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2. Greater sensitivity and specificitythan CK-MB3. Detection of recent MI up to
1. Low sensitivity in veryearly phase of MI(less than 6 h aftersymptom onset) and
2 weeks after onset4. Useful for selection of therapy5. Detection of reperfusion
requires repeatmeasurement at 8 to12 h, if negative2. Limited ability todetect late minorreinfarction
CK-MB 1. Rapid, cost-efficient, accurateassays2. Ability to detect early reinfarction
1. Loss of specificityin setting of skeletalmuscle disease orinjury, includingsurgery2. Low sensitivity duringvery early MI (less than6 h after symptomonset) or later aftersymptom onset (morethan 36 h) and forminor myocardialdamage (detectablewith troponins)
Myoglobin 1. High sensitivity2. Useful in early detection of MI3. Detection of reperfusion4. Most useful in ruling out MI
1. Very low specificity insetting of skeletalmuscle injury ordisease2. Rapid return to normalrange limits sensitivityfor later presentations
Fibrinolytic Therapy: Contraindications and Cautions for Fibrinolytic Use in STEMI From ACC/AHA 2004 Guideline
Update* Absolute Contraindications • Any prior intracranial hemorrhage • Known structural cerebral vascular lesion (eg, AVM) • Known malignant intracranial neoplasm (primary or metastatic) • Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours • Suspected aortic dissection • Active bleeding or bleeding diathesis (excluding menses) • Significant closed head trauma or facial trauma within 3 monthsRelative Contraindications • History of chronic, severe, poorly controlled hypertension • Severe uncontrolled hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg) • History of prior ischemic stroke >3 months, dementia, or known intracranial pathology not covered in contraindications • Traumatic or prolonged (>10 minutes) CPR or major surgery (<3 weeks) • Recent (within 2 to 4 weeks) internal bleeding • Noncompressible vascular punctures • For streptokinase/anistreplase: prior exposure (>5 days ago) or prior allergic reaction to these agents • Pregnancy • Active peptic ulcer • Current use of anticoagulants: the higher the INR, the higher the risk of bleeding
การใหยา Fibinolytic drug ควรใหเร3วท�,ส.ดูเท าท�,จะท5าไดู ถาสามารถให fibrinolytic drug
ผู้�ป่�วย high risk ดู�งตี อไป่น�4ควรไดูร�บการร�กษาแบบ early invasivePatient CharacteristicRecurrent angina or ischemia at rest or with low-levelactivities despite intensive medical therapyElevated cardiac biomarkers (TnT or TnI)New or presumably new ST-segment depressionSigns or symptoms of HF or new or worsening mitralregurgitation
High-risk findings from noninvasive testingHemodynamic instabilitySustained ventricular tachycardiaPCI within 6 monthsPrior CABGHigh risk score (e.g., TIMI, GRACE)Reduced left ventricular function (LVEF less than 40%)
Table 3. Short-Term Risk of Death or Nonfatal MI in Patients With UA/NSTEMI*
High Risk Intermediate Risk Low Risk
At least 1 of the following features must
No high-risk feature, but must have 1 of the
No high-or intermediate-risk feature but
Feature be present: following: may have any of the following features:
History Accelerating tempo of ischemic symptoms
Prior MI, peripheral or cerebrovascular disease,
in preceding 48 h or CABG; prior aspirin use
Character of pain
Prolonged ongoing (greater than 20 min)
Prolonged (greater than 20 min) rest angina,
Increased angina frequency, severity, or
rest pain now resolved, with moderate or high duration likelihood of CAD Angina provoked at a lower
threshold Rest angina (greater than 20 min) or relieved
New onset angina with onset 2 weeks to
with rest or sublingual NTG 2 months prior to presentation
Nocturnal angina
New-onset or progressive CCS class III or IV angina in the past 2 weeks without
prolonged (greater than 20 min) rest pain but with intermediate or high likelihood of CAD (see Table 6)
Clinical findings
Pulmonary edema, most likely due to Age greater than 70 years
ischemia
New or worsening MR murmur
S3 or new/worsening rales
Hypotension, bradycardia, tachycardia
Age greater than 75 years
ECG Angina at rest with transient ST-segment
T-wave changes Normal or unchanged ECG
changes greater than 0.5 mm Pathological Q waves or resting ST-depression
Bundle-branch block, new or presumed
less than 1 mm in multiple lead groups
new (anterior, inferior, lateral)
Sustained ventricular tachycardia
Cardiac markers
Elevated cardiac TnT, TnI, or CK-MB (e.g.,
Slightly elevated cardiac TnT, TnI, or CK-MB
Normal
TnT or TnI greater than 0.1 ng per ml) (e.g., TnT greater than 0.01 but less than
0.1 ng per ml)
TABLE 4. TIMI Risk Score for Patients With Unstable Angina and Non–ST-Segment Elevation MI: Predictor Variables
Predictor Variable Point Value of Variable Definition
Age 65 years 13 risk factors for CAD 1 Risk factors
• Family history of CAD• Hypertension• Hypercholesterolemia• Diabetes• Current smoker
Aspirin use in last 7 days 1Recent, severe symptoms of angina 1 2 anginal events in last 24 hoursElevated cardiac markers 1 CK-MB or cardiac-specific troponin levelST deviation 0.5 mm 1 ST depression 0.5 mm is significant; transient ST elevation >0.5
mm for <20 minutes is treated as ST-segment depression and is high risk; ST elevation 1 mm for more than 20 minutes places these patients in the STEMI treatment category
Prior coronary artery stenosis 50% 1 Risk predictor remains valid even if this information is unknown
Calculated TIMI Risk Score Risk of 1 Primary End
Point* in 14 Days Risk Status
0 or 1 5% Low2 8%3 13% Intermediate4 20%5 26% High6 or 7 41%
*Primary end points: death, new or recurrent MI, or need for urgent revascularization.
Table 5 . Properties of Beta Blockers in Clinical Use
Drugs Selectivity Partial Agonist Activity Usual Dose for Angina
Propranolol None No 20 to 80 mg twice daily
Metoprolol Beta1 No 50 to 200 mg twice daily Atenolol Beta1 No 50 to 200 mg per d Nadolol None No 40 to 80 mg per d
Timolol None No 10 mg twice daily
Acebutolol Beta1 Yes 200 to 600 mg twice daily
Betaxolol Beta1 No 10 to 20 mg per d
Bisoprolol Beta1 No 10 mg per d Esmolol (intravenous)
Beta1 No 50 to 300 mcg per kg per min
Labetalol None Yes 200 to 600 mg twice daily
Pindolol None Yes 2.5 to 7.5 mg 3 times daily
Carvedilol None Yes 6.25 mg twice daily, uptitrated to a maximum of 25 mg twice daily
ตีารางท�, 6. Dosage Table for Antiplatelet and anticoagulant in patient with UA/ NSTEMI
Drug* Initial Medical Treatment
During PCI
After PCI At Hospital Discharge
Patient Received Initial Medical Treatment
Patient Did Not Receive Initial Medical Treatment
Oral Antiplatelet Therapy
Aspirin 162 to 325 mg nonenteric formulation, orally or chewed
No additional treatment
162 to 325 mg nonenteric formulation orally or chewed
162 to 325 mg daily should be given† for at least 1 month after BMS implantation, 3 months after SES implantation, and 6 months after PES implantation, after which daily chronic aspirin should be continued indefinitely at a dose of 75 to 162 mg
162 to 325 mg daily should be given† for at least 1 month after BMS implantation, 3 months after SES implantation, and 6 months after PES implantation, after which daily chronic aspirin should be continued indefinitely at a dose of 75 to 162 mg
Clopidogrel LD of 300 to 600 mg orally MD of 75 mg
orally per day
A second LD of 300 mg orally may be given to supplement a prior LD of 300 mg
LD of 300 to 600 mg orally
For BMS: 75 mg daily for at least 1 month and ideally up to 1 year. For DES, 75 mg daily for at least 1 year (in patients who are not at high risk of bleeding) (See Fig. 11)
For BMS: 75 mg daily for at least 1 month and ideally up to 1 year. For DES, 75 mg daily for at least 1 year (in patients who are not at high risk of bleeding) (See Fig. 11)
Ticlopidine LD of 500 mg orally MD of 250 mg orally twice daily
No additional treatment
LD of 500 mg orally
MD of 250 mg orally twice daily (duration same as clopidogrel)
MD of 250 mg orally twice daily (duration same as clopidogrel)
Anticoagulants
Enoxaparin LD of 30 mg IV bolus may be given� MD � 1 mg per kg SC every 12 h_; extend dosing interval to 1 mg per kg every 24 h if estimated creatinine clearance less than 30 mL per min�
Last SC dose less than 8 h: no additional therapy Last SC dose greater than 8 h: 0.3 mg per kg IV bolus
0.5 to 0.75 mg per kg IV bolus
No additional treatment
Fondaparinux 2.5 mg SC once daily.
Avoid for creatinine 50 to 60 U per kg IV bolus of UFH is
50 to 60 U per kg IV bolus of UFH is
No additional treatment
clearance less than 30 mL per min�
recommended by the OASIS 5 Investigators¶
recommended by the OASIS 5 Investigators¶
Unfractionated heparin
LD of 60 U per kg (max 4,000 U) as IV bolus� MD of IV infusion of 12 U per kg per h (max 1,000 U per h) to maintain aPTT at 1.5 to 2.0 times control (approximately 50 to 70 s)�
IV GP IIb/IIIa planned: target ACT 200 s No IV GP IIb/IIIa planned: target ACT 250 to 300 s for HemoTec; 300 to 350 s for Hemochron
IV GP IIb/IIIa planned: 60 to 70 U per kg§ No IV GP IIb/IIIa planned: 100 to 140 U per kg
No additional treatment
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