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Acute coronary syndrome

Acute coronary syndrome, NSTEMI, STEMI, UA, unstable angina, Cardiology, rounds, IM, Internal Medicine, Cebu, CDUH, Evardone

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Acute coronary syndrome

  1. 1. ACUTE CORONARY SYNDROME Jose Socrates ‘Dee’ Matuod Evardone Cardiology RIC Level II CDUH-IM JULY 2015
  2. 2. CASE Profile: 78F, Filipino Hypertensive, Non-DM, Non-smoker, Non-alcoholic beverage drinker CC: CHEST PAIN
  3. 3. CASE HPI: 2 hours PTA- sudden onset of squeezing, retrosternal chest pain, radiating towards the neck, associated with headache. (+) Vomiting x1, pain score of 8/10, not relieved by rest, about >10 minutes. Admitted at primary hospital and managed as essential hypertension with NSSTWCs on ECG. Subsequently transferred to a Tertiary level for further workup and management
  4. 4. CASEPhysical Exam Awake, coherent, in mild distress Warm, good turgor and mobility, CRT <2 seconds, Anicteric sclerae, pink palpebral conjunctivae, Equal chest expansion, dec BS on both lower lung fields, with crackles Distinct heart sounds, , tachycardic, regular, no murmur Flat, Normoactive bowel sounds, soft, no organomegaly Strong peripheral pulses, no edema Neurologic: WNL BP: 130/60mmHg, HR: 118 bpm, RR: 26 cpm, 99% O2 mp: 36.5° Neck: No JVD, no murmur
  6. 6. CASE DIAGNOSTICS: ECG – Sinus Rhythm with NSSTWCs CXR – Beginning congestion, inflammatory process bilaterally Troponin I – 3.13 (elevated)
  7. 7. CASE MANAGEMENT: (ER) Aspirin 80 mg 4 tabs chewed, swallowed Clopidogrel 75mg , 4 tabs Clexane 0.4cc Attached to cardiac monitor Advised ICU/CCU admission
  9. 9. ACUTE CORONARY SYNDROME I: Diagnosis and Management of Patients with Stable Ischemic Heart Disease II: Diagnosis and Management of Patients with Non-ST Elevation Acute Coronary Syndrome III: Diagnosis and Management of Patients with ST Segment Elevation Myocardial Infarction
  10. 10. ACUTE CORONARY SYNDROME What is ACS? - refers to a spectrum of clinical presentations ranging from those for ST-segment elevation myocardial infarction (STEMI) to presentations found in non–ST- segment elevation myocardial infarction (NSTEMI) or in unstable angina - in general reserved for ischemia precipitated by acute coronary atherothrombosis
  11. 11. Ischemic Heart Disease
  12. 12. ACUTE CORONARY SYNDROME Ischemic Heart Disease Chronic coronary artery disease (CAD) with STABLE ANGINA Acute Coronary Syndrome STEMI 1) NSTEMI-ACS 2) Unstable Angina
  13. 13. ACUTE CORONARY SYNDROME Classic manifestation of ischemia is angina pectoris: Pressure, Tightness, Squeezing, Heaviness, Burning ACS most commonly occurs without obvious precipitating factors
  14. 14. Coronary Circulation
  15. 15. Coronary Circulation
  16. 16. Coronary Circulation
  17. 17. LOCALIZATION OF CORONARY CIRCULATION IN M.I. ANATOMIC ECG LEADS CORONARY ARTERY Septal V1-v2 Proximal LAD Anterior V3-V4 LAD Apical V5-V6 Distal LAD, LCx, or RCA Lateral I, aVL LCx Inferior II, III, aVF RCA(85%), LCx (15%) RV V1-V2 & V4R (most Se) Proximal RCA Posterior ST depression V1-V3 RCA or LCx
  20. 20. ACUTE CORONARY SYNDROME The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines list the following as pain descriptions uncharacteristic of myocardial ischemia: • Pleuritic pain (i.e., sharp or knifelike pain brought on by respiratory movements or coughing) • Primary or sole location of the discomfort in the middle or lower abdominal region • Pain that may be localized by the tip of one finger, particularly over the left ventricular apex • Pain reproduced with movement or palpation of the chest wall or arms • Constant pain that persists for many hours • Very brief episodes of pain that last a few seconds or less • Pain that radiates into the lower extremities
  22. 22. Ischemic Heart Disease The major determinants of myocardial oxygen demand (MVO2) are: 1) heart rate, 2) myocardial contractility, and 3) myocardial wall tension (stress) About 75% of the total coronary resistance to flow occurs across three sets of arteries: (1) large epicardial arteries (Resistance 1 = R1), (2) prearteriolar vessels (R2), and (3) arteriolar and intramyocardial capillary vessels (R3)
  23. 23. 50% Stenosis: there is a limitation of the ability to increase flow to meet increased myocardial demand. 80% Stenosis: myocardial ischemia at rest or with minimal stress Ischemic Heart Disease Coronary Blood Flow Limitation: • spasm, • arterial thrombi, and, • rarely, coronary emboli • as well as by ostial narrowing due to aortitis • Congenital Anomalies
  25. 25. The severity and duration of the imbalance between myocardial oxygen supply and demand determine whether the damage is :  reversible (≤20 min for total occlusion in the absence of collaterals) or  permanent, with subsequent myocardial necrosis (>20 min). Ischemic Heart Disease
  26. 26. ACUTE CORONARY SYNDROME Evaluation of the patient with known or suspected ischemic heart disease
  27. 27. Requirements : • Two sets of cardiac enzymes at 4-hr intervals should be normal • ECG at the time of arrival and preexercise 12-lead ECG show no significant abnormality • Absence of rest electrocardiographic abnormalities that would preclude accurate assessment of the exercise ECG • From admission to the time that results are available from the second set of cardiac enzymes: patient asymptomatic, lessening chest pain symptoms, or persistent atypical symptoms • Absence of ischemic chest pain at the time of exercise testing Indications and Contraindications for Exercise Electrocardiographic Testing in the Emergency Department Contraindications • New or evolving electrocardiographic abnormalities on the rest tracing • Abnormal cardiac enzyme levels • Inability to perform exercise • Worsening or persistent ischemic chest pain symptoms from admission to the time of exercise testing • Clinical risk profiling indicating that imminent coronary angiography is likely
  28. 28. A C U T E C O R O N A R Y S Y N D R O M E
  30. 30. STABLE ISCHEMIC HEART DISEASE Laboratory Tests: 1. Fasting lipid profile 2. Fasting glucose and/or glycated hemoglobin (HbA1c) level if available; additional oral glucose tolerance test (OGTT) if both are inconclusive; 3. Complete blood count (CBC); 4. Creatinine level with estimation of glomerular filtration rate (GFR); 5. Biochemical markers of myocardial injury (Troponin T or I) if clinical evaluation suggests an Acute Coronary Syndrome (ACS); 6. Thyroid hormone levels 7. Liver function tests early after beginning statin therapy.
  31. 31. ISCHEMIC HEART DISEASE Pre-Test Probability (PTP) Assessment Diamond and Forrester pre-test probability of cad by age, sex and symptoms
  33. 33. ISCHEMIC HEART DISEASE ESTABLISHING DIAGNOSIS Non-invasive stress testing Stress Imaging
  35. 35. ISCHEMIC HEART DISEASE ESTABLISHING DIAGNOSIS Exercise ECG (Treadmill Exercise Test or TET) its simplicity, lower cost and widespread availability, the TET is the initial test of choice to identify inducible ischemia in the majority of patients with intermediate PTP who are able to exercise The low sensitivity of the TET (45% to 50%) despite a high specificity (85% to 90%) is the reason why it is not recommended in patients with a PTP greater than 65% In the latter case,a stress imaging study is more appropriate.
  36. 36. ISCHEMIC HEART DISEASE CORONARY ARTERIOGRAPHY Coronary arteriography is indicated in: (1) patients with chronic stable angina pectoris who are severely symptomatic despite medical therapy and are being considered for revascularization, i.e., a percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG); (2) patients with troublesome symptoms that present diagnostic difficulties in whom there is a need to confirm or rule out the diagnosis of IHD; (3) patients with known or possible angina pectoris who have survived cardiac arrest; (4) patients with angina or evidence of ischemia on noninvasive testing with clinical or laboratory evidence of ventricular dysfunction; and (5) patients judged to be at high risk of sustaining coronary events based on signs of severe ischemia on noninvasive testing, regardless of the presence or severity of symptoms
  37. 37. ISCHEMIC HEART DISEASE MANAGEMENT Lifestyle Modification and Treatment of Risk Factors 1) Healthy Diet 2) Physical Activity 3) Hypertension 4) Smoking 5) DM 6) Weight Management 7) Lipid Management
  38. 38. ISCHEMIC HEART DISEASE MANAGEMENT Pharmacologic Therapy to Improve Prognosis Whether or not revascularization is being considered, receive the following medications to improve prognosis, thereby reducing the risk for MI and death: 1. Aspirin low-dose (80 to 160 mg/day) 2. Clopidogrel in case of aspirin intolerance (75 mg/day) 3. Statins irrespective of LDL-cholesterol levels 4. Beta blockers post-MI 5. ACEIs or ARBs (especially in patients with concomitant HF, hypertension or diabetes)
  39. 39. Pharmacologic Therapy to Improve Prognosis
  40. 40. Pharmacologic Therapy to Improve Prognosis
  41. 41. Pharmacologic Therapy to Improve Prognosis
  42. 42. R E V A S C U L A R I Z A T I O N
  43. 43. Non-ST-Segment Elevation Acute Coronary Syndrome (Non-ST-Segment Elevation Myocardial Infarction and Unstable Angina)
  44. 44. NSTE-ACS Pathophysiology: 1. imbalance between oxygen supply and oxygen demand resulting from a partially occluding thrombus forming on a disrupted atherothrombotic coronary plaque or on eroded coronary artery endothelium 2. dynamic obstruction 3. severe mechanical obstruction 4. increased myocardial oxygen demand
  45. 45. NSTE-ACS
  46. 46. NSTE-ACS
  47. 47. NSTE-ACS DIAGNOSIS: Clinical : (1) it occurs at rest (or with minimal exertion), lasting >10 minutes; (2) it is of relatively recent onset (i.e., within the prior 2 weeks); and/or (3) it occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than previous episodes) NSTEMI - elevated levels of biomarkers of cardiac necrosis
  48. 48. NSTE-ACS DIAGNOSIS: 3 major noninvasive tools are used in the evaluation of NSTEMI-ACS: 1. the electrocardiogram (ECG), 2. cardiac biomarkers, and 3. stress testing GOALS : (1) recognize or exclude myocardial infarction (MI) using cardiac biomarkers, preferably cTn; (2) detect rest ischemia (using serial or continuous ECGs); and (3) detect significant coronary obstruction at rest with CCTA and myocardial ischemia using stress testing
  49. 49. C a u s e s o f e l e v a t e d t r o p o n i n
  50. 50. C a u s e s o f e l e v a t e d t r o p o n i n
  51. 51. MEDICAL TREATMENT • Bed rest • Continuous ECG monitoring • Ambulation only if No recurrence of ischemia (symptoms or ECG changes) Does not develop an elevation of a biomarker of necrosis for 12–24 h ANTI-ISCHEMIC ANTITHROMBOTIC
  52. 52. NSTE-ACS Drugs Commonly Used in Intensive Medical Management of Patients with UA and NSTEMI
  54. 54. NSTE-ACS ORAL ANTIPLATELETS Aspirin Initial dose of 325 mg nonenteric formulation followed by 75–100 mg/d of an enteric or a nonenteric formulation Clopidogrel Loading dose of 300–600 mg followed by 75 mg/d Prasugrel Pre-PCI: Loading dose 60 mg followed by 10 mg/d Ticagrelor Loading dose of 180 mg followed by 90 mg twice daily Intravenous Antiplatelet Therapy Abciximab 0.25 mg/kg bolus followed by infusion of 0.125 μg/ kg per min (maximum 10 μg/min) for 12–24 h Eptifibatide 180 μg/kg bolus followed 10 min later by second bolus of 180 μg with infusion of 2.0 μg/kg per min for 72–96 h following first bolus Tirofiban 5 μg/kg per min followed by infusion of 0.15 μg/kg per min for 48– 96 h
  55. 55. NSTE-ACS HEPARINS Unfractionated heparin (UFH) Bolus 70–100 U/kg (maximum 5000 U) IV followed by infusion of 12–15 U/kg per h (initial maximum 1000 U/h) titrated to ACT 250–300 s Enoxaparin 1 mg/kg SC every 12 h; the first dose may be preceded by a 30-mg IV bolus; renal adjustment to 1 mg/kg once daily if creatine clearance <30 cc/min Fondaparinux 2.5 mg SC qd Bivalirudin Initial IV bolus of 0.75 mg/kg and an infusion of 1.75 mg/kg per h.
  56. 56. NSTE-ACS Class I Recommendations for Use of an Early Invasive Strategy in Patients with Non-ST-Segment Elevation Acute Coronary Syndrome: Class I (Level of Evidence: A) Indications 1. Recurrent angina at rest/low-level activity despite treatment 2. Elevated TnT or TnI 3. New ST-segment depression 4. CHF symptoms, rales, MR 5. EF <0.40 6. Sustained VT 7. PCI <6 months, prior CABG 8. High-risk findings from noninvasive testing 9. Hemodynamic instability 10. Mild-to-moderate renal dysfunction 11. Diabetes mellitus 12. High TIMI Risk Score (>3)b
  57. 57. NSTE-ACS PRINZMETAL’S VARIANT ANGINA - syndrome of severe ischemic pain that usually occurs at rest and is associated with transient ST segment elevation - focal spasm of an epicardial coronary artery, leading to severe transient myocardial ischemia and occasionally infarction - may be related to hypercontractility of vascular smooth muscle due to adrenergic vasoconstrictors, leukotrienes, or serotonin - has decreased substantially during the past few decades - PVA are generally younger and have fewer coronary risk factors - The clinical diagnosis of PVA is made by the detection of transient ST-segment elevation with rest pain - Focal spasm is most common in the right coronary artery
  58. 58. NSTE-ACS PRINZMETAL’S VARIANT ANGINA Diagnosis: Hyperventilation or intracoronary acetylcholine has been used to provoke focal coronary stenosis on angiography or to provoke rest angina with ST-segment elevation to establish the diagnosis TREATMENT Nitrates and Calcium Channel Blockers Aspirin- may actually increase the severity of ischemic episodes PROGNOSIS 1. Survival at 5 years is excellent (∼90–95%) 2. Nonfatal MI occurs in up to 20% of patients by 5 years 3. There is a tendency for symptoms 4. and cardiac events to diminish over time
  59. 59. NSTE-ACS CORONARY ANGIOGRAPHY IS NOT RECOMMENDED in patients with • extensive co-morbidities (e.g., liver or pulmonary failure; cancer); • in whom the risks of revascularization are not likely to outweigh the benefits; • in patients with acute chest pain and a low likelihood of ACS; • or in patients who will not consent to revascularization regardless of the findings.
  60. 60. NSTE-ACS Revascularization by PCI PCI IS RECOMMENDED for NSTE-ACS patients with 1- to 2-vessel CAD, with or without significant proximal left anterior descending CAD, but with a large area of viable myocardium and high-risk criteria on noninvasive testing.
  61. 61. NSTE-ACS Revascularization by CABG Surgery CABG IS RECOMMENDED for patients with 1. significant left main disease, and is the preferred revascularization strategy for patients with 2. multi-vessel coronary disease; 3. vessels with lesions not favorable for PCI; 4. depressed systolic function (LVEF lower than 50%); and diabetes.
  62. 62. NSTE-ACS Drug/Medication Management Strongly RECOMMENDED for patients with 1. aspirin indefinitely, and ticagrelor 90 mg twice daily or clopidogrel 75 mg daily, for 12 months 2. underwent stenting, with aspirin indefinitely, plus ticagrelor 90 mg twice daily or prasugrel 10 mg daily or clopidogrel 75 mg daily, for 12 months in patients with drug-eluting stents, and 6 months in patients with bare metal stents 3. beta blockers be continued indefinitely for all NSTE- ACS patients unless contraindicated
  63. 63. ST-Segment Elevation Myocardial Infarction (STEMI)
  66. 66. STEMI Criteria for Acute Myocardial Infarction • Detection of a rise and/or fall of cardiac biomarker values (preferably cardiac troponin [cTn]) with at least one value above the 99th percentile upper reference limit (URL) and with at least one of the following: • Symptoms of ischemia • New or presumed new significant ST-segment T-wave (ST-T) changes or new left bundle branch block (LBBB) • Development of pathologic Q waves in the electrocardiogram (ECG) • Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality • Identification of an intracoronary thrombus by angiography or autopsy • Cardiac death with symptoms suggestive of myocardial ischemia and presumed new ischemic ECG changes of new LBBB, but death occurred before cardiac biomarkers were obtained or before cardiac biomarker values would be increased.
  67. 67. STEMI Criteria for Acute Myocardial Infarction • Percutaneous coronary intervention (PCI)–related MI is arbitrarily defined by elevation of cTn values (>5 × 99th percentile URL) in patients with normal baseline values (≤99th percentile URL) or a rise of cTn values >20% if the baseline values are elevated and are stable or falling. In addition, either • Coronary artery bypass grafting (CABG)–related MI is arbitrarily defined by elevation of cardiac biomarker values (>10 × 99th percentile URL) in patients with normal baseline cTn values (≤99th percentile URL). In addition, either (i) symptoms suggestive of myocardial ischemia, or (ii) new ischemic ECG changes, or (iii) angiographic findings consistent with a procedural complication, or (iv) imaging demonstration of new loss of viable myocardium or new regional wall motion abnormality are required. • Stent thrombosis associated with MI when detected by coronary angiography or autopsy in the setting of myocardial ischemia and with a rise and/ or fall of cardiac biomarker values with at least one value above the 99th percentile URL. (i) new pathologic Q waves or new LBBB, or (ii) angiographic documented new graft or new native coronary artery occlusion, or (iii) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.
  68. 68. STEMI Classification of Myocardial Infarction Type I: Spontaneous Myocardial Infarction Type 2: Myocardial Infarction Secondary to an Ischemic Imbalance Type 3: Myocardial Infarction Resulting in Death When Biomarker Values Are Unavailable Type 4a: Myocardial Infarction Related to Percutaneous Coronary Intervention (PCI) Type 4b: Myocardial Infarction Related to Stent Thrombosis Type 5: Myocardial Infarction Related to Coronary Artery Bypass Grafting (CABG
  70. 70. STEMI the goals for the management of patients with suspected STEMI include: 1. control of cardiac discomfort, 2. rapid identification of patients who are candidates for urgent reperfusion therapy, 3. triage of lower-risk patients to the appropriate location in the hospital, and 4. avoidance of inappropriate discharge of patients with STEMI MANAGEMENT IN THE EMERGENCY DEPARTMENT Aspirin is essential in the management of patients with suspected STEMI and is effective across the entire spectrum of acute coronary syndromes OXYGEN O2 should be administered by nasal prongs or face mask (2–4 L/min) for the first 6–12 h after infarction
  71. 71. STEMI 1) Sublingual nitroglycerin Up to three doses of 0.4 mg should be administered at about 5-min intervals 2) Morphine 3) Intravenous beta blockers/ Oral Beta blockers CONTROL OF DISCOMFORT in the first 24 h for patients who do not have any of the following: (1) signs of heart failure, (2) evidence of a low-output state, (3) increased risk for cardiogenic shock, or (4) other relative contraindications to beta blockade (PR interval greater than 0.24 seconds, second- or third-degree heart block, active asthma, or reactive airway disease). Fifteen minutes after the last intravenous dose, an oral regimen is initiated of 50 mg every 6 h for 48 h, followed by 100 mg every 12 h
  72. 72. STEMI
  73. 73. STEMI Initial ER Management • Aspirin 160 to 320 mg tablet (non-enteric coated, chewed); • Clopidogrel 300 to 600 mg whether or not fibrinolysis will be given; • Clopidgrel 600 mg or prasugrel 60 mg or ticagrelor 180 mg when a patient will undergo PCI; • Nitrates, either via sublingual or intravenous(IV) routes. Nitrates are contraindicated in patients with hypotension or those who took a phosphodiesterase 5 (PDE5) inhibitor within 24 hrs (48 hrs for tadalafil); • Morphine 2 to 4 mg IV for relief of chest pain, and; • Supplemental oxygen MAY BE RECOMMENDED during the first 6 hours to patients with arterial oxygen saturation of less than 90%.
  74. 74. STEMI In-hospital Treatment Reperfusion therapy IS RECOMMENDED to all eligible patients with STEMI with symptom onset within the prior 12 hours. Early revascularization, the goal being 12 hours, is a primary treatment goal in patients with STEMI
  75. 75. STEMI
  76. 76. STEMI Fibrinolysis 15-mg bolus followed byTPA • 50 mg intravenously over the first 30 min, • followed by 35 mg over the next 60 min 1.5 million units (MU) intravenously over 1 hStreptokinase given as a single weight-based intravenous bolus of 0.53 mg/kg over 10 s Tenecteplase (TNK) double-bolus regimen consisting of a 10-MU bolus given over 2–3 min, followed byReteplase (rPA) • second 10-MU bolus 30 min later
  77. 77. STEMI
  78. 78. STEMI
  79. 79. STEMI TIMI FLOW GRADE — The degree of perfusion in the infarct-related artery (IRA) is typically described by the TIMI flow grade: ●TIMI 0 refers to the absence of antegrade flow beyond a coronary occlusion. ●TIMI 1 flow is faint antegrade coronary flow beyond the occlusion, although filling of the distal coronary bed is incomplete. ●TIMI 2 flow is delayed or sluggish antegrade flow with complete filling of the distal territory. ●TIMI 3 flow is normal flow which fills the distal coronary bed completely. TIMI
  80. 80. STEMI Primary Percutaneous Coronary Intervention (PCI) 1. RECOMMENDED in patients with STEMI and ischemic symptoms of less than 12 hours’ duration 2. RECOMMENDED in patients with STEMI and ischemic symptoms of less than 12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from first medical contact. 3. RECOMMENDED in patients with STEMI and cardiogenic shock or acute severe heart failure (HF), irrespective of time delay from MI onset 4. MAY BE RECOMMENDED in patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia between 12 and 24 hours after symptom onset
  81. 81. STEMI Coronary Artery Bypass Grafting (CABG) 1. IS RECOMMENDED in failed PCI with persistent pain or hemodynamic instability in patients with coronary anatomy suitable for surgery 2. IS RECOMMENDED in persistent or recurrent ischemia refractory to medical therapy in patients who have coronary anatomy suitable for surgery, and are not candidates for PCI or fibronolytic therapy 3. RECOMMENDED in patients with STEMI at the time of operative repair of mechanical defects.
  82. 82. STEMI Antiplatelets and Antithrombotics 1. It IS RECOMMENDED that aspirin should be used indefinitely in all patients with STEMI with a dosage of 80 to 100 mg/day. 2. It IS RECOMMENDED that clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI and maintained for at least 14 days 3. It IS RECOMMENDED that patients who are truly intolerant to aspirin can instead receive clopidogrel 75 mg per day as long-term secondary prevention
  83. 83. STEMI Duration of Dual Antiplatelet Therapy and Antithrombotic Combination Therapies after STEMI 1. Combination Therapies after STEMI DAPT by combining aspirin and an ADP-receptor blocker (clopidogrel, prasugrel or ticagrelor) IS RECOMMENDED in patients with STEMI who are undergoing primary PCI (for up to 12 months) or (clopidogrel) fibrinolysis (for up to 12 months, although the data available pertain only to one month of DAPT), and in those who have not undergone reperfusion therapy (for at least 1 month and up to 12 months).
  84. 84. STEMI Lipid Lowering Agents 1. High-dose statins are RECOMMENDED in all patients during the first 24 hours of admission for STEMI, irrespective of the patient’s cholesterol concentration, in the absence of contraindications (allergy, active liver disease). 2. Atorvastatin or Rosuvastatin are recommended during the early phase of therapy up to at least four weeks. 3. It IS RECOMMENDED to give high-dose rosuvastatin (20 to 40 mg) or atorvastatin (40 to 80 mg) therapy before emergency percutaneous coronary intervention to 1. reduce periprocedural inflammatory response, 2. to reduce myocardial dysfunction, and 3. to prevent contrast-induced nephropathy
  85. 85. THANK YOU
  87. 87. STABLE ISCHEMIC HEART DISEASE Recommended: Echocardiography Ambulatory ECG Monitoring
  88. 88. Ischemic Heart Disease
  89. 89. Ischemic Heart Disease
  95. 95. STEMI
  96. 96. STEMI
  97. 97. ACUTE CORONARY SYNDROME Definition of Myocardial Infarction
  98. 98. ACUTE CORONARY SYNDROME Classification of Myocardial Infarction