วันศุกร์ที่ 6 กรกฎาคม พ.ศ. 2555

Unstable angina/NSTEMI/STEMI

Canadian Cardiovascular Society Classification










Unstable angina characteristic









Short-Term Risk of Death in Patients with Unstable Angina



























General measure: O2 canular 2 LPM keep O2 > 90%, iv access, ECG monitoring

Emergency Treatment of Unstable Angina/Non-ST-Segment Elevation Myocardial Infarction

1. Antiplatelet Agents: ASA 162–325 mg PO + Clopidogrel Loading dose of 300 (600 if PCI) mg PO followed by 75 mg/d

***omeprazole 50% reduction in the antiplatelet aggregation effects of clopidogrel; prefer H2 blocker

2. Antithrombins: Enoxaparin 1 mg/kg SC q 12 h or Fondaparinux 2.5 mg SC or Bivalirudin

3. Glycoprotein IIb/IIIa Inhibitors: delayed to the time of PCI resulted in less bleeding with otherwise similar outcomes. eptifibatide and tirofiban are considered (IIa) if PCI is not planned.

4. Anti-Ischemic:

 NTG 0.4 mg SL q 5 min x 3 PRN pain; IV: Start at 10 g/min, titrate to 10% reduction in MAP if normotensive, 30% reduction in MAP if hypertensive; contra: sildenafil use within 24 hr, tadalafil use within 48 hr ; caution in inferior wall MI

 β-blocker PO within 24 hr of symptom onset: Metoprolol 50 mg PO q 12 h first day, Atenolol 25–50 mg PO; withhold if the patient is at risk for cardiogenic shock/adverse effects*

* HF, low CO, risk for cardiogenic shock (age >70 yrs, SBP <120 mmHg, HR >110/min or <60/min, long duration of STEMI symptoms before diagnosis and treatment)

* Relative contra to β-blocker: PR interval >0.24 sec, 2nd -3rd heart block, active asthma, or reactive airway disease

Emergency Treatment of STEMI

1. Antiplatelet Agents: ASA 162–325 mg PO + Clopidogrel Loading dose of 300(600 if PCI) mg PO followed by 75 mg/d

***No loading dose is administered in patients >75 y old receiving fibrinolytics

2. Antithrombins: Enoxaparin 30 mg iv bolus then 1 mg/kg SC q 12 h or Fondaparinux 2.5 mg SC

3. PCI >> Fibrinolytic Agents: Streptokinase 1.5 mu over 60 min, Alteplase (tPA) 15 mg IV bolus; 50 mg (0.75 mg/kg if BW < 67kg) infused over next 30 min; 35 mg (0.5 mg/kg) infused over next 60 min, Reteplase (rt-PA) 10 U IV over 2 min then 10 U IV bolus 30 min later, Tenecteplase <60 kg-30 mg iv (35-40-45-50 every 10 kg)

4. Anti-Ischemic (same)

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