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HỘI CHỨNG VÀNH CẤP CHẨN ĐOÁN VÀ ĐIỀU TRỊ
1. PGS.TS. Trương Quang Bình MD, PhD, FACC, FSCAI.
University Medical Center
HỘI CHỨNG VÀNH CẤP:
CHẨN ĐOÁN VÀ ĐiỀU TRỊ
2. TỶ LỆ NHẬP VIỆN Ở HOA KỲ DO
HỘI CHỨNG MẠCH VÀNH CẤP
Acute Coronary
Syndromes*
1.57 Million Hospital Admissions - ACS
UA/NSTEMI† STEMI
1.24 million Admissions
per year
0.33 million Admissions
per year
*Primary and secondary diagnoses. †About 0.57 million NSTEMI and 0.67 million UA.
Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69–171.
11. Thời gian tăng các biomarker cơ tim
sau khi bị NMCT cấp
Shapiro BP, Jaffe AS. Cardiac biomarkers. In: Murphy JG, Lloyd MA, editors. Mayo Clinic Cardiology: Concise Textbook. 3rd ed. Rochester, MN:
Mayo Clinic Scientific Press and New York: Informa Healthcare USA, 2007:773–80. Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Figure 5.
26. Điều trị cấp cứu chung
• Điều trị tại CCU, ICU
• Đường truyền, Oxygen
• Giảm đau
• Kháng tiểu cầu
• Kháng đông
• Nitrate
• Chẹn bêta
• Ức chế men chuyển
• Statin
• Kháng Aldosterone
27. CCU
• Theo dõi liên tục ECG, sinh hiệu
• Theo dõi xâm lấn: HA ĐM
• Đầy đủ các lọai thuốc : chống RLNT, suy bơm
• Máy sốc điện
• Máy thở
• IABP
29. Đường truyền
• Bắt buộc
• Kim lớn 18
• Xét nghiệm : men tim, CTM, Ion đồ, lipid
• Có thể phải truyền dịch, dùng thuốc đường
TM nhanh chóng (rối lọan nhịp, suy bơm)
30. Oxygen
• Chỉ định: giảm oxy máu,
• Liều lượng 2 – 4 lít phút, cao hơn nếu SpO 2
còn thấp.
• Nếu tăng oxy quá mức cần thiết có thể gây co
mạch: tăng HA, tăng kháng lực hệ thống
• KMĐM khi suy hô hấp.
• Thở máy nếu cần: giảm nhu cầu oxy cơ tim
31. Giảm đau
• Nitrate
• Chẹn bêta
• Morphine:
- Giảm đau trung ương
- Giảm đau giảm lo lắng giảm
catecholamine máu giảm nhu cầu oxy cơ tim
- 2-4 mg TM mỗi 5-10p cho đến khi có td phụ
- Phải có naloxone và atropine sẳn
32. Nitrate
• Td: dãn TM hệ thống, dãn ĐM vành giảm đau
ngực, có thể giảm size nhồi máu
• CCĐ: M<50, >110; HATT<90, NMCT thất P, hẹp
buồng tống thất T, có dùng thuốc điều trị rối lọan
cương trong vòng 36h
• Liều dùng: Nitroglycerin 0,4 mg NDL 1x3 lần
mỗi 5 phút TTM 10 mcg/p tăng dần mỗi 5 phút
cho đến khi kiểm sóat được đau
33. Nitrate: ACC/AHA
• Class I: NMCTC + Suy tim, trước rộng, Tăng
HA, TMCB kéo dài, đau ngực tái phát – phải
dùng trong 48 h đầu
• Class IIb: Dùng cho tất cả BN NMCT cấp mà
không có chống chỉ định
Không dùng lọai nitrate tác dụng dài
36. Chẹn bêta
• Td: giảm nhu cầu oxy cơ tim, giảm đau ngực,
giảm size nhồi máu
• Dùng sớm trong vòng 24 giờ nếu không CCĐ
• Metoprolol 5 mg TM mỗi 5 phút đến 3 liều nếu
huyết động ổn dạng uống
• Nếu ổn thì dùng lâu dài sau đó để phòng ngừa
thứ phát
37. CCĐ chẹn bêta
• Ran ẩm hơn 1/3 dưới hai phế trường
• HR < 60bpm
• HA tâm thu < 90 mmHg
• PR > 0,25 s
• High grade AV block, AV block III
• Co thắt PQ nặng
• Bệnh ĐM ngọai biên nặng
38. Beta Blockers
Oral beta blockers should be initiated in the first 24 hours
in patients with STEMI who do not have any of the
following: signs of HF, evidence of a low output state,
increased risk for cardiogenic shock,* or other
contraindications to use of oral beta blockers (PR interval
>0.24 seconds, second- or third-degree heart block, active
asthma, or reactive airways disease).
Beta blockers should be continued during and after
hospitalization for all patients with STEMI and with no
contraindications to their use.
I IIa IIb III
I IIa IIb III
*Risk factors for cardiogenic shock (the greater the number of risk factors present, the higher the
risk of developing cardiogenic shock) are age >70 years, systolic BP <120 mm Hg, sinus
tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of
STEMI.
39. Beta Blockers
Patients with initial contraindications to the use of beta
blockers in the first 24 hours after STEMI should be
reevaluated to determine their subsequent eligibility.
It is reasonable to administer intravenous beta blockers at
the time of presentation to patients with STEMI and no
contraindications to their use who are hypertensive or
have ongoing ischemia.
I IIa IIb III
I IIa IIb III
41. Ức chế men chuyển
• Td: giảm hậu tải, chống tái cấu trúc cơ tim
• Giảm tỷ lệ tử vong ngắn hạn
• Dùng trong 24 h đầu
• Lợi ích nhất cho BN có suy tim, NMCT vùng
trước, TS NMCT
• CCĐ: HA thấp, có suy thận
42. Thöïc haønh duøng UCMC trong NMCTC
Duøng sôùm, trong voøng 24 giôø sau NMCT caáp
Duøng: Lisinopril, Captopril, Enalapril, ramipril
Lieàu thöôøng duøng laø thấp
Trong quùa trình ñieàu trò: HA <100 mmHg
giaûm lieàu
Ngöng ñieàu trò khi HA ≤ 90 mmHg
Chuù yù BN coù TS THA: khoâng duøng hoaëc duøng
raát thaän troïng khi HA <120 mmHg. Deã bò tuït HA
ôû nhoùm BN naøy.
Tieáp tuïc duøng laâu daøi sau ñoù.
43. Renin-Angiotensin-Aldosterone
System Inhibitors
An ACE inhibitor should be administered within
the first 24 hours to all patients with STEMI with
anterior location, HF, or EF less than or equal to
0.40, unless contraindicated.
An ARB should be given to patients with
STEMI who have indications for but are
intolerant of ACE inhibitors.
I IIa IIb III
I IIa IIb III
44. Renin-Angiotensin-Aldosterone
System Inhibitors
An aldosterone antagonist should be given to
patients with STEMI and no contraindications
who are already receiving an ACE inhibitor and
beta blocker and who have an EF less than or
equal to 0.40 and either symptomatic HF or
diabetes mellitus.
ACE inhibitors are reasonable for all patients
with STEMI and no contraindications to their
use.
I IIa IIb III
I IIa IIb III
46. 9/12/2016TS.BS DO QUANG HUAN
Tất cả Bệnh nhân HCVC, phải sử dụng statin
liều cao ngay sau nhập viện hay sớm nhất có
thể, để đạt mục tiêu LDL-C
70mg/dl(1.8mM/l)...
47. Mức giảm LDL-C với các statin và liều tương ứng
• ESC/EAS 2011 50%
48. STATIN
High-intensity statin therapy should be initiated
or continued in all patients with STEMI and no
contraindications to its use.
It is reasonable to obtain a fasting lipid profile in
patients with STEMI, preferably within 24 hours
of presentation.
I IIa IIb III
I IIa IIb III
50. Tái tưới máu (reperfusion)
Tái thông ĐM vành
• STEMI: tắc nghẽn hòan tòan do huyết khối
• Mở thông chỗ tắc, tái thông ĐMV, tái tưới máu
giảm size NM, bảo tồn chức năng thất T, giảm
tử vong.
• Biện pháp điều trị chủ động
• TSH, PCI, CABG
• “Time is muscle”
51. Thời gian tái tưới máu
• Thời gian từ lúc đau ngực – tái tưới máu.
• Thời gian CỬA - KIM, CỬA – BÓNG.
• Là YT quyết định dự hậu quan trọng.
• Tiêu chuẩn:
- CỬA-KIM <60ph, tối ưu <30ph
- CỬA-BÓNG <90ph
55. Acute Myocardial Infarction
Current
Goal
Thrombolysis
Primary PTCA
Onset
of MI
Patient
response
Door
Data Decision
Drug
start
Flow
restored
Cath PCI
15 min < 30 min D–N = 30 min
D-B = 90 + 30 min
Patient
Transport
Inhospital
Reperfusion
Methods of
speeding
time to
reperfusionMedia campaign
Public education
191 expansion
Prehospital Rx
AMI protocol
Prehospital ECG
Bolus lytics
Combination reperfusion
Dedicated PCI team
56. Acute Myocardial
Infarction
Pt. with ischemic-type chest discomfort
Assess initial 12 lead ECG
Normal or
non-diagnostic ECG
ST Elevation or
New or presumably
new BBB
ECG strongly suspicious for ischemia
(ST depression, T inversion)
Unstable angina/non-Q MI
guidelines
•Assess contraindications to
thrombolysis
•Initiate anti-ischemic therapy
•Initiate reperfusion strategy
GOAL = 10 mins
GOAL:
< 30 min. for TT
< 60 min. for 1’ PTCA
57. ĐIỀU TRỊ STEMI:
Điều trị tái tưới máu bằng
Primary Percutaneous
Coronary intervention (PCI)
68. Antiplatelet Therapy to Support
Primary PCI for STEMI
Aspirin 162 to 325 mg should be given before primary PCI.
After PCI, aspirin should be continued indefinitely.
I IIa IIb III
I IIa IIb III
69. Antiplatelet Therapy to Support
Primary PCI for STEMI
A loading dose of a P2Y12 receptor inhibitor should be given as
early as possible or at time of primary PCI to patients with STEMI.
Options include:
• Clopidogrel 600 mg; or
I IIa IIb III
• Prasugrel 60 mg; or
• Ticagrelor 180 mg
70. Antiplatelet Therapy to Support
Primary PCI for STEMI
P2Y12 inhibitor therapy should be given for 1 year to patients with
STEMI who receive a stent (BMS or DES) during primary PCI
using the following maintenance doses:
• Clopidogrel 75 mg daily; or
I IIa IIb III
• Prasugrel 10 mg daily; or
• Ticagrelor 90 mg twice a day*
*The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg
daily.
71. Antiplatelet Therapy to Support
Primary PCI for STEMI
It is reasonable to use 81 mg of aspirin per day in preference to
higher maintenance doses after primary PCI.
I IIa IIb III
72. Antiplatelet Therapy to Support
Primary PCI for STEMI
It is reasonable to start treatment with an intravenous GP IIb/IIIa
receptor antagonist at the time of primary PCI (with or without
stenting or clopidogrel pretreatment) in selected patients with
STEMI who are receiving UFH.
• Double-bolus eptifibatide: 180 mcg/kg IV bolus, then 2
mcg/kg/min; a 2nd 180-mcg/kg bolus is administered 10 min
after the 1st bolus.
• Abciximab: 0.25 mg/kg IV bolus, then 0.125 mcg/kg/min
(maximum 10 mcg/min); or
• High-bolus-dose tirofiban: 25 mcg/kg IV bolus, then 0.15
mcg/kg/min; or
I IIa IIb III
I IIa IIb III
I IIa IIb III
73. Antiplatelet Therapy to Support
Primary PCI for STEMI
It may be reasonable to administer intravenous GP IIb/IIIa
receptor antagonist in the precatheterization laboratory setting
(e.g., ambulance, ED) to patients with STEMI for whom primary
PCI is intended.
It may be reasonable to administer intracoronary abciximab to
patients with STEMI undergoing primary PCI.
I IIa IIb III
I IIa IIb III
Continuation of a P2Y12 inhibitor beyond 1 year may be
considered in patients undergoing DES placement.
I IIa IIb III
74. Antiplatelet Therapy to Support
Primary PCI for STEMI
Prasugrel should not be administered to patients with a history of
prior stroke or transient ischemic attack.
I IIa IIb III
Harm
75. Khuyến cáo Mức độ
Aspirin cho mọi BN nếu không có chống chỉ định
Liều nạp 150-300 mg (đường uống) hoặc 80-150 mg (đường tĩnh mạch), liều
duy trì 75-100 mg/ngày bất kể chiến lược điều trị.
I A
Thuốc ức chế P2Y12 phối hợp với aspirin, dùng duy trì 12 tháng, trừ khi có
chống chỉ định hoặc chảy máu nặng. Các lựa chọn bao gồm:
I A
• Prasugrel (liều nạp 60 mg, liều duy trì 10 mg/ngày) nếu không có chống chỉ
định
I B
• Ticagrelor (liều nạp 180 mg, liều duy trì 90 mg 2 lần/ngày) nếu không có
chống chỉ định
I B
• Clopidogrel (liều nạp 600 mg, liều duy trì 75 mg lần/ngày), chỉ dùng khi
không có Prasugrel hay Ticagrelor, hoặc có chống chỉ định
I B
Khuyến cáo nên dùng thuốc ức chế P2Y12 ngay lần tiếp xúc y tế đầu tiên I B
Khuyến cáo ESC/EACTS 2014 về tái tưới máu cơ tim:
Thuốc UCKTTC cho HCMVC ST chênh & được PCI tiên phát
Windecker S et al. Eur. H. Journal, August 29, 2014
77. Anticoagulant Therapy to Support
Primary PCI
For patients with STEMI undergoing primary PCI, the following
supportive anticoagulant regimens are recommended:
• UFH, with additional boluses administered as needed to
maintain therapeutic activated clotting time levels, taking into
account whether a GP IIb/IIIa receptor antagonist has been
administered; or
• Bivalirudin with or without prior treatment with UFH.
I IIa IIb III
I IIa IIb III
78. Anticoagulant Therapy to Support
Primary PCI
In patients with STEMI undergoing PCI who are at high risk of
bleeding, it is reasonable to use bivalirudin monotherapy in
preference to the combination of UFH and a GP IIb/IIIa receptor
antagonist.
Fondaparinux should not be used as the sole anticoagulant to
support primary PCI because of the risk of catheter thrombosis.
I IIa IIb III
I IIa IIb III
Harm
79. Adjunctive Antithrombotic Therapy to Support
Reperfusion With Primary PCI
*The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.
80. Adjunctive Antithrombotic Therapy to Support
Reperfusion With Primary PCI (cont.)
*The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.
†Balloon angioplasty without stent placement may be used in selected patients. It might be reasonable to provide P2Y12
inhibitor therapy to patients with STEMI undergoing balloon angioplasty alone according to the recommendations listed for
BMS. (LOE: C).
82. Adjunctive Antithrombotic Therapy to Support
Reperfusion With Primary PCI (cont.)
‡The recommended ACT with planned GP IIb/IIIa receptor antagonist treatment is 200 to 250 s.
§The recommended ACT with no planned GP IIb/IIIa receptor antagonist treatment is 250 to 300 s (HemoTec device) or 300
to 350 s (Hemochron device).
84. ĐIỀU TRỊ STEMI:
Điều trị tái tưới máu bằng
thuốc tiêu sợi huyết
(Thrombolytic therapy)
85. Fibrinolytic Therapy When
There Is an Anticipated Delay
to Performing Primary PCI
Within 120 Minutes of FMC
Reperfusion at a Non–PCI-Capable
Hospital
86. Fibrinolytic Therapy When There Is an
Anticipated Delay to Performing Primary PCI
Within 120 Minutes of FMC
In the absence of contraindications, fibrinolytic therapy should be
given to patients with STEMI and onset of ischemic symptoms
within the previous 12 hours when it is anticipated that primary
PCI cannot be performed within 120 minutes of FMC.
In the absence of contraindications and when PCI is not
available, fibrinolytic therapy is reasonable for patients with
STEMI if there is clinical and/or ECG evidence of ongoing
ischemia within 12 to 24 hours of symptom onset and a large
area of myocardium at risk or hemodynamic instability.
Fibrinolytic therapy should not be administered to patients with
ST depression except when a true posterior (inferobasal) MI is
suspected or when associated with ST elevation in lead aVR.
I IIa IIb III
I IIa IIb III
I IIa IIb III
Harm
89. Adjunctive Antiplatelet Therapy With
Fibrinolysis
Aspirin (162- to 325-mg loading dose) and clopidogrel (300-mg
loading dose for patients ≤75 years of age, 75-mg dose for
patients >75 years of age) should be administered to patients
with STEMI who receive fibrinolytic therapy.
I IIa IIb III
90. Adjunctive Antiplatelet Therapy With
Fibrinolysis
• aspirin should be continued indefinitely and
In patients with STEMI who receive fibrinolytic therapy:
I IIa IIb III
• clopidogrel (75 mg daily) for at least 14 days
o and up to 1 year
I IIa IIb III
I IIa IIb III
91. Adjunctive Antiplatelet Therapy With
Fibrinolysis
It is reasonable to use aspirin 81 mg per day in preference to
higher maintenance doses after fibrinolytic therapy.
I IIa IIb III
93. Adjunctive Anticoagulant Therapy With
Fibrinolysis
Patients with STEMI undergoing reperfusion with fibrinolytic therapy
should receive anticoagulant therapy for a minimum of 48 hours, and
preferably for the duration of the index hospitalization, up to 8 days or
until revascularization if performed. Recommended regimens include:
a. UFH administered as a weight-adjusted intravenous bolus and
infusion to obtain an activated partial thromboplastin time of 1.5 to
2.0 times control, for 48 hours or until revascularization;
b. Enoxaparin administered according to age, weight, and creatinine
clearance, given as an intravenous bolus, followed in 15 minutes by
subcutaneous injection for the duration of the index hospitalization,
up to 8 days or until revascularization; or
c. Fondaparinux administered with initial intravenous dose, followed in
24 hours by daily subcutaneous injections if the estimated creatinine
clearance is greater than 30 mL/min, for the duration of the index
hospitalization, up to 8 days or until revascularization.
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
99. CABG in Patients With STEMI
Urgent CABG is indicated in patients with STEMI and coronary
anatomy not amenable to PCI who have ongoing or recurrent ischemia,
cardiogenic shock, severe HF, or other high-risk features.
CABG is recommended in patients with STEMI at time of operative
repair of mechanical defects.
I IIaIIbIII
I IIaIIbIII
100. CABG in Patients With STEMI
The use of mechanical circulatory support is reasonable in patients with
STEMI who are hemodynamically unstable and require urgent CABG.
Emergency CABG within 6 hours of symptom onset may be considered
in patients with STEMI who do not have cardiogenic shock and are not
candidates for PCI or fibrinolytic therapy.
I IIaIIbIII
I IIaIIbIII
103. Chóang tim do NMCT cấp
• Tỷ lệ tử vong 85%
• IABP
• Thở máy
• Tăng co bóp cơ tim: Dopamin, Noradrenalin,
Dobutamin
• Xét can thiệp ĐM vành cấp cứu
104. Treatment of Cardiogenic Shock
Emergency revascularization with either PCI or
CABG is recommended in suitable patients with
cardiogenic shock due to pump failure after STEMI
irrespective of the time delay from MI onset.
In the absence of contraindications, fibrinolytic
therapy should be administered to patients with
STEMI and cardiogenic shock who are unsuitable
candidates for either PCI or CABG.
I IIaIIbIII
I IIaIIbIII
105. Treatment of Cardiogenic Shock
The use of intra-aortic balloon pump counterpulsation
can be useful for patients with cardiogenic shock after
STEMI who do not quickly stabilize with
pharmacological.
Alternative LV assist devices for circulatory support
may be considered in patients with refractory
cardiogenic shock.
I IIaIIbIII
I IIaIIbIII
111. Management of Pericarditis After
STEMI
Aspirin is recommended for treatment of pericarditis
after STEMI.
Glucocorticoids and nonsteroidal antiinflammatory
drugs are potentially harmful for treatment of
pericarditis after STEMI.
I IIaIIbIII
Administration of acetaminophen, colchicine, or
narcotic analgesics may be reasonable if aspirin, even
in higher doses, is not effective.
I IIaIIbIII
I IIaIIbIII
Harm
112. Biến chứng cơ học, cấu trúc
• Hở van 2 lá cấp, thủng vách liên thất,
vỡ thành tự do thất.
• Chụp mạch vành
• CABG cấp cứu
• Điều trị nội khoa hổ trợ: giãn mạch,
IABP, vận mạch…
118. TIMI Risk Score For UA/NSTEMI
7 Independent Predictors of death/MI/Urgent revascularization
1.
2.
3.
4.
5.
6.
7.
Age > 65 years
> 3 CAD Risk Factors
( chol, FHx, HTN, DM, smoking)
Prior CAD (cath stenosis >50%)
ASA in last 7 days
> 2 Anginal events < 24 hours
ST deviation
Elevated Cardiac Markers (CKMB or Troponin)
Antman et al JAMA 2000;284: 835.
119. 119
Thang ñieåm nguy cô TIMI/ hoäi chöùng ÑMV
caáp khoâng ST cheânh leân
TL: De Lemos JA et al. Hurt’s The Heart, 13th ed 2011, McGraw-Hill. p. 1328-1351
120. Nguy cô cao
1. Tái diễn đau ngực/các triệu chứng thiếu máu cơ tim lúc nghỉ hoặc khi vận
động rất nhẹ dù đã điều trị nội khoa tối ưu.
2. Men Troponin tăng
3. Mới xuất hiện đoạn ST chênh xuống trên điện tâm đồ
4. Tái diễn đau ngực/các triệu chứng thiếu máu cơ tim kèm theo các triệu
chứng của suy tim, tiếng ngựa phi T3, phù phổi, ran ở phổi tăng lên, hở van
2 lá mới xuất hiện hoặc nặng thêm lên.
5. Xuất hiện các biểu hiện nguy cơ cao khi thăm dò gắng sức không xâm lấn.
6. Rối loạn chức năng tâm thu thất trái (thăm dò không xâm lấn: phân suất
tống máu < 40%)
7. Huyết động không ổn định
8. Nhịp nhanh thất dai dẳng
9. Can thiệp động mạch vành trong vòng 6 tháng
10. Tiền sử phẫu thuật bắc cầu động mạch vành
121. 121
So sánh giữa can thiệp sớm với can
thiệp muộn/ bệnh nhân HCĐMVC- KSTC
(tử vong, NMCT, đột quỵ)
Mehta SR et al.N Engl J Med 2009; 288: 1851-
1858
122. Pts presenting with NSTE-ACS
ASA/Clopidogrel/UFH
Nitrate, Betablocker
High risk Low risk
Initally planned
invasive stratey
Initally planned
conservative stratey
Immediate (< 2.5 hrs)
angio planned: GPI can be
postponed
Early (< 48 hrs) angio
planned: upstream GPI
(Tirofiban, Eptifibatide)
Early noninvasive
stress testing
PCI PCI PCI Medical
treatment
123. 2014 ESC/EACTS Guidelines on myocardial revascularization:
Recommendations for Antiplatelet Therapy in NSTE-ACS patients
undergoing PCI
Windecker S et al. Eur. H. Journal, August 29, 2014
Recommendations Class/Level
ASA is recommended for all patients without contraindications at an initial oral
loading dose of 150–300 mg (or 80–150 mg i.v.), and at a maintenance dose of
75–100 mg daily long-term regardless of treatment strategy.
I A
A P2Y12 inhibitor is recommended in addition to ASA, and maintained over 12
months unless there are contraindications such as excessive risk of bleeding.
Options are:
I A
• Prasugrel (60 mg loading dose, 10 mg daily dose) in patients in whom
coronary anatomy is known and who are proceeding to PCI if no
contraindication.
I B
• Ticagrelor (180 mg loading dose, 90 mg twice daily) for patients at
moderate-to-high risk of ischaemic events, regardless of initial treatment
strategy including those pre-treated with clopidogrel if no contraindication.
I B
• Clopidogrel (600 mg loading dose, 75 mg daily dose), only when
prasugrel or ticagrelor are not available or are contraindicated.
I B
124. Amsterdam EA, et al. 2014 AHA/ACC NSTE-ACS Management Guideline. J Am Coll Cardiol 2014;Sep23
AHA/ACC 2014: Recommendations for Initial Antiplatelet
in NSTE-ACS patients and PCI
Recommendations COR LOE
Aspirin
Non–enteric-coated aspirin to all patients promptly after presentation: 162 mg–
325 mg
I A
Aspirin maintenance dose continued indefinitely: 81 mg/d–162 mg/d I A
P2Y12 inhibitors
Clopidogrel loading dose followed by daily maintenance dose in patients unable
to take aspirin 75 mg
I B
P2Y12 inhibitor, in addition to aspirin, for up to 12 mo for patients treated
initially with either an early invasive or initial ischemia-guided strategy:
- Clopidogrel 300-mg or 600-mg loading dose, then 75 mg/d
- Ticagrelor* 180-mg loading dose, then 90 mg BID
I B
P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) continued for at
least 12 months in post–PCI patients treated with coronary stents
I B
- Ticagrelor in preference to clopidogrel for patients treated with an early
invasive or ischemia-guided strategy
IIa B
125. KẾT LUẬN
Chẩn đoán STEMI: không mới
Chẩn đoán NSTEMI: 1 giờ
Điều trị STEMI:
- Chung
- Tái tưới máu
- Biến chứng
Điều trị NSTEMI: Phân tầng, không
TSH
126. BS ơi, XN men tim siêu nhạy gấp
Xin cảm ơn quý BS
