2. Acute Coronary Syndrome Dr. S.A. moezzi

3. ACS Overview Overview of ACS Overview of ACS Assessment of “Likelihood of ACS” Assessment of “Likelihood of ACS” Early Risk Stratification Early Risk Stratification Invasive vs Conservative Strategy Invasive vs Conservative Strategy Pharmacotherapy Pharmacotherapy Long-term Therapy/Secondary Prevention Long-term Therapy/Secondary Prevention

4. Scope of the Problem 5 million ER visits nationwide for CP 5 million ER visits nationwide for CP 800,000 experience an MI each year 800,000 experience an MI each year 213,000 die from their event 213,000 die from their event ½ of those die before reaching the ER ½ of those die before reaching the ER Pre-CCU, mortality for MI was >30% Pre-CCU, mortality for MI was >30% Fell to 15% with CCU Fell to 15% with CCU With current interventions, in hospital mortality of STEMI is 6-7% With current interventions, in hospital mortality of STEMI is 6-7%

5. Overview of ACS 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.

6. Acute Coronary Syndrome (ACS) Definition: The spectrum of acute ischemia related syndromes ranging from UA to MI with or without ST elevation that are secondary to acute plaque rupture or plaque erosion. Definition: The spectrum of acute ischemia related syndromes ranging from UA to MI with or without ST elevation that are secondary to acute plaque rupture or plaque erosion. [----UA---------NSTEMI----------STEMI----] [----UA---------NSTEMI----------STEMI----]

7. Decreased O 2 Supply Flow- limiting stenosis Anemia Plaque rupture/clot Increased O 2 Demand O 2 supply/demand mismatch→Ischemia Myocardial ischemia→necrosis Pathophysiology ACS Asymptomatic Angina Myocardial Infarction Pathophysiology of Stable Angina and ACS

8. Pathophysiology of ACS Evolution of Coronary Thrombosis

9. Unstable Angina Unstable Angina STEMI NSTEMI NSTEMI Non occlusive thrombus Non specific ECG Normal cardiac enzymes Non-occlusive thrombus sufficient to cause tissue damage & mild myocardial necrosis ST depression +/- T wave inversion on ECG Elevated cardiac enzymes Complete thrombus occlusion ST elevations on ECG or new LBBB Elevated cardiac enzymes More severe symptoms

10. STEMI Name 3 situations in which you cannot diagnose STEMI Name 3 situations in which you cannot diagnose STEMI

11. STEMI Left Ventricular Hypertrophy Left Ventricular Hypertrophy Chronic or Rate Dependent LBBB Chronic or Rate Dependent LBBB Paced Rhythm Paced Rhythm

12. Diagnosis of ACS At least 2 of the following At least 2 of the following History ( angina or angina equivalent) History ( angina or angina equivalent) Acute ischemic ECG changes Acute ischemic ECG changes Typical rise and fall of cardiac markers Typical rise and fall of cardiac markers Absence of another identifiable etiology Absence of another identifiable etiology

13. Likelihood of ACS by Hx/PE History/Examination History/Examination Pain in Chest or Left Arm Pain in Chest or Left Arm CP Radiation CP Radiation Right Shoulder Right Shoulder Left Arm Left Arm Both Left & Right Arm Both Left & Right Arm Diaphoresis Diaphoresis 3 rd Heart Sound 3 rd Heart Sound SBP < 80 mm Hg SBP < 80 mm Hg Pulmonary Crackles Pulmonary Crackles Panju AA. JAMA. 1998;280:1256. Panju AA. JAMA. 1998;280:1256. Suggesting AMI LR 2.7 LR 2.9 (1.4-6.0) LR 2.3 (1.7-3.1) LR 7.1 (3.6-14.2) LR 2.0 (1.9-2.2) LR 3.2 (1.6-6.5) LR 3.1 (1.8-5.2) LR 2.1 (1.4-3.1)

14. Likelihood of ACS by Hx/PE Clinical Examination – Clinical Examination – Pleuritic Chest Pain Pleuritic Chest Pain Sharp or Stabbing Pain Sharp or Stabbing Pain Positional Chest Pain Positional Chest Pain Reproducible Chest Pain Reproducible Chest Pain Panju AA. JAMA. 1998;280:1256. Panju AA. JAMA. 1998;280:1256. Against AMI LR 0.2 (0.2-0.3) LR 0.3 (0.2-0.5) LR 0.3 (0.2-0.4) LR 0.2-0.4

16. Risk Stratification by ECG Simple, quick, noninvasive tool Simple, quick, noninvasive tool Universally available, cheap Universally available, cheap Correlates with risk and prognosis Correlates with risk and prognosis Guides treatment decisions Guides treatment decisions Can identify alternative causes Can identify alternative causes

17. Risk Stratification by ECG ECG Findings and Associated LR for AMI ECG Findings and Associated LR for AMI New ST-E > 1mmLR 5.7-53.9 New ST-E > 1mmLR 5.7-53.9 New Q wavesLR 5.3-24.8 New Q wavesLR 5.3-24.8 Any ST-ELR 11.2 (7.1-17.8) Any ST-ELR 11.2 (7.1-17.8) New Conduction DefectLR 6.3 ( 2.5-15.7) New Conduction DefectLR 6.3 ( 2.5-15.7) New ST-DLR 3.0-5.2 New ST-DLR 3.0-5.2 NORMAL ECGLR 0.1-0.4 NORMAL ECGLR 0.1-0.4 Panju AA. JAMA. 1998;280:1256.

18. Risk Stratification by ECG 1-8% AMI have a normal ECG 1-8% AMI have a normal ECG Only Approx 50% of AMI patients have diagnostic changes on their initial ECG Only Approx 50% of AMI patients have diagnostic changes on their initial ECG Peter J. Zimetbaum, M.D., N Engl J Med 2003;348:933-40.

19. Risk Stratification by ECG 1 ECG cannot exclude AMI 1 ECG cannot exclude AMI Brief sample of a dynamic process Brief sample of a dynamic process Small regions of ischemia or infarction may be missed Small regions of ischemia or infarction may be missed Peter J. Zimetbaum, M.D., N Engl J Med 2003;348:933-40.

21. How Sensitive is the ECG Alone?

22. How Predictive is NTG response?

23. Timing of Release of Various Biomarkers After Acute Myocardial Infarction Shapiro BP, Jaffe AS. Cardiac biomarkers. In: Murphy JG, Lloyd MA, editors. Mayo Clinic Cardiology: Concise Textbook. 3 rd 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.

24. Mortality at 42 Days 8311741481345067  % % % % % % Risk Stratification by Troponin

25. National Academy of Clinical Biochemistry Laboratory Medicine (NACB) and the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction Cardiac troponin is the preferred marker for the diagnosis of MI and for risk stratification. CK-MB by mass assay is an acceptable alternative when troponin in not available. Cardiac troponin is the preferred marker for the diagnosis of MI and for risk stratification. CK-MB by mass assay is an acceptable alternative when troponin in not available. CK-MB was preferred by the NACB for the detection of reinfarction early after the index event CK-MB was preferred by the NACB for the detection of reinfarction early after the index event increased sensitivity and specificity of cTn should make it the marker of choice it is unnecessary to obtain both values. increased sensitivity and specificity of cTn should make it the marker of choice it is unnecessary to obtain both values. Cardiac troponins I and T are equally useful. Cardiac troponins I and T are equally useful.

26. Non ACS causes of Troponin Elevation 1. Trauma (including contusion; ablation; pacing; ICD firings,, endomyocardial biopsy, cardiac surgery, after-interventional closure of ASDs) 2. Congestive heart failure (acute and chronic) 3. Aortic valve disease and HOCM with significant LVH 4. Hypertension 5. Hypotension, often with arrhythmias 6. Noncardiac surgery 7. Renal failure 8. Critically ill patients, especially with diabetes, respiratory failure 9. Drug toxicity (eg, adriamycin, 5 FU, herceptin, snake venoms) 10. Hypothyroidism 11. Coronary vasospasm, including apical ballooning syndrome 12. Inflammatory diseases (eg, myocarditis, Kawasaki disease, smallpox vaccination, 13. Post-PCI 14. Pulmonary embolism, severe pulmonary hypertension 15. Sepsis 16. Burns, especially if TBSA greater than 30% 17. Infiltrative diseases: amyloidosis, hemachromatosis, sarcoidosis, and scleroderma 18. Acute neurologic disease, including CVA, subarchnoid bleeds 19. Rhabdomyolysis with cardiac injury 20. Transplant vasculopathy 21. Vital exhaustion Modified from Apple FS, et al Heart J. 2002;144:981-986.

27. Combined Sensitivities for ACS

28. Unstable angina/NSTEMI cardiac care Evaluate for conservative vs. invasive strategy based upon: Evaluate for conservative vs. invasive strategy based upon: Likelihood of actual ACS Likelihood of actual ACS Risk stratification by TIMI risk score Risk stratification by TIMI risk score ACS risk categories per AHA guidelines ACS risk categories per AHA guidelines Low Intermediate High

29. TIMI Risk Score Predicts risk of death, new/recurrent MI, need for urgent revascularization within 14 days

30. TIMI Risk Score T: Troponin elevation (or CK-MB elevation) H: History or CAD (>50% Stenosis) R: Risk Factors: > 3 (HTN, Hyperlipidemia, Family Hx, DM II, Active Smoker) E: EKG changes: ST elevation or depression 0.5 mm concordant leads A 2 :Aspirin use within the past 7 days; Age over 65 T: Two or more episodes of CP within 24 hours

31. Deciding between Early Invasive vs a Conservative Strategies Hemodynamic instabilityHemodynamic instability Elecrical instabilityElecrical instability Refractory anginaRefractory angina PCI in past 6 monthsPCI in past 6 months CABGCABG EF <40%EF <40%

33. Specifics of Early Hospital Care Anti-Ischemic Therapy Anti-Ischemic Therapy Anti-Platelet Therapy Anti-Platelet Therapy Anticoagulant Therapy Anticoagulant Therapy

34. Early Hospital Care Anti-Ischemic Therapy Class I Class I Bed/Chair rest and Telemetry Bed/Chair rest and Telemetry Oxygen (maintain saturation >90%) Oxygen (maintain saturation >90%) Nitrates (SLx3 Oral/topical. IV for ongoing iscemia, heart failure, hypertension) Nitrates (SLx3 Oral/topical. IV for ongoing iscemia, heart failure, hypertension) Oral B-blockers in First 24-hours if no contraindications. (IV B-blockers class IIa indication) Oral B-blockers in First 24-hours if no contraindications. (IV B-blockers class IIa indication) Non-dihydropyridine Ca-channel blockers for those with contraindication fo B-blockers Non-dihydropyridine Ca-channel blockers for those with contraindication fo B-blockers ACE inhibitors in first 24-hours for heart failure or EF<40% (Class IIa for all other pts) (ARBs for those intolerant) ACE inhibitors in first 24-hours for heart failure or EF<40% (Class IIa for all other pts) (ARBs for those intolerant) Statins Statins

35. Early Hospital Care Anti-Ischemic Therapy Class III Class III Nitrates if BP<90 mmHg or RV infarction Nitrates if BP<90 mmHg or RV infarction Nitrates within 24-hrs of Sildenafil or 48 hrs of Tadalafil Nitrates within 24-hrs of Sildenafil or 48 hrs of Tadalafil Immediate release dihydropyradine Ca-blockers in the absence of B-Blocker therapy Immediate release dihydropyradine Ca-blockers in the absence of B-Blocker therapy IV ACE-inhibitors IV ACE-inhibitors IV B-blockers in patients with acute HF, Low output state or cardiogenic shock, PR interval >0.24 sec, 2 nd or 3 rd degree heart block, active asthma, or reactive airway disease IV B-blockers in patients with acute HF, Low output state or cardiogenic shock, PR interval >0.24 sec, 2 nd or 3 rd degree heart block, active asthma, or reactive airway disease NSAIDS and Cox-2 inhibitors NSAIDS and Cox-2 inhibitors

36. Early Hospital Care Anti-Platelet Therapy Class I Class I Aspirin (162-325 mg), non enteric coated Aspirin (162-325 mg), non enteric coated Clopidogrel for those with Aspirin allergy/intolerance (300-600 mg load and 75 mg/d) Clopidogrel for those with Aspirin allergy/intolerance (300-600 mg load and 75 mg/d) GI prophylaxis if a Hx of GI bleed GI prophylaxis if a Hx of GI bleed GP IIb/IIIa inhibitors should be evaluated based on whether an invasive or conservative strategy is used GP IIb/IIIa inhibitors should be evaluated based on whether an invasive or conservative strategy is used GP IIb/IIIa inhibitors recommended for all diabetics and all patient in early invasive arm GP IIb/IIIa inhibitors recommended for all diabetics and all patient in early invasive arm

37. secondary prevention At present, the United States Food and Drug Administration recommends daily doses of 75 to 325 mg, At present, the United States Food and Drug Administration recommends daily doses of 75 to 325 mg, the 2006 American College of Cardiology /American Heart Association (ACC/AHA) guidelines on recommends daily doses of 75 to 162 mg for secondary prevention [38]. the 2006 American College of Cardiology /American Heart Association (ACC/AHA) guidelines on recommends daily doses of 75 to 162 mg for secondary prevention [38]. The ACCP recommends a daily dose of 75 to 100 mg The ACCP recommends a daily dose of 75 to 100 mg

38. Early Hospital Care Anticoagulant Therapy Class I Class I Unfractionated Heparin Unfractionated Heparin Enoxaparin Enoxaparin Bivalarudin Bivalarudin Fondaparinux Fondaparinux Relative choice depends on invasive vs conservative strategy and bleeding risk Relative choice depends on invasive vs conservative strategy and bleeding risk

39. Early Hospital Care Statin Therapy MIRACL Trial Inclusion Criteria MIRACL Trial Inclusion Criteria 3086 patients with Non ST ACS 3086 patients with Non ST ACS Total cholesterol <270 mg/dl Total cholesterol <270 mg/dl No planned PCI No planned PCI Randomized to Atorvastatin vs Placebo Randomized to Atorvastatin vs Placebo Drug started at 24-96 hours Drug started at 24-96 hours

40. Statin Evidence: MIRACL Study Relative risk = 0.84 P =.048 95% CI 0.701-0.999 Atorvastatin Placebo 0 5 10 15 0481216 Time Since Randomization (weeks) Cumulative Incidence (%) Time to first occurrence of: Death (any cause) Nonfatal MI Resuscitated cardiac arrest Worsening angina with new objective evidence and urgent rehospitalization 17.4% 14.8% Primary Efficacy Measure Schwartz GG, et al. JAMA. 2001;285:1711-1718.

41. Statin Evidence: MIRACL Study 0 0.5 1 1.5 2 0481216 Time Since Randomization (weeks) Cumulative Incidence (%) Relative risk = 0.49 P =.04 95% CI 0.24-0.98 Atorvastatin Placebo Fatal and Nonfatal Stroke Waters DD, et al. Circulation. 2002;106:1690-1695. S24

42. All-Cause Death or Major CV Events in All Randomized Subjects031821242730691215 % with Event Months of Follow-up Pravastatin 40mg (26.3%) Atorvastatin 80mg (22.4%) 16% RR (P = 0.005) 30 25 20 15 10 5 0 PROVE-IT Trial

43. Summary of PROVE-IT Results In patients recently hospitalized within 10 days for an acute coronary syndrome: In patients recently hospitalized within 10 days for an acute coronary syndrome:  “Intensive” high-dose LDL-C lowering (median LDL-C 62 mg/dL) compared to “moderate” standard-dose lipid-lowering therapy (median LDL-C 95 mg/dL) reduced the risk of all cause mortality or major cardiac events by 16% (p=0.005)  Benefits emerged within 30 days post ACS with continued benefit observed throughout the 2.5 years of follow-up  Benefits were consistent across all cardiovascular endpoints, except stroke, and most clinical subgroups

44. Invasive vs Conservative Strategies

45. Invasive vs Conservative Strategy Clinical Trials TIMI IIIB (94) Conservative Strategy Favored N=920 Invasive Strategy Favored N=7,018 VANQWISH (98) MATE FRISC II (99) TACTICS- TIMI 18 (01) VINO RITA-3 (02) TRUCS ISAR- COOL ICTUS (05) No difference N=2,874 Weight of the evidence

46. How Early is Early?

47. Secondary Prevention Class I Indications Aspirin Aspirin Beta-blockers: (all pts, slow titration with moderate to severe failure Beta-blockers: (all pts, slow titration with moderate to severe failure ACE-Inhibitors: CHF, EF<40%, HTN, DM ACE-Inhibitors: CHF, EF<40%, HTN, DM (All pts-Class IIa) ARB when intolerant to ACE. (Class IIa as alternative to ACEI) (All pts-Class IIa) ARB when intolerant to ACE. (Class IIa as alternative to ACEI) Aldosterone blockade: An ACEI, CHF with either EF 30 ml/min and K 30 ml/min and K<5.0 mEq/L Statins Statins Standard Risk Factor Management Standard Risk Factor Management

48. Long-Term Antithrombotic Therapy at Hospital Discharge after UA/NSTEMI Medical Therapy without Stent Bare Metal Stent Group Drug Eluting Stent Group ASA 162 to 325 mg/d for at least 1 month, then 75 to 162 mg/d indefinitely (Class I, LOE: A) & Clopidogrel 75 mg/d for at least 1 month and up to 1 year (Class I, LOE:B) Add: Warfarin (INR 2.0 to 2.5) (Class IIb, LOE: B) Continue with dual antiplatelet therapy as above YesNo Indication for Anticoagulation? ASA 75 to 162 mg/d indefinitely (Class I, LOE: A) & Clopidogrel 75 mg/d at least 1 month (Class I, LOE: A) and up to 1 year (Class I, LOE: B) ASA 162 to 325 mg/d for at least 3 to 6 months, then 75 to 162 mg/d indefinitely (Class I, LOE: A) & Clopidogrel 75 mg/d for at least 1 year (Class I, LOE: B) Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Figure 11. INR = international normalized ratio; LOE = level of evidence. UA/NSTEMI Patient Groups at Discharge New

49. Secondary Prevention Class III Hormone Replacement Therapy Hormone Replacement Therapy Antioxidants (Vit C, Vit E) Antioxidants (Vit C, Vit E) Folic Acid Folic Acid

51. Early Treatment with Clopidogrel

52. Shortcomings of the CURE Trial Conducted primarily at centers without routine use of early invasive strategy Conducted primarily at centers without routine use of early invasive strategy Only 462 (3.7%) patients enrolled from the U.S. Only 462 (3.7%) patients enrolled from the U.S. 44% had catheterization during index hospitalization 44% had catheterization during index hospitalization Adverse event reduced only in nonfatal MI set Adverse event reduced only in nonfatal MI set Major Bleeding rate of 9.6% among patients who were administered clopidogrel within 5 days of CABG Major Bleeding rate of 9.6% among patients who were administered clopidogrel within 5 days of CABG

53. Clopidogrel Bleeding Risk and CABG “In hospitals in which patients with UA/NSTEMI undergo rapid diagnostic catheterization within 24 hours of admission, clopidogrel is not started until it is clear that CABG will not be scheduled within the next several days. However, unstable patients should receive clopidogrel or be take for immediate angiography.” “In hospitals in which patients with UA/NSTEMI undergo rapid diagnostic catheterization within 24 hours of admission, clopidogrel is not started until it is clear that CABG will not be scheduled within the next several days. However, unstable patients should receive clopidogrel or be take for immediate angiography.”

54. Clopidogrel vs. Prasugrel

60. Prasugrel-Key Facts Contraindicated in pts with prior TIA/Stroke Contraindicated in pts with prior TIA/Stroke Not recommended for patients >75 years Not recommended for patients >75 years 5 mg maintenance dose suggested in patients <60 Kg, though this dose has not been studied 5 mg maintenance dose suggested in patients <60 Kg, though this dose has not been studied

61. Summary ACS includes UA, NSTEMI, and STEMI ACS includes UA, NSTEMI, and STEMI Management guideline focus Management guideline focus Immediate assessment/intervention (MONA+BAH) Immediate assessment/intervention (MONA+BAH) Risk stratification (UA/NSTEMI vs. STEMI) Risk stratification (UA/NSTEMI vs. STEMI) RAPID reperfusion for STEMI (PCI vs. Thrombolytics) RAPID reperfusion for STEMI (PCI vs. Thrombolytics) Conservative vs Invasive therapy for UA/NSTEMI Conservative vs Invasive therapy for UA/NSTEMI Aggressive attention to secondary prevention initiatives for ACS patients Aggressive attention to secondary prevention initiatives for ACS patients Beta blocker, ASA, ACE-I, Statin Beta blocker, ASA, ACE-I, Statin

62. Ten Points to Remember from the 2009 STEMI Guideline Update Antman EM, Hand M, Armstrong PW, et al.,

63. 1. Patients routinely taking NSAIDs (except for aspirin), both nonselective as well as COX-2 selective agents, before STEMI should have those agents discontinued at the time of presentation with STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use. Ten Points to Remember from the 2009 STEMI Guideline Update

64. 2. Oral beta-blocker therapy should be initiated in the first 24 hours for patients who do not have any of the following: a) Signs of heart failure b) Evidence of a low output state c) Increased risk for cardiogenic shock d) Other relative contraindications to beta blockade PR interval > 0.24 seconds PR interval > 0.24 seconds Second- or third-degree heart block Second- or third-degree heart block Active asthma or reactive airway disease Active asthma or reactive airway disease Ten Points to Remember from the 2009 STEMI Guideline Update

65. 3. STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact as a systems goal. 4. STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center and undergo PCI within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation as a systems goal unless fibrinolytic therapy is contraindicated. Ten Points to Remember from the 2009 STEMI Guideline Update

66. 5. A strategy of coronary angiography with intent to perform PCI (or emergency CABG) is recommended for patients who have received fibrinolytic therapy and have any of the following: Cardiogenic shock in patients <75 years who are suitable candidates for revascularization, Cardiogenic shock in patients <75 years who are suitable candidates for revascularization, Severe congestive heart failure and/or pulmonary edema (Killip class III), or Severe congestive heart failure and/or pulmonary edema (Killip class III), or Hemodynamically compromising ventricular arrhythmias Hemodynamically compromising ventricular arrhythmias

67. Ten Points to Remember from the 2009 STEMI Guideline Update 6. Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 hours and preferably for the duration of the index hospitalization, up to 8 days (regimens other than unfractionated heparin [UFH] are recommended if anticoagulant therapy is given for more than 48 hours because of the risk of heparin- induced thrombocytopenia with prolonged UFH treatment).

68. Ten Points to Remember from the 2009 STEMI Guideline Update 7. Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. Treatment with clopidogrel should continue for at least 14 days. 8. Every tobacco user and family members who smoke should be advised to quit at every visit.

69. Ten Points to Remember from the 2007 STEMI Guideline Update 9.For all post-PCI STEMI stented patients without aspirin resistance, allergy, or increased risk of bleeding, aspirin at a dose of 162-325 mg daily should be given for at least 1 month after bare- metal stent (BMS) implantation, 3 months after sirolimus-eluting stent implantation, and 6 months after paclitaxel-eluting stent implantation, after which long-term aspirin use should be continued indefinitely at a dose of 75-162 mg daily.

70. Ten Points to Remember from the 2007 STEMI Guideline Update 10. For all post-PCI patients who receive a drug- eluting stent, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-PCI patients receiving a BMS, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks).

71. ACC/AHA Guideline Classification System Level of Evidence (LOE)

72. Beta-blockers in STEMI Class I - oral beta-blockers should be initiated within 24 hours* LOE B Class I - oral beta-blockers should be initiated within 24 hours* LOE B Class IIa - reasonable to administer IV beta-blocker at the time of presentation who are hypertensive* LOE B Class IIa - reasonable to administer IV beta-blocker at the time of presentation who are hypertensive* LOE B Class III - IV beta-blockers should not be administered to patients with any of the following* LOE A Class III - IV beta-blockers should not be administered to patients with any of the following* LOE A * Contraindications include 1) signs of heart failure, 2) evidence of low output state, 3) risk for cardiogenic shock (age>70, SBP 110bpm, HR 0.24s, heart block, active asthma)

73. UFH/ LMWH in STEMI Class I - Patients receiving fibrinolytics should receive anticoagulant therapy for a minimum of 48 hrs, LOE C. Because of heparin induced thrombocytopenia, regimens other than UFH are recommended for patients receiving anticoagulant therapy > 48 hrs, LOE A. Class I - Patients receiving fibrinolytics should receive anticoagulant therapy for a minimum of 48 hrs, LOE C. Because of heparin induced thrombocytopenia, regimens other than UFH are recommended for patients receiving anticoagulant therapy > 48 hrs, LOE A.DOSE: UFH - 60 U/kg (max 4000 U) bolus, then 12 U/kg per hr drip UFH - 60 U/kg (max 4000 U) bolus, then 12 U/kg per hr drip Enoxaparin - (Cr <2.5 men, <2.0 women) Enoxaparin - (Cr <2.5 men, <2.0 women) For pts age <75 give 30mg IV bolus followed 15min later by 1 mg/kg subq. For pts age <75 give 30mg IV bolus followed 15min later by 1 mg/kg subq. For pts >=75, no IV bolus and reduce subq dose to 0.75 mg/kg For pts >=75, no IV bolus and reduce subq dose to 0.75 mg/kg

74. Clopidogrel in STEMI Class I - Clopidogrel 75mg/ day should be added to ASA in pts with STEMI regardless of fibrinolytic use LOE A Class I - Clopidogrel 75mg/ day should be added to ASA in pts with STEMI regardless of fibrinolytic use LOE A Class IIa - In patients < 75yo, it is reasonable to consider a loading dose of 300mg LOE C Class IIa - In patients < 75yo, it is reasonable to consider a loading dose of 300mg LOE C - recent studies suggest a loading dose of Plavix 600mg - recent studies suggest a loading dose of Plavix 600mg

75. Questions?