. |
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What is the place of NSAIDS in managing pain in MI |
nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided if at all possible, as the use of these agents has been associated with adverse cardiovascular events. |
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What are the key components of managing MI |
rapid recognition and timely reperfusion. |
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What is the principal determinant of the outcome of an MI |
The total ischaemic time |
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What is the timing of reperfusion treatment |
Mechanical / Pharmacological within 12h of symptom onset for those with |
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Who should undergo early reperfusion ASAP within 12h of symptom onset |
have persistent ST-segment elevation or new or presumed new left bundle branch block (LBBB) |
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In whom should we consider early reperfusion when presented even after 12h to 24h of symptom onset |
When there is clinical and/or ECG evidence of ongoing ischemia, with primary PCI being the preferred method in this population |
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After coming to the hospital within how Long should we commence mechanical thrombolysis |
emergent coronary angiography and primary PCI should be accomplished within 90 minutes. |
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What factors matter to still consider PCI when it is not initiated 120 mins following presentation |
fibrinolytic therapy: 1.The time from onset of symptoms 2.The risk of complications related to STEMI 3.The risk of bleeding with fibrinolysis therapy 4.The presence of shock or severe heart failure 5.The time required for transfer to a PCI-capable hospital |
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What is Primary percutaneous intervention |
emergent percutaneous coronary intervention in the setting of STEMI, without previous fibrinolytic treatment. |
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Which is better for STEMI PCI or FIBRINOLYTIC therapy. |
PCI achieves superior reperfusion outcomes and is associated with less complications, death, and long-term complications of STEMI when compared to fibrinolytic therapy. [ |
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In whom is PCI strongly recommended |
Those with STEMI presenting with symptoms of less than 12 hours' duration,
those who present with cardiogenic shock or who develop acute severe heart failure, irrespective of time of delay from onset of symptoms. |
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What is the place of dual anti platelet therapy in those who have undergone PCI |
Placement of coronary stents requires dual antiplatelet therapy for an extended time period |
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A major lethal complication of PCI in STEMI patients is |
Cardiac rupture |
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When should we consider Fibrinolytic therapy |
in settings where primary PCI cannot be offered to STEMI patients within the recommended timelines |
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In whom can we see the largest benefit from fibrinolytic therapy |
administered early (within 12 hours after symptomatic onset) and in patients with the highest cardiovascular risk, including patients older than 75 years. |
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What are the absolute contraindications for fibrinolytic therapy related to brain |
•Any prior intracranial hemorrhage Known structural cerebral vascular lesion •Known intracranial neoplasm (primary or metastatic) •Ischemic stroke within the past 3 months (except for acute stroke within 4.5 hours) •Significant closed-head or facial trauma within 3 months •Intracranial or intraspinal surgery within 2 months
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Which drug use is considered an absolute CI for fibrinolytic therapy |
streptokinase (no longer marketed in the US): Prior treatment within previous 6 months |
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What are the other absolute CI for fibrinolytic therapy |
• Suspected aortic dissection • Active bleeding or bleeding diathesis (excluding menses) • Severe uncontrolled hypertension (unresponsive to emergency therapy) |
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What are the relative contraindications for fibrinolytic therapy |
• History of chronic, severe, poorly controlled hypertension • Systolic pressure >180 mm Hg or diastolic pressure >110 mm Hg • History of prior ischemic stroke >3 months • Dementia • Known intracranial pathology not covered in absolute contraindications • Traumatic or prolonged CPR (>10 minutes) • Recent (within 2-4 weeks) internal bleeding • Noncompressible vascular punctures • Pregnancy • Active peptic ulcer disease • Current use of anticoagulants: The higher the INR, the higher the risk of bleeding • For streptokinase (no longer marketed in the US): Prior exposure (>5 days previously) or prior allergic reaction to these agents |
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Even though the best outcome of fibrinolytic therapy is achieved when it is given within 12 hours of symptom onset, in which conditions should we consider when presented after 12h |
symptomatic patients with a large area of myocardium at risk (based on ECG or cardiovascular imaging) or hemodynamic instability if PCI is unavailable |
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Fibrinolytic therapy is associated with increased risk of stroke. What are the conditions that increase this risk |
with advanced age, lower weight, female sex, prior cerebrovascular disease, and hypertension on admission |
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What are the two types of fibrinolytic drugs |
Non Fibrin specific -streptokinase Fibrin specific - considered better -Tenecteplase (TNK-tPA) Reteplase (rPA) Alteplase (tPA) |
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What is the place of CABG in ACUTE management of MI |
Despite great improvement of intraoperative myocardial preservation, CABG has a limited role in the acute management of STEMI. |
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What are the indications for CABG in MI |
cardiogenic shock, failed PCI, high-risk anatomy, surgical repair of a mechanical complication of STEMI (eg, ventricular septal rupture, free-wall rupture, or severe mitral regurgitation from papillary muscle dysfunction or rupture). For patients with unprotected left main disease |
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What is the place of anticoagulants in reperfusion therapy |
They are important adjunctive therapy for reperfusion therapy regardless of the strategy chosen (ie, whether it is primary PCI or fibrinolysis therapy) |
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What factors decide which anticoagulant to be used |
clinical context taking into account the method of reperfusion. |
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What are preferred in PCI |
unfractionated heparin (UFH), bivalirudin, low molecular weight heparin (LMWH) (eg, enoxaparin ) are the available options. |
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What is CI in PCI |
Fondaparinux is not used in this setting because of the increased risk of catheter thrombosis. |
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What is the place of anticoagulants in fibrinolytic therapy .UFH or LMWH may be used, with LMWH (enoxaparin) being preferred. |
In patients receiving fibrinolytic therapy, anticoagulation should be given until revascularization is performed; if reperfusion is not feasible anticoagulants should be given for at least 48 hours or for the duration of hospital stay up to 8 days. |
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Caution for the use of enoxaparin |
in patients older than 75 years as well as those with impaired renal function, because the use of enoxaparin is associated with a higher risk of intracranial bleeding. |
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What can be used for those with heparin induced thrombocytopenia |
Bivalirudin |
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What is the place of antiplatelets |
They should be given to all regardless of mode of therapy |
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Timing of the use of antiplatelets -ASPIRIN |
An emperic dose of Nonenteric-coated chewable aspirin 150 to 325 mg should be given to all patients with NSTE-ACS as soon as possible after presentation. A maintenance dose of aspirin 75-100 mg daily should be continued indefinitely life long.
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Timing of the use of antiplatelets - P2Y12 receptor inhibitors
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Initial loading dose-ClopidogrelA loading dose of clopidogrel 300-600 mg is recommended, followed by a maintenance dose of 75 mg daily up to 12 months for all
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What is the place of clopidogrel in ACS |
clopidogrel can be used in patients with NSTE-ACS who are intolerant to aspirin. In conjunction with Aspirin Clopidogrel loading dose of clopidogrel 300-600 mg is recommended, followed by a maintenance dose of 75 mg daily for for 1 year for all types of ACS
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For how long should we use clopidogrel |
For both post PCI/ Fibrinolysis it has to be continued for 1 year Post fibrinolytic therapy for a minimum of 14 days |
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What are the other antiplatelet agents given in STEMI |
adjunctive use of IV GP IIb/IIIa agents at the time of PCI can be considered on an individual basis for a large thrombus burden or inadequate P2Y12 receptor antagonist loading. |
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What are the treatment options for NSTE ACS |
an early invasive strategy with angiography, with intent for revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), or a conservative strategy with initial medical therapy and noninvasive cardiovascular imaging. |
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Who should undergo an early invasive strategy. |
Patients with refractory angina, clinical evidence of heart failure, or hemodynamic or electrical instability who do not have serious comorbidities or contraindications to angiography/PCI for patient who are stable but at a high risk for clinical events. |
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Timing for invasive therapy in NSTE ACS |
early invasive strategy within 24 hours of admission in patients with intermediate/high risk. For patients who fall out of this category a delayed invasive strategy within 25 to 72 hours of admission |
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When should beta blockers be initiated |
These agents are recommended to be given orally within the first 24 hours. |
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What are actions of beta blockers |
Beta blockers work by reduction of oxygen consumption of the myocardium by lowering the heart rate, blood pressure, and myocardial contractility.
They also play an important role in reduction of reinfarction and complex ventricular arrhythmias |
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What are the three drugs proven to reduce mortality in heart failure patients: |
metoprolol, carvedilol, or bisoprolol. |
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Beta blockers are contraindicated in |
first-degree heart block with a PR interval >240 ms, second or third-degree heart block without a cardiac pacemaker recent cocaine use severe/advanced active reactive airway disease |
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In whom is the IV form of beta blockers contraindicated |
with evidence of low cardiac output state (heart rate >110 beats/min or systolic blood pressure < 100 mmHg), |
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In whom should we use beta blockers with caution |
in elderly patients or in individuals with an unknown left ventricular ejection fraction |
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What is preferred for patients with chronic obstructive lung disease or chronic asthma, |
beta-1 selective beta blockers are preferred and should be initiated at low doses. |
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What is the place of CCB IN ACS |
Non-dihydropyridine calcium channel blockers (eg, verapamil or diltiazem) should be given for recurrent myocardial ischemia only if there are contraindications to using beta blockers. |
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What are the conditions to be cautious about in ACS |
Similar to beta blockers, use of non-dihydropyridine calcium channel blockers can also increase the likelihood of developing cardiogenic shock, thus, similar caution should be used. |
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What is the place of short acting nifedipine in ACS |
Avoid short-acting nifedipine in patients who are not receiving beta blockers, as this may result in increased mortality in patients with ACS |
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What is the place of anticoagulants in NSTE ACS |
Anticoagulant agents are recommended to be given to all patients with NSTE-ACS, regardless of the initial treatment strategy, in addition to antiplatelet therapy. |
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What are the types of anticoagulants |
LMWH-Enoxaparin Unfractionated Heparin Bivalirudin - direct thrombin inhibitor Fundoparinox - factor X inhibitor |
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For how long should the anticoagulants be used in NSTE ACS |
UH Dose adjusted with aPTT for 48h or until PCI commenced LMWH/ Bivalirudin / fundoparinox - For duration of hospital stay / until PCI performed
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What are the doses and frequencies of anticoagulants |
Unfractionated heparin (UH)An initial loading dose of 60 IU/kg (maximum 4,000 IU) with an initial infusion of 12 IU/kg per hour (maximum 1,000 IU/h) adjusted per activated partial thromboplastin time (PTT) is
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Dose and frequency |
Enoxaparin is given at a dose of 1 mg/kg subcutaneously (SC) every 12 hours |
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Dose and frequency |
Bivilirudin given as 0.1 mg/kg loading dose, followed by 0.25 mg/kg per hour only in patients managed with an early invasive strategy. |
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Dose and frequency |
Fundoparinox -once-daily SC injection of 2.5 mg, |
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CI for fundoparinox |
fondarparinux is contraindicated in patients with impaired kidney function. |
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Which is better of the two Enoxaparin UH |
Enoxaparin results in a more predictable and efficient anticoagulation compared to unfractionated heparin, leading to reduction in recurrent MI events |
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What are the long-term goals post stabilising acute MI |
restore normal activities, prevent long-term complications, as well as aggressively modify lifestyle and risk factors. |
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What are the cardioprotective drugs used post acute MI |
Inhibitors of the renin-angiotensin- aldosterone (RAA) system-ACEI(ARB)-For those with HTN, DM,EF less than 40%,stable ckd Aldosterone antagonist -who have had an MI with a reduced left ventricular ejection fraction of less than 40%, provided they have no renal impairment and have normal blood potassium levels (< 5 mEq/L). Beta blockers -After an MI, all patients should be maintained on a beta blocker. Statins-All patients with an acute MI should be started on high-potency statin therapy and continued indefinitely. |
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What is the place of statin post acute MI |
a reduction in mortality rates in patients who received high-potency statins after acute MI atorvastatin 40 mg or 80 mg, or rosuvastatin 20 mg. |
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What are the lifestyle modifications required for better long term reduction in recurrent MI and further progression of the disease |
dietary changes that adopt a low-fat and low-salt diet smoking cessation, up-to-date vaccination, and an increase in physical activity and exercise. |
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What is the role of exercise for long term benefit |
aerobic exercise training with the need for an evaluation of both exercise capacity and exercise-associated risk. The recommended frequency of regular exercise training is three or more times a week, for at least 30 minutes per session. |
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What are the special considerations for elderly people |
Elderly patients should be treated aggressively. However, this patient population with MI is at an increased risk for developing complications, such as a greater risk of bleeding with thrombolytic therapy, but they also have the most to gain from this treatment. |
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What is the treatment modality for the elderly |
Very elderly patients should undergo primary angioplasty if available, but they should receive thrombolytic agents if excessive delay is anticipated before angioplasty can be performed. |
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What are the complications of MI |
arrhythmic complications, mechanical complications, left ventricular aneurysm formation, ventricular septal rupture, associated right ventricular infarction, ventricular pseudoaneurysm, and other issue |
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When do cardiac arrhythmias occur in relation to MI |
During and after VF and other serious arrhythmias risk is greatest in 1st hour of an MI 25% of arrhythmias occur within 24h of an MI Most peri-infarction arrhythmias are benign and self-limited. |
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Q |
WOF Rx concerning the Rx of acute MI is correct?A prolonged PR developing within the first 24 hours requires urgent interventionDipyridamole therapy reduces re infarction within the first yearHeparin is beneficial if given within SKProphylactic lignocaine given in the first 48 hours is effective in preventing ventricular fibrillationCHB is more common in anterior MI than inferior MI |
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What are the drugs with survival benefit |
A |
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Q |
WOF drugs can be used in the symptom control of anginaAtenololDiltiazemNicorandilIvabradineRanolazine
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What is the place of nicorandil in angina |
It |
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What is the place of ranolazine in angina |
ItQ |
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What is the place of ivabadrin in angina |
It |
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What |
What |
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What are the cardioprotective medications ACEI/ARB |
Inhibitors of the renin-angiotensin-aldosterone (RAA) systemInitiate angiotensin-converting enzyme (ACE) inhibitors and continue administration indefinitely in all patients with a left ventricular ejection fraction that is less than 40% and in those with hypertension diabetes mellitus, or stable chronic kidney disease, unless contraindicated. (Angiotensin-receptor blockers (ARBs) are recommended in patients who are intolerant of ACE inhibitors.
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What is place of aldosterone as a cardioprotective drug |
Aldosterone blockers are recommended in addition to beta blockers and ACE inhibitors in patient who have had an MI with a reduced left ventricular ejection fraction of less than 40%, provided they have no renal impairment and have normal blood potassium levels (< 5 mEq/L).
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What is the place of beta-blockers as a cardioprotective drug |
Beta blockers After an MI, all patients should be maintained on a beta blocker. Current clinical practice guidelines recommend use of one of three beta blocker agents proven to reduce mortality in patients with heart failure: metoprolol, carvedilol, or bisoprolol. |
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Cardioprotective statin |
StatinsAll patients with an acute MI should be started on high-potency statin therapy and continued indefinitely.Current clinical practice guidelines, high potency statins such as atorvastatin 40 mg or 80 mg, or rosuvastatin 20 mg are recommended. The Effects of Atorvastatin on Early Recurrent Ischemic Events In Acute Coronary Syndromes (MIRACL) trial [115]and the Atorvastatin for Reduction of Myocardial Damage During Angioplasty-Acute Coronary Syndromes (ARMYDA-ACS) trial [116] demonstrated a reduction in mortality rates in patients who received high-potency statins after acute MI as compared to placebo. |
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Cardioprotective drugs |
ACEI ARB BETA BLOCKERS ALDOSTERONE ANTAGONISTS STATIN |
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Select the group of medication that is not used for patients with acute ST-elevation myocardial infarction. 1. Angiotensin converting enzyme inhibitors 2. Beta-blockers 3. Calcium channel blockers 4. Loop diuretics |
Well done! You answered successfullyTeaching PointsCalcium channel blockers can increase morbidity and mortality in patients with ST-elevation myocardial infarction.Medications proven to reduce mortality are beta blockers, thrombolytics, and angiotensin-converting enzyme inhibitors.Diuretics should be used as needed.Most calcium channel blockers are negative inotropes with no benefit on cardiac remodeling, their use in acute ST-elevation myocardial infarction can cause cardiac decompensation. |
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70-year-old female presents with acute ST elevation myocardial infarction and is treated with percutaneous coronary revascularization. Immediately after the procedure, the patient has several episodes of nonsustained ventricular tachycardia. Treatment with a statin, aspirin, beta blocker, and angiotensin converting enzyme inhibitor is instituted. There are no further arrhythmias. Select the next step in assessment and prevention. 1. Echocardiogram 2. Electrophysiologic testing 3. Holter monitor as an outpatient 4. No further assessment or treatment is necessary
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Well done! You answered successfullyTeaching PointsEchocardiography is indicated to assess the function of the left ventricle.The risk for future events would be best predicted by reduced left ventricular function.Arrhythmias during or just after revascularization are usually transient.Electrophysiologic studies are not indicated. A holter monitor is only needed if the patient has symptoms. |
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Which patient with myocardial infarction (MI) is a candidate for reperfusion therapy? 1. Non-Q wave MI 2. ST-elevation MI seen within 12 hours of onset of symptoms 3. Non-ST-elevation MI 4. None of the above |
Well done! You answered successfullyTeaching PointsPatients with ST-elevation myocardial infarction (STEMI) presenting within 12 hours of onset of symptoms are candidates for reperfusion therapy.Reperfusion therapy reduces infarct size.It also limits ventricular dysfunction and reduces serious complications.Reperfusion therapy is not appropriate for those with non-Q wave myocardial infarction and on-ST-elevation MI. |
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What is the most likely diagnosis of a 68-year-old male with chest pain and ST elevation three anterior leads? 1. Pulmonary embolism 2. Pneumothorax 3. Cardiac tamponade 4. Myocardial infarction
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Well done! You answered successfullyTeaching PointsAngina with ST change is highly suggestive of an MI.This is likely an anterior wall infarction.Leads V1-V4 are the anterior leads.V1 and V2 are associated with anterior infarctions involving the septum. |
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64-year-old male with a past medical history of diabetes mellitus, hypertension, obesity, and tobacco abuse presents to the emergency department in a rural area with crushing 10/10 substernal chest pain of 30 minutes duration. He receives 162 mg of aspirin and 0.4 mg of sublingual nitroglycerin en route to the hospital. Emergency medical services report ST elevations in V3-V6 which is corroborated by the EKG acquired upon arrival to the emergency department. Initial troponin is 14.6 ng/mL. What is the most appropriate next step in treatment? 1. Transfer to percutaneous coronary intervention (PCI) capable facility 4 hours away 2. Thrombolytic therapy followed by transfer to a PCI capable facility 4 hours away 3. Thrombolytic therapy followed by a heparin drip 4. Start patient on 1 mg/kg of low molecular weight heparin |
Well done! You answered successfullyTeaching PointsIn patients where percutaneous coronary intervention (PCI) cannot be performed in under 2 hours, the decision should be made to begin fibrinolytic therapy.Patients who receive thrombolytic therapy should still be transferred to a PCI capable facility to undergo PCI in the first 3 to 24 hours after the ST-elevation myocardial infarction.Thrombolytic therapy alone is only effective in 50% of patients.Thrombolysis or PCI treatment is the treatment for ST-elevation myocardial infarction, anticoagulation alone is not sufficient. |
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ACS |
STEMI NSTEMI UNSTABLE ANGINA |
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ACS |
STEMI NSTEMI UNSTABLE ANGINA |
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Treatment principles for all ACS |
Early reperfusion treatment PCI WITH ANGIOGRAPHY / THROMBOLYSIS |
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Time frame for PCI IN STEMI |
Within 12 h of onset of symptoms is the best
From 12 h to 24 h with with clinical or ECG evidence of ongoing ischemia
Regardless of time cardiogenic shock / acute severe heart failure
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Timely reperfusion |
With STEMI presenting within 12 h of onset of symptoms having persistent ST elevation in ECG or new or presume new LBBB. Need immediate PCI OR FIBRINOLYSIS |
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Treatment principles are the same |
For both STEMI AND NSTEMI REPERFUSION - ANTICOAGULATION - ANTIPLATELET AND CARDIOPROTECTIVE DRUGS BUT FOR STEMI 12 H FOR NSTEMI 24 H FOR REPERFUSION |
