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1 The Management of AMI and ACS Patients in the Emergency Department.

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Presentation on theme: "1 The Management of AMI and ACS Patients in the Emergency Department."— Presentation transcript:

1 1 The Management of AMI and ACS Patients in the Emergency Department

2 2 Part 2: AMI/ACS Treatment

3 3 Acute Myocardial Infraction Part II: Reperfusion Therapies for UA, NSTEMI, and STEMI

4 4 Professor Department of Emergency Medicine, University of Illinois at Chicago Chicago, IL Edward P. Sloan, MD, MPH, FACEP

5 5 Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Medical Center

6 6 Global Objectives  Learn more about AMI and ACS  Increase awareness of Rx options  Enhance our ED management  Improve patient care & outcomes  Maximize staff & patient satisfaction  Be prepared for the EM board exam

7 7 Session Objectives  Provide AMI, ACS overview  Ask clinically relevant questions

8 8 AMI/ACS Rx: Global Objectives

9 9 AMI/ACS Rx: Objectives AMI/ACS Rx: Objectives  What are the global objectives of AMI Rx in the ED?

10 10 AMI/ACS Rx: Objectives AMI/ACS Rx: Objectives  Maximize coronary dilatation and myocardial O 2 delivery  Minimize myocardium O 2 demand  Achieve TIMI-III coronary flow  Minimize myocardium damage  Minimize chronic LV dysfunction  Prevent dysrhythmias, sudden death

11 11 AMI/ACS Rx: Pharmacological Interventions

12 12 Pharmacotherapy of AMI/ACS  ASA  NTG  Morphine  Heparin, LMW  Thrombolytics  Antidysrhythmics  Fluid & pressure therapies

13 13 AMI/ACS Rx: Oxygen AMI/ACS Rx: Oxygen  AMI/ACS  Limited O2 delivery  Increased myocardial O2 use  IV, O2, monitor  NC at 4 L/min  Quick, easy, cheap

14 14 AMI Rx: ASA, Platelet Meds AMI Rx: ASA, Platelet Meds  When are ASA and other platelet meds indicated?

15 15 AMI/ACS Rx: Aspirin  ISIS 2: as good as streptokinase  Decreased platelet aggregation (Tbx A2)  mg ASAP  High dose: prostacyclin production decreases, with decreased benefits

16 16 AMI/ACS Rx: Aspirin  All AMI/ACS pts should get ASA  Dose of 162 mg reduces  mortality by 23%  reinfarction by 49%  stroke by 46%

17 17 AMI/ACS Rx: Platelet Rx  Dipyridamole  Ticlopidine  Clopidogrel  Consider when ASA allergic  Caution in acute setting!

18 18 AMI/ACS Rx: Nitrates AMI/ACS Rx: Nitrates  When are nitrates indicated?  What is the appropriate dose of NTG in AMI/ACS patients?

19 19 AMI/ACS Rx: Nitrates AMI/ACS Rx: Nitrates  Coronary dilation  Increased collateral flow  Decrease preload, myocardial O 2 use  SL 1/150, 1/400  Spray, paste, IV  SL rarely causes critical hypotension

20 20 AMI/ACS Rx: Nitrates AMI/ACS Rx: Nitrates  SL NTG 1/150  400 ucg q 5 minutes  80 ucg per minute  Good bioavailability  NTG drip: can start at > 10 ucg/min  Critical hypotension reversible

21 21 AMI/ACS Rx: Nitrates  Expect SBP to drop with NTG  SBP drop 10% with normal BP  SBP drop 30% with elevated BP

22 22 AMI/ACS Rx: Nitrates AMI/ACS Rx: Nitrates  Caution with RV infarction!  Reduces preload & LV filling  Reduces cardiac output  Hypotension can occur  Must still maximize O 2 delivery  Can reduce mortality by 35%

23 23 AMI/ACS Rx: Morphine AMI/ACS Rx: Morphine  What are the indications for morphine in AMI/ACS patients?

24 24 AMI/ACS Rx: Morphine AMI/ACS Rx: Morphine  Provides analgesia  Reduces central sympathetic output  May  myocardial O 2 consumption  May mask ongoing ischemia??  Risk/benefit favors use  Use with marked pain and anxiety  2-5 mg IVP

25 25 AMI/ACS: Antidysrhythmics AMI/ACS: Antidysrhythmics  What are the indications for antidysrhythmics in AMI/ACS patients?

26 26 AMI/ACS Rx: VT, VF Rx AMI/ACS Rx: VT, VF Rx  VF: Shock at 200j, 300j, 360j, unsynch  VT (Polymorphic, unstable): same  VT (Monomorphic, unstable): 100j, synch  VT (Monomorphic, stable):  Amiodarone: slow IVP  Lidocaine: mg/kg bolus injection  Procainamide: mg/kg, 20-30/min  Synch cardioversion, 50j, 100j

27 27 Monomorphic VTach Monomorphic VTach

28 28 Polymorphic VTach

29 29 AMI/ACS Rx: AFib Rx AMI/ACS Rx: AFib Rx  Cardioversion: unstable patients  Rapid digitalization  IV Beta blockers  Diltiazem or verapamil  Heparin

30 30 Atrial Fibrillation

31 31 AMI/ACS Rx: Adenosine AMI/ACS Rx: Adenosine  Slow conduction thru AV node  Interrupts reentrant pathways  Used in PSVT  6 mg IVP, then 12 mg IVP

32 32 Paroxysmal SVT

33 33 AMI/ACS Rx: Amiodarone AMI/ACS Rx: Amiodarone  Class III agent  Treats supraventricular and ventricular dysrhythmias  Prolongs refractory period  Sustained monomorphic VT  VF and unstable VT

34 34 AMI/ACS Rx: Atropine  Sinus brady, poor perfusion, PVCs  Sinus brady, low SBP after NTG  Inferior AMI with high grade block  Inferior AMI, symptomatic brady  N/V after morphine  EMD, with epinephrine

35 35 AMI/ACS Rx: Beta-blockade AMI/ACS Rx: Beta-blockade  What are the indications for beta- blockade in AMI/ACS patients?

36 36 AMI/ACS Rx: Beta-blockade AMI/ACS Rx: Beta-blockade  Ischemic penumbra preserved  Decreased catecholamines  Decreased dysrhythmias  Decreased HR and BP  Decreased infarct size

37 37 AMI/ACS Rx: Beta-blockade AMI/ACS Rx: Beta-blockade  Consider in all AMI and ACS pts  Continued, recurrent ischemic pain  Tachyarrhythmias: rapid AFib, Flutter  May even be useful in patients with relative contraindications  Metoprolol 5mg IV q5mx3  Within 12 hours of presentation

38 38 AMI/ACS Rx: Beta-blockade AMI/ACS Rx: Beta-blockade  Contraindications  Moderate to severe CHF  COPD/asthma  Bradycardia  Hypotension  2 nd or 3 rd degree A-V blocks

39 39 AMI/ACS Rx: Beta-blockade AMI/ACS Rx: Beta-blockade  Not consistently achieved in AMI  Why do clinicians defer this Rx?  May be optimal with HTN, tachycardia  With HR < 80, normal BP, less use  Not mandated in the ED, prior to PCI

40 40 AMI/ACS Rx: Ca ++ Channel  Rate control in atrial fib, flutter  If unable to provide beta blockade  Not viewed in same way a use of metoprolol in AMI

41 41 AMI/ACS Rx: Digitalis  Rapid load in rapid atrial fibrillation  Provided before beta blocker use  Not used for its inotropic effects

42 42 AMI/ACS Rx: Lidocaine AMI/ACS Rx: Lidocaine  Limited use  New, symptomatic VT  Malignant dysrhythmias, VF  mg/kg, 2-4 mg/min drip  Caution in ventricular escape rhythm  Can cause asystole  No real prophylactic use

43 43 AMI/ACS Rx: Magnesium AMI/ACS Rx: Magnesium  Documented Mg deficit with diuretics  Prolonged QT, torsade de pointes VT  1-2 gram bolus over 5 minutes  Empiric therapy in refractory VF?

44 44 Torsade de Pointes

45 45 AMI/ACS: BP/Fluid Rx AMI/ACS: BP/Fluid Rx  How should BP and fluids be managed in AMI/ACS patients?

46 46 AMI/ACS Rx: IV Fluids AMI/ACS Rx: IV Fluids  What are the indications for an acute fluid bolus?  When should large volumes of IVF be infused in a hypotensive AMI/ACS patient?

47 47 AMI/ACS Rx: IV Fluids AMI/ACS Rx: IV Fluids  Normal saline  Bolus hypotensive pts  Starling curve supports use  200 cc even with CHF  RV AMI: Repeated boluses

48 48 AMI/ACS Rx: IV Fluids AMI/ACS Rx: IV Fluids

49 49 AMI/ACS Rx: Dopamine AMI/ACS Rx: Dopamine  Dopamine useful in ED  Enhanced vital organ flow  Supports nitrates with labile BP  Increases HR, SVR, cardiac O 2 use  Increased inotropy  Ischemia, dysrhythmias can occur

50 50 AMI/ACS Rx: Dobutamine AMI/ACS Rx: Dobutamine  Dobutamine can also be used in ED  Pulmonary edema, LV dysfunction  No endogenous norepi release  Less myocardial O 2 use increase  Improved inotropy  Improved coronary artery flow  Can be used with dopamine

51 51 AMI/ACS Rx: Norepinephrine AMI/ACS Rx: Norepinephrine  Used in refractory hypotension  No response to other pressors  Increased myocardial O 2 use  Improved inotropy, but no increase in cardiac output as SVR is increased  Ectopy, dysrhythmias can occur

52 52 AMI/ACS Rx: Inotropes AMI/ACS Rx: Inotropes

53 53 AMI/ACS Rx: Diuretics AMI/ACS Rx: Diuretics  Furosemide: NaCl clearance  Used in pulmonary edema & LV dysfunction  Volume, Starling effects  More optimal LV filling, stroke volume, and cardiac output

54 54 AMI/ACS Rx: ACE Inhibitors AMI/ACS Rx: ACE Inhibitors  Reduces LV dilatation and dysfunction, improves remodeling  Slows development of CHF  AMI/ACS patients, especially critically ill anterior wall MI patients with pulmonary edema show greatest benefit  Captopril, enalapril, or lisinopril  Early use may reduce mortality

55 55 AMI/ACS Rx: ACE Inhibitors AMI/ACS Rx: ACE Inhibitors  Not mandated to be ED Rx  Contraindications  Hypotension  Bilateral renal artery stenosis  Renal insufficiency/failure

56 56 AMI/ACS Rx: Clot Therapies AMI/ACS Rx: Clot Therapies  What are the indications for heparin, IIb/IIIa, and thrombolytic therapy?

57 57 AMI/ACS Rx: Heparin (LMW) AMI/ACS Rx: Heparin (LMW)  What are the indications for heparin and LMW heparin in AMI/ACS patients?  How does LMW heparin work differently than un-fractionated heparin?

58 58 AMI/ACS Rx: Heparin (LMW) AMI/ACS Rx: Heparin (LMW)  Prevents late thrombus formation  Maintains patent coronary artery  Prevents mural thrombus from forming in anterior wall MI  Prevents cerebral emboli with AMI  Doesn’t Rx already formed thrombi  Platelet Rx: White clot, ACS, NSTEMI  Thrombolytic Rx: Red clot, STEMI

59 59 AMI/ACS Rx: Heparin (LMW) AMI/ACS Rx: Heparin (LMW)  Thrombin inhibition  Prevents clot propagation, formation  High embolism risk pts identified:  Large or ant MI, Afib, previous embolus, known LV thrombus  Complication reduction:  Reinfarction reduced by 30%  Mortality reduced by 21%

60 60 AMI/ACS Rx: Heparin (LMW) AMI/ACS Rx: Heparin (LMW)  Indicated in patients with PCI or surgical revascularization  Also used in pts who get tPA and those with ACS, NSTEMI

61 61 AMI/ACS Rx: Heparin AMI/ACS Rx: Heparin  Over 1300u/hr associated with bleeding complications  Attempt to achieve a PTT that is times normal (60-85 seconds)

62 62 AMI/ACS Rx: Heparin AMI/ACS Rx: Heparin  Bolus: 60 units/kg  Infusion: 12 U/kg per hour  Max recommended dose  4000 units bolus  1000 units per hour infusion

63 63 AMI/ACS Rx: LMW Heparin AMI/ACS Rx: LMW Heparin  Similar indications to heparin  1 mg/kg SQ BID  Prior suggestion that heparin preferred in highest risk pts  Some prefer heparin prior to PCI  No demonstrated difference between heparin and LMW in these patients

64 64 AMI/ACS Rx: IIb/IIIa Inhibitors AMI/ACS Rx: IIb/IIIa Inhibitors  What are the indications for IIb/IIIa inhibitors in AMI/ACS patients?  How do these drugs work?

65 65 AMI/ACS Rx: IIb/IIIa Inhibitors AMI/ACS Rx: IIb/IIIa Inhibitors  Abciximab (ReoPro): long acting Ab  Eptifibatide (Integrillin): peptide  Tirofiban (Aggrastat): peptide  Used in ACS, NSTEMI patients, especially those who undergo PCI  High risk patients (positive troponin)  Requires hrs of infusion to demonstrate benefits

66 66 AMI/ACS Rx: IIb/IIIa Inhibitors AMI/ACS Rx: IIb/IIIa Inhibitors  Useful in treatment of pts with refractory unstable angina  Treats white clot: ACS, NSTEMI  Few head to head studies that compare IIb/IIIa inhibitors  Rate of ICH lower than with fibrinolysis

67 67 AMI/ACS Rx: IIb/IIIa Inhibitors AMI/ACS Rx: IIb/IIIa Inhibitors  50,000 receptors per platelet  Final common pathway  Platelets bind with fibrinogen  Forms hemostatic plug (white clot)  IIb/IIIa glycoprotein prevents this binding and formation of white clot

68 68 Platelet Activation

69 69 AMI/ACS Rx: IIb/IIIa Inhibitors AMI/ACS Rx: IIb/IIIa Inhibitors  Inhibit 80% of receptors, then there is no platelet aggregation  Prevents ongoing platelet deposition  No effect on thrombin generation  No effect on coagulation, inflammation  Combo therapy with thrombin drugs  Use with heparin is indicated

70 70 White Clot: ACS, NSTEMI Platelets, Fibrin, Red Cells Platelets, Fibrin, Red Cells

71 71 AMI/ACS Rx: IIb/IIIa Inhibitors AMI/ACS Rx: IIb/IIIa Inhibitors  Beneficial effects of platelet inhibition  Decreased re-occlusion after thrombolysis and/or PCI  Decreased re-infarction risk because of better coronary artery healing  Minimizes extent of occlusion as a result of acute plaque disruption

72 72 AMI/ACS Rx: IIb/IIIa Inhibitors AMI/ACS Rx: IIb/IIIa Inhibitors  Clinical use in ED is indicated in ACS  Actual use is somewhat limited by availability of PCI for most critically ill ACS, NSTEMI patients  Although use should begin in ED, many cardiologists begin infusion following PCI  Still important prior to transfer for PCI

73 73 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics  What are the indications for thrombolytic therapy in AMI/ACS patients?  How do thrombolytics work?

74 74 Red Thrombus in STEMI  Thrombin, fibrin, clotting factors

75 75 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics  Time is muscle  Restoration of TIMI-3 flow  Myocardial salvage  Reduced ventricular dysfunction  Reduced ectopy  Sudden death less likley

76 76 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics  Indications  Classic history  EKG with > 1mm ST  in 2 limb leads or > 2mm ST  in > 2 precordial leads  New LBBB

77 77 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics  No contraindications  No cardiogenic shock (??)  Presentation within 12 hours of symptom onset

78 78 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics  Maximal benefit when given within first 2 hours of infarct  Greater mortality benefit in patients with anterior wall AMI as opposed to those with inferior wall AMI

79 79 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics  Streptokinase  APSAC  tPA  Retavase (rPA)  TNK t-PA

80 80 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics tPA  Clot specific  Not antigenic  Reduces mortality 28%  ½ life only 5 minutes  Higher risk of ICH than SK

81 81 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics tPA  Dosing:  15 mg IV over 2 min  0.75 mg/kg (max 50) over 30 min  0.50 mg/kg (max 35) over 60 min  Start heparin, ASA concurrently

82 82 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics Retavase (rPA)  At least as effective as SK  Comparable tPA mortality benefit  Dosing: 10mg IV bolus at 0 min and 30 min

83 83 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics TNK t-PA  Genetic variant of tPA  Slower plasma clearance  Greater fibrin specificity  0.53 mg/kg bolus, 50mg max  Heparin infusion, ASA use

84 84 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics  Absolute contraindications  Any active bleeding  Recent GI bleed (within 10 days)  Hemorrhagic CVA at any time  Non-hemorrhagic CVA in last 6 months

85 85 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics  Absolute contraindications  Aortic dissection  Pericarditis  Childbirth within 10 days  HTN (SBP >200 or DBP>120)

86 86 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics  Absolute contraindications  Intracranial/spinal mass lesion, aneurysm, AV malformation  Surgery within 2 months  Serious head trauma in last month  Bleeding disorder  Pregnancy

87 87 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics  Relative Contraindications  Traumatic CPR  PUD  Current anticoagulant use  Hx of HTN with DBP > 100

88 88 AMI/ACS Rx: Thrombolytics AMI/ACS Rx: Thrombolytics  Relative contraindications  Diabetic/hemorrhagic retinopathy  Non-compressible vein cannulation  Over age 70

89 89 AMI/ACS Rx: Mechanical Interventions

90 90 AMI/ACS Rx: Cardiac Pacing AMI/ACS Rx: Cardiac Pacing  What are the indications for cardiac pacing in AMI/ACS patients?

91 91 AMI/ACS Rx: Cardiac Pacing AMI/ACS Rx: Cardiac Pacing  For large anterior STEMIs  Not as an Rx for vagal reaction  To Rx symptomatic bradycardia  Overdrive suppression (+/-)

92 92 AMI/ACS Rx: Cardiac Pacing Transcutaneous Cardiac Pacing  Sinus brady, low BP, no Rx effect  Mobitz type II second degree block  Third degree block  Bifascicular block  LBBB  RBBB or LBBB & first degree AV block  Less so for stable bradycardia, RBBB

93 93 AMI/ACS Rx: Cardiac Pacing Transvenous Cardiac Pacing  Asystole  Sinus brady, low BP, no Rx effect  Mobitz type II second degree block  Third degree block  Bifascicular block  RBBB & first degree AV block (+/-)  Overdrive suppression for VT (+/-)  3 sec sinus pauses, no Rx effect (+/-)

94 94 AMI/ACS Rx: Cardiac Pacing Cardiac Pacing Approach  Establish rhythm disturbance  Determine that rate, rhythm are effecting adequate perfusion  Attempt to Rx BP  Attempt to improve rate with atropine  Attempt transcutaneous pacing  Place sheath for transvenous pacer  Insert transvenous pacer as needed

95 95 AMI/ACS Mechanical Interventions Mechanical Ventilation  Intubation, mechanical ventilation  Decreased work of breathing  Increases BP (hopefully)  Decreases myocardial O 2 use  Increases O2 delivery (CHF)  Critical in cardiogenic shock

96 96 AMI/ACS Mechanical Interventions Intraaortic Balloon Pump  What are the indications for intraaortic balloon pump support in AMI/ACS patients?  How does the intraaortic balloon pump work?

97 97 AMI/ACS Mechanical Interventions Intraaortic Balloon Pump  Refractory cardiogenic shock  Fluids, pressors without effect  Persistent pain, shock  Rapid systole balloon deflation  Vacuum assists LV function  Improves cardiac output

98 98 AMI/ACS Mechanical Interventions Intraaortic Balloon Pump  Refractory cardiogenic shock  As a stabilizing measure prior to PCI  Acute mitral regurgitation, VSD (STEMI mechanical complications)  Intractable ventricular dysrhythmias  Refractory post-MI ischemia, as bridge  Unstable pts when LV is “at risk” (+/-)

99 99 AMI/ACS Mechanical Interventions Percutaneous Coronary Interventions  What is PCI?  What are the PCI indications?  What is the goal of PCI?  Over what time period should revascularization occur?

100 100 AMI/ACS Rx: Revascularization AMI/ACS Rx: Revascularization  Over what time period should revascularization occur?  ACEP and AHA/ACC guidelines  120 minutes door to balloon time  If not, consider tPA use in ED

101 101 AMI/ACS Mechanical Interventions Percutaneous Coronary Interventions  PCI optimal for single lesion, grafts  May be able to treat multiple lesions  May require multiple procedures  Extensive small vessel disease precludes effective PCI Rx  Multiple occluded vessels: CABG

102 102 AMI/ACS Mechanical Interventions Percutaneous Coronary Interventions  PCI is the industry standard  Door to balloon time can be > 120 min  When PCI is imminent:  Front loaded tPA not often utilized  IIb/IIIa inhibitors not often utilized  Need to optimize ED process

103 103 AMI/ACS Rx: EMS Triage AMI/ACS Rx: EMS Triage  Is there evidence to support directed triage to “cardiac” centers?

104 104 AMI/ACS Rx: EMS Triage AMI/ACS Rx: EMS Triage  Is there evidence to support directed triage to “cardiac” centers? No.  It is unclear that door to balloon time is significantly decreased, nor is patient outcome worsened if a transfer agreement is in place  Caveat: cardiogenic shock patients probably would benefit from direct triage for immediate PCI

105 105 AMI/ACS Rx: Pre-hospital Rx AMI/ACS Rx: Pre-hospital Rx  What out-of-hospital therapies have been demonstrated to improve outcome in AMI?

106 106 AMI/ACS Rx: Pre-hospital Rx AMI/ACS Rx: Pre-hospital Rx  911 activation  Early defibrillation, first responders  12 lead EKG, thrombolysis (+/-)

107 107 AMI/ACS: Specific Issues  Elderly and females associated with more atypical presentations  Pts with symptoms of AMI/ACS after PCI should be assumed to have abrupt vessel closure

108 108 AMI/ACS: Hospital Admission  Pts at high risk for CAD, AMI, or death admit to ICU  ED observation units and non-ICU monitored beds are safe for pts with normal ECGs and low to moderate risk  Low risk patients: 2 hour rule out and outpatient stress testing

109 109 History Case #1  58 year old male  Chest pain, sub-sternal, severe  Onset less than one hour prior  Nausea, diaphoresis  No known cardiac history  Smoker, ?cholesterol

110 110 Px Case #1  /  Gen: Screaming in pain, diaphoretic  Chest: BS equal  CV: Reg rhythm without

111 111

112 112

113 113 Diagnosis Case #1  Having the big one.  Acute anterior wall MI  Complete occlusion of the left main coronary artery

114 114 Treatment Case #1  IV NTG  ASA, Oxygen  Morphine  Heparin  Cardioversion (200j) (VTach)  Rapid transfer for PTCA

115 115 History Case #2  48 year old male  Sudden onset of chest pain  SOB, nausea  ? Cardiac hx, on ASA

116 116 Px Case #2  /  Gen: Diaphoretic, pale, anxious  Chest: Clear BSBE  CV: Reg without  Exam otherwise normal

117 117

118 118

119 119

120 120

121 121 Diagnosis Case #2  Inferior wall MI  Likely R coronary artery occlusion

122 122 Treatment Case #2  IV NTG  ASA, Oxygen  Morphine  Heparin  Rapid transfer for PTCA

123 123 Conclusions AMI/ACS Rx in the E.D.  Common problem  ED staff has an important role  Many therapies are available  Chance to make a difference  Good guidelines exist  Interested consultants

124 124 Conclusions AMI/ACS: Relevant Questions  Is there an acute plaque rupture?  Is this ACS (white clot) req platelet Rx?  Is this STEMI (red clot) req TT, PCI?  What Rx must be provided in the ED?  How can revascularization best be achieved given the ED processes?

125 125 AMI/ACS Diagnosis Questions?  2002, 2004 ACC/AHA guidelines  or  2000 ACEP guidelines    PDF file allows for optimal printing  (312)


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