Transcript of "management of acute coronary syndrome"
D.Basem elsaid enany
Lecturer of cardiology
Cautious with nitartes+sildenafil or
1. Thienopyridine: If the patient is undergoing same day PCI, give
clopidogrel 600 mg; for patients undergoing early PCI in whom
thienopyridine is withheld before PCI AND who are not at high
risk of bleeding (age <75 years, weight ≥60 kilograms, no history of
stroke or TIA) give prasugrel 60 mg instead of clopidogrel
2. GP IIb/IIIa inhibitor (either eptifibatide or tirofiban) may be
added to or in place of clopidogrel in some circumstances (eg, high
risk patient). Abciximab is contraindicated in patients not referred
for cardiac catheterization.
** AIVR: incidence is about 2% ,after 72 h(10% in STEMI, first
AIVR is neither a sensitive nor very specific marker for
successful reperfusion with no ttt as usually transient.
•Sustained monomorphic VT that is hemodynamically
tolerated and asymptomatic can be treated initially with
intravenous amiodarone if fail after initial 150mg
Synchronized electrical cardioversion
•Electrolytes should be aggressively repleted (serum
potassium goal >4.0 meq/L and serum magnesium goal >2.0
The 2010 AHA guidelines give a weak recommendation
regarding the use of intravenous lidocaine for the treatment
of recurrent sustained VT, stating it should only be
considered for use if amiodarone is not available
--(no ttt for PVCs, NSVT)
-The AHA recommends that beta-blockers not be administered acutely in patients with ACS
or undifferentiated chest pain in the setting of cocaine useunopposed a-adrenergic effect
-The administration of labetolol in the setting of cocaine use is not recommended by the
AHA. Labetolol has substantially more beta-blocking than alphablocking effects.
-Not well studied: short-acting nifedipine should never be used, and verapamil and
diltiazem should be avoided in the setting of heart failure or decreased left ventricular
-Sinus tachycardia and atrial tachyarrhythmias may respond to benzodiazepines. In cases of
atrial tachyarrhythmias that do not respond to benzodiazepines, verapamil or diltiazem can
-Ventricular arrhythmias that occur immediately after cocaine use are thought to result from
effects on the sodium channel and may respond to the administration of sodium
bicarbonate, similar to arrhythmias associated with type IA and IC agents.
Ventricular arrhythmias that occur several hours after cocaine use usually are due to
ischemia. In case of persistent ventricular arrhythmias, lidocaine can be used.
Proinflammatory and prothrombotic effects of red blood
cell transfusion have been demonstrated.
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