Professional Documents
Culture Documents
antithrombotics
Dr. Gilbert Boucher
R4 Emergency Medicine
McGill
Goals
$rognostic "actors.
%urrent thera&ies.
S&ecial cases.
What's New?
October 4 , 2001
Practice Guidelines: Atherosclerotic Cardiovascular Disease
September 1 , 2001
Practice Guidelines: Atrial Fibrillation
April 27 , 2001
Practice Guidelines: Percutaneous Coronary Intervention
April 27 , 2001
E!ert Consensus Docu"ent: Catheteri#ation $aboratory %tandard
April 3 , 2001
Consensus Conference Report: Care of the Patient ith A!ult Con"enital #eart $isease
April 2 , 2001
%&pert Consensus $ocument: Stan!ar!s for Ac'uisition, (easurement an! Reportin" of )ntra*ascular +ltrasoun!
Stu!ies
(arch 1, 2001
,eachin" Sli!es: ACC-A#A .ui!elines for the (ana"ement of +nstable An"ina an! /on0S,0Se"ment %le*ation
(1ocar!ial )nfarction
2anuar1 1, 2001
Consensus Conference Report: (echanical Car!iac Support 2000: Current Applications an! 3uture ,rial $esi"n
/o*ember 1, 2000
Clinical Competence Statement: )n*asi*e %lectroph1siolo"1 Stu!ies, Catheter Ablation, an! Car!io*ersion
October 1, 2000
Clinical Competence Statement: Stress ,estin"
September 1, 2000
Practice .ui!elines: (ana"ement of Patients ith +nstable An"ina an! /on0S,0Se"ment %le*ation (1ocar!ial
)nfarction
September 1, 2000
Consensus Conference Report: (1ocar!ial )nfarction Re!efine!4A Consensus $ocument of the 2oint %uropean
Societ1 of Car!iolo"1-American Colle"e of Car!iolo"1 Committee for the Re!efinition of (1ocar!ial )nfarction
2ul1 1, 2000
%&pert Consensus $ocument: %lectron05eam Compute! ,omo"raph1 for the $ia"nosis an! Pro"nosis of Coronar1
Arter1 $isease
2une 1, 2000
,rainin" Statement: A!ult Car!io*ascular (e!icine 6COCA,S7 Re*ise! 8-00 ,as9 3orce :;: ,rainin" in /uclear
Car!iolo"1
!!!.acc.org
ACUTE CORONARY SYNDROME ACUTE CORONARY SYNDROME
No ST Elevation No ST Elevation
ST Elevation ST Elevation ST Elevation ST Elevation
Unstable Angina NQMI QwMI
Myocardial Inarction
NSTEMI
Myocardial in"arction'
acute( eoling( recent
Typical rise and gradual fall (troponin) or
more rapid rise and fall (CK-MB) of
biochemical markers of myocardial
necrosis with at least one of the following:
a) ischemic symptoms!
I s T,
-
Tro&onin I does not accumulate in renal "ailure
-
Di""erent assays o" same tro&onin hae di""erent
alues due to di""erent isoto&es o" antibodies
.ery sensitie
-
Estimate that /01 o" &atients !ith 234 are no!
diagnosed !ith NSTEMI due to eleated tro&onins
%lass I'
-
4s&irin( Nitrate( B#bloc:ers( mor&hine( @6 F&rnG.
-
Nondihydro&yridine FcardiHem3era&amilG.
-
4%Ei "or s&eci"ics.
%lass 6a'
-
4%Ei "or all.
-
=ong#acting %%B "or recurrent ischemia.
-
I4B$ i" all "ails.
%lass 6b'
-
EItended "orm o" Nondihydro&yridine.
-
Short acting dihydro&yridine in the &resence o" B#
bloc:er.
@Iygen
Jor'
-
%yanosis
-
Res& distress
-
5igh ris: "eatures
%onsume resources
Eidence is lac:ing.
Nitrates' Decr M.@6( incr coronaries
oIygenation
4ctions
-
Dilate enous bed' decr &reload and entricular !all
tension.
-
Smaller dilatation o" arterial system' decr a"terload
and entricular !all tension.
Need B#bloc:er
-
Dilatation o" atherosclerotic coronaries
-
Decreased &latelets adhesieness.
Jor
-
ischemia des&ite nitro K / and i B#bloc:ade
-
high#ris: &atients Fnon#hy&otensieG.
$otentially bene"icial
-
.enous dilatation
- Decr 5R
-
Decr sB$ FDecr M.@6G
-
4ctiates neutral endo&e&tidases
4nn Emerg Med. May 600<L/9'448#44>.
5y&otension
Decr sB$
%ontraindications FconsensusG'
-
<
st
degre 4. bloc: M64 msec
-
6
nd
or /
rd
degre 4. bloc: !ithout &acema:er
-
4sthma
- Seere =. dys"unction !ith %5J
%aution !ith'
-
%@$D
-
Bradycardia N80
-
5y&otension N>0
4. bloc:
%onclusion'
-
Good sym&tom relieer
-
Trend o" im&roed outcome !ith non#
dihydro&yridine agents
4s&irin 4S4$O
-
Thieno&yridine Fclo&idogrel or ticlo&idineG i"
hy&ersensitiity o" maPor GI intolerance
4s&irin
%yclooIygenase#< inhibitor
-
$reents thromboIane 46 "ormation
$laiI'
Sa"ety i" angio or used !ith
G&6b/4 inh
6700 &ts.
2J5
=M* he&arin
5irudin
2J5
2n&redictable.
-
*eight adPusted dosage
Incr need in DM and smo:ing( lo!er !ith age
,
Therou= et al' - $ngl 2 Med
34>>!634:33?733'
/nclear significance
,
$ptifibatide (integrilin)( tirofiban
(aggrastat): "ery specific binding achie"e
A>?@ within 7 minutes
,
1ifferent antagonists can bind at different
sites and can parado=ically acti"ates the
%;..b*...a receptor
4 main studies
6 &osities
5igh#ris: "eatures
<<.91 s B.91(
<8.91 s <4.61
Numbers,
;ig(re ,: )d<(sted hazard ratios *012
58/ for treatment with tirofi4an 4y
troponin 8 '(artiles
;ig(re #: =vent-rate c(rves
*mortality% myocardial
infarction/ for $.-day follow-
(p for patients with > troponin
8
Numbers,
,
;rism-plus: ;latelet Ceceptor .nhibition in
.schemic &yndrome Management in
;atients Fimited by /nstable &igns and
&ymptoms
,
T+$ study
,
&T changes or E en:ymes
,
Tiroban alone dropped due to too much
mortality
33 ??? pts
.ncidence of 9'7@
,
G6@ mortality
,
But median time to shock G5 hrsI
)ge A 57yo
&t de"iation
Retros&ectie
4bciIimab' 6000W3treatment
-
But ho! come !e are almost neer using
stre&to:inase anymore, are !e
reasonableCCC
*hat about'
$laiI s G$ IIb3IIIaC
<B.B1 s <7.81
<9.> s <6.>1
D2ST a thought ,
But bac: to standard o" care,
The classics' 5o! do !e doC
6000 &ts
4torastatin B0mg3d bet!een 64 and >7hrs o"
admission.
%oronary asos&asms
-
*orsen by minimal atherosclerosis
-
Reersed by %%B
-
ST#changes in /B1 o" &ts in detoI centers
In cath lab
No change in 5r or B$ but'
-
801 incr in coronary resistance !ith 601 decr in "lo!
No mention o" benHosCCCCCCC
%onclusion