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5")*? B 1 (2E@<=!E1=L!E(E@<>+A#(=0I=#"4R$6<=!E1=L!E(E@(HS@ PC B@;?2!@4=, B;<=>46L! Stable angina PC B@;?I.+<=!E1=L!E*? B/46=,;(IB'MH;>'<'"(=06@9>+(stable fixed atherosclerotic plaque) *TA4;?I.+<=!E1=L!EG"@#'/$.(94(unstable plaque) *TAG)=>' <"4;?1)?%@/$.;":H!@=. B;1=L!E1=S4'K!%M;B2B@I=A+A#9"%1N?%G)=>';?1)?%@1#SG!4#"44=K";1'L K!<>+A#H"E1=L!E1$?%4 +B" Unstable angina (9B<"4=. B;1=L!E;?/$.;":;"4#014.E4=K";1'L K!<>+A#9"%1N?%G)=>'(Myocardial infarction) PC B@#T('4(949B"@4>'9";(9B+B";?4"$%49>+H!@ ST segment EK+%4"$9$+#6=L B'MWWK"<>+A#<$L!M;B
A'4$:?* B?;4? "$%49>+;>4;?= B;. 1=L!E!,E9>'(thrombus) /$.;":;"414L!G19S;<=!E1=L!E (9B4=, B;*? B M;B;? ST segment %49>+;>4;?= B.;1=L!E'K!%4+B"#')!;?1=L!EIB"'M/MEKGK"@ !%B"@M$4SE4? "$+.'#. N>%5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'A'4$:?* B M;B ? ; ? ST-segment %49>+;?6+";%, B@%"4;"44+B"4=, B;*? B; ? ST-T K segment %4EK+%/$04"$9B!M/'? 1. <"4M;B;?4"$1/=? B%'(/=@H!@6=L B'MWWK"<>+A#AEO 4"$+.'#. N>%5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'#T1/S'9K!@!"8>%4"$9$+#*"@94. "$ <$L! Cardiac biomarkers MEK(4B Myoglobin, Cardiac specific Creatinine Phosphokinase enzymes (Isoform MB) (=0 Troponin T <$L! I 2. A'4=, B;*? B;?!"4"$1#SG!4M;B#T1)"0#"4R$6<=!E1=L!E(E@R6R$'"$? (;K#0;?$0E>G Cardiac biomarkers 1). B; KHC'4S!"#1/S'I=#"45"+0!L B'*? B2B@I=A+A#G"E1#SG<$L!9"%4S MEK (non coronary cause of myocardial necrosis) <$L! secondary coronary ischemia K/B+%*? B2@2>% 3. 1$"!"#[email protected]";$0E>G Cardiac biomarkes $B+;4>G4"$1/=? B%'(/=@H!@6=L B'MWWK"<>+A#A'IJ 5"+0<=!E1=L!E(E@<>+A#1N?%G)=>' 1)L B!EJ4"$1/=? B%'(/=@ (=0$0E>G Cardiac biomarkers *? B1). B; KHC'<$L!=E=@(rise K!<>+A#9"%H"E1=L!E(3) and fall of biomarkers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
5")*? B 2 (2E@E,=%&$0<+B"@!,/2@6&(=0!,/*"'H!@4=K";1'L K!<>+A# PC B@;?/>##>%6+G6,;<="4<="% PC [email protected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
4"$$>4D"*? B1<;"02;;. A7B%"9K"'14$SE1=L!EE>@17B'4=, B;*? B14.E=. B;1=L!E!,E9>' <"4(9B1/S'4"$(4K MH5"+0P?E (=0$>4D"(I=A'4$01)"0!"<"$ '!4#"4'? K%"9K"'14$SE1=L!E!"#*TA+A#H"E1=L!EA'5"+0<=!E1=L!E(E@ <>+A#1N?%G)=>'2B+'A ;?;=J 3"'#"4 =. B;1=L!E*? B4!B 9>+!%B"@$+E1$S+;"!,E K4>' <=!E1=L!E1!@$B+;4>G4"$9?G(6G1=S4'K!% H!@<=!E1=L!E(E@R6R$'"$?1E.;*TA+A#
5")*? B 4 (2E@4=M42"1<9,H!@4=K";1'L K! <>+A#H"E1=L!EA'R$64=K";1'L K!<>+A#H"E 1=L!E1$L K!$>@PC B@;?!"4"$9B!1;L B!;?4"$1). B; 6+";9K!@4"$H!@4=K";1'L K!<>+A# RE%;?4"$9?G(6G1E.;H!@<=!E1=L!E(E@ <>+A#PC B@6B!'HK"@6@*? B (=0/<$L!$B+;4>G 4"$9?G(6G1). B;19.; #"44"$@<=!E1=L!E
5")*? B 5 (2E@4=M42"1<9,H!@4=K";1'L K! <>+A#H"E1=L!E!>'1/S'I=#"4/>##>%!L B' (secondary coronary ischemia)
PC B@!"#;?<$L!M;B;+A#!%B"@;"4<$L!;?4"$!>412G9.E17L K! KHC';"
<"44"$9$+#6=L B'MWWK"<>+A#1/S'/49. 4"$+.'#. N>%#0;?6+";%, B@%"4;"4HC K' #T1/S'9K!@!"8>%4"$9$+#*"@9.4"$1). B;19.; MEK(4B4"$9$+#$0E>G Cardiac Biomarkers !"*.17B' 1!'MP;& Creatinine Phosphokinase (isozyme MB ;?6+";#T1)"02J@2,E), Myoglobin (=0*? B()$B<="%(=017L B!FL!*? B2,EMEK(4B Cardiac Troponin PC B@;. A7B1!'MP;&(9B1/S'2"$*? B$B+;A'4"$4"$*T@"' H!@4=K";1'L K!<>+A# *> K@1!'MP;& <$L! Cardiac biomarkers !L B';?$0E>GA'1=L!E1/=? B%'(/=@<=>@#"4 5"+04=K";1'L K!<>+A#9"%H"E1=L!EM/9";7B+@1+=" (5")*? B 7) RE%#0MEK4=B"+A'$"%=01!?%E9B!M/
A'/>##,G>';?14:Y&4"$+.'#. N>%4=K";1'L K!<>+A#9"%H"E1=L!E*? B1/S'2"4=(Universal definition of myocardial infarction) KHC';"RE%6+";$B+;;L!H!@ European Society of Cardiology(ESC), American College of Cardiology Foundation(ACCF), B 2,EA'/? 6.8. 2012(3) American Heart Association(AHA) (=0 The World Heart Federation(WHF) PC B@;?14:Y&=" !>'1/S'14:Y&$B+;4>'6$> K@*? B 3 RE%(GB@1/S'2!@4=, B;<=>4E>@ K'? K!<>+A#9"%H"E1=L!E1N?%G)=>' 1. 4=K";1'L 9K!@;?<=>43"'H!@4=K";1'L K!<>+A#9"%(myocardial necrosis) $B+;4>G=>4D:0*"@6=.'.4!>'GB@FC@5"+04=K";1'L K!<>+A# H"E1=L!E(myocardial ischemia) (GB@!!41/S' 5 4=, B;E>@ K'? K!<>+A#9"%H"E1=L!E1N?%G)=>'*? B14.E KHC'1!@ (spontaneous myocardial infarction(MI)) 1. 4=K";1'L PC B@;>414.E#"4(IB'MH;>'A9KI.+<=!E1=L!E(E@R6R$'"$?/$.(94, 14.E(I=#'14.E$B!@G'I.+ <$L!(;K(9B/$.(%4(dissecting) 5"%A'I'>@<=!E1=L!E1!@*TA+ (=0(;K(9B= B;. 1=L!E/=.+;"!,E K4>'!%B"@'K!%A'<'C B@(H'@H!@<=!E1=L!E(E@R6R$'"$? 1/S'1<9, A+A#*? B<=!E1=L!E'> K'1=? K%@!%J B9"%H"E1=L!E 1$";>4)G<=!E1=L!E(E@R6R$'"$?9G? 9>' (9BG"@$"%!"#M;B)G4S1/S'MEK %L'%>'EK+%4"$9$+#)G$0E>G Cardiac biomarkers 1). B; KHC'(=0/<$L!=E=@ (rise/fall
2.
3.
4.
4=K";1'L K!<>+A#9"%H"E1=L!E#"42"1<9,! BL' (secondary to ischemic imbalance) PC B@1/S'I=A+A# A'IJ K/B+%G"@$"%!"#;?<=!E1=L!E9?G9>'1E.; <$L!M;B4 MEK S (9B;/? $.;":6+";9K!@4"$H!@4=K";1'L K!1). B;2J@ KHC' <$L!;?/>##>%!L B'=E*!'/$.;":1=L!E *? B2JGN?E!%B"@*>'*? 17B' 4"$9.E17L K! 6+";E>'R=<.9*? B9 T=@ B (5"+07Z!6) <$L!5"+0P?E 1/S'9K'(9"$"@*? B 1) 4=K";1'L K!<>+A#9"%H"E1=L!E$B+;4>G4"$12?%7?+9. N>G)=>' (MI resulting cardiac death) ;?4"$12?%7?+9. *? B;43"'GB@FC@5"+04=K";1'L K!<>+A#H"E1=L!E <$L!9$+#)G6=L B'MWWK"<>+A#1/=? B%'(/=@A<;B <$L! left bundle branch block A<;B RE%M;B;I? =9$+# Cardiac biomarkers 4B!'12?%7?+9. 4=K";1'L K!<>+A#9"%H"E1=L!E#"44"$*T<>9F4"$FB"@H%"%<=!E1=L!E(E@R6R$'"$?#T('41/S' K!<>+A#9"%H"E1=L!E#"44"$*T<>9F4"$FB"@H%"%<=!E1=L!E(E@R6R$'"$? (related to i. 4=K";1'L Percutaneous Coronary Intervention, PCI)(4a) 14.E$B+;4>G4"$*T<>9F4"$ PCI (=0)G$0E>G HC'14.'4+B" 5 1*B"H!@*? B 99 percentile <"4;?$0E>G Cardiac Cardiac Troponin(cTn) 1). B; K Troponin 4B!'*T<>9F4"$/49. !"#$%&'() *+ , -%.' - 20% /0.%1') <"4$0E>G4B!'*T2J@4+B"/49. (=0/<$L!4T=>@=E=@ $B+;4>G=>4D:09B!M/'? K!%B"@AE!%B"@<'C B@ K!<>+A#H"E1=L!E 1. ;?!"4"$4=K";1'L 2. ;?6=L B'MWWK"<>+A#1/=? B%'(/=@A<;B <$L! left bundle branch block A<;B 3. I=4"$9$+#<=!E1=L!E)G4"$!,E9>'<$L!9?G(6GA<;B A'(H'@A9F4"$ K!<>+A#+A#A<;B <$L!;?4"$9"%M/A<;BH!@4=K";1'L K!<>+A# th
(new loss of viable myocardium)
4=K";1'L K!<>+A#9"%H"E1=L!E#"4HE=+E!,E9>' (related to stent thrombosis)(4b) KIJ/B+%9K!@16%MEK$>G4"$FB"@H%"%<=!E1=L!E(E@R6R$'"$?)$K!;+"@HE=+EFB"@H%"%(coronary artery stenting) (=09$+#)G=. B;1=L!E5"%A'HE=+EE>@4=B"+ $B+;4>G4"$)G%L'%>'EK+%4"$9$+#)G$0E>G Cardiac biomarkers 1). B; KHC'(=0/<$L!=E=@ B <'C B@6B"AE2J@4+B"*? B 99 percentile (rise/fall) (=0;?6" 4=K";1'L K!<>+A#9"%H"E1=L!E#"44"$IB"9>E*"@1G? B%@<=!E1=L!E(E@<>+A# (related to coronary artery bypass ii.
th
5.
grafting)
;>4FL!+B"14.E#"44"$IB"9>E CABG <"4;?$0E>G Cardiac biomarker 14.'4+B" 10 1*B"H!@*? B 99 percentile A'IJ K* B?1E.;;?6"B Cardiac Troponin /49. $B+;4>G=>4D:09B!M/'? K!%B"@AE!%B"@<'C B@ th
1. 2. 3.
6=L B'MWWK")G Q wave A<;B <$L! left bundle branch block A<;B I=4"$9$+#<=!E1=L!E)G4"$!,E9>'<$L!9?G(6GA<;B A'(H'@H!@<=!E1=L!E graft <$L!<=!E1=L!E(E@R6R$'"$?1E.; I=4"$9$+#4"$*T@"'H!@4=K";1'L K!<>+A#+A#A<;B <$L!;?4"$9"%M/A<;BH!@4=K";1'L K!<>+A# (new loss of viable myocardium)
2.
4=K";1'L K!<>+A#9"%H"E1=L!E1E.; +.'.#N>%1;L B!)G<=>43"'AE<=>43"'<'C B@9B!M/'? K K@*? B;? <$L!M;B;!? "4"$H!@4=K";1'L K!<>+A#H"E1=L!E 6. 6=L B'MWWK"<>+A#(2E@ Pathologic Q wave *> (=0M;B;2? "1<9,! BL'!Q.G"%(absence of non ischemic cause) K!<>+A##"44"$9$+#5")<>+A# !"*.17B' 7. )G4"$9"%H!@4=K";1'L 4"$G"@9>+=@$B+;4>G4"$*T@"'=E=@H!@4=K";1'L K!<>+A# (=0M;B;?2"1<9,! BL'!Q.G"%(absence of non ischemic cause)
8.
9$+#)G4=K";1'L K!<>+A#9"%#"4I=)%"Q.+.*%"
5")*? B 6 (2E@#T'+'IJ K/B+%$"%A<;B* B;? ?4=K";1'L K!<>+A#9"%H"E1=L!E$+;(MI) (=04=B ,;*? B; ? ST segment %49>+(STEMI) <$L!M;B%49>+(Non-STEMI) 9B!/$07"4$ 100000 6' A'2<$>3'>G#"4/? 1999 FC@ 2008 (2E@AG1). B; KHC' PC B@1/S'I=2B+'<'C B@H!@4"$9$+#+.'#. N>%;?6+";M+1). B; KHC';"44+B"(9B4!B ' *TA%4=, B; KIJ/B+%*? B1E.;+.'#. N>% ? =K";1'L K!9"%H'"E'K!%(=02";"$F9$+#)GMEKEK+%4"$9$+#+.Q?1E.;1HK";"1). B;$+; Unstable angina (9B;4 (=0%>@$+;IJ K/B+%4=, B;R$6!L B'*? B;5? %>'9$"%9B!4=K";1'L K!<>+A#EK+% (6>E=!4#"4G$$:"',4$;(4))
9"$"@*? B 1 (2E@R$6(=05"+0*? B1/S'2"1<9, AG Cardiac biomarkers [email protected]/49. (E>E(/=@#"4G$$:"',4$;(3)) 8&* /9%-(34 5!#.2#:;%6!,< ;"=>-?@A%2!:<"2 8&* /9%-(34 5!#.2@%#$%!=B1" 5<,
4=K";1'L K!<>+A#9"%#"44"$H"E1=L!ERE%9$@(primary ischemia) 5%>'9$"%9B!4=K";1'L K!<>+A#*? B M;B MEK14.E#"44"$H"E1=L!E •
(IB'MH;>'/$.(94(plaque rupture)
•
Cardiac contusion,
4"$IB"9>E<>+A#, ablation, 4"$4$09, K'<>+A#, 4"$7Z!64$09,4<>+A#EK+%MWWK"
•
14.E=. B;1=L!E5"%A'<=!E1=L!E(E@R6R$'"$? KHC'1!@
•
Rhabdomyolysis
•
4=K";1'L K!<>+A#!>412G
•
2"$).D<$L!%"*? B1/S').D9B!<>+A# 17B' Anthracyclines,
*? B14.E'!4<>+A#
Trastuzumab
4=K";1'L K!<>+A#9"%#"44"$12?%2;E,=H!@$0GG<=B!1=? K%@ 4=K";1'L K!<>+A#(supply/demand imbalance)
5%>'9$"%9B!4=K";1'L K!<>+A#*? B M;B*$"G4=M47>E1#'
•
<>+A#19K'I.E#>@<+0
•
5"+0<>+A#=K;1<=+
•
<=!E1=L!E1!!!$&94. /$.(%4 (Aortic dissection) <$L!R$6=K .'1!!!$&94. I.E/49.!%B"@$,'($@
•
Stress (Takotsubo) Cardiomyopathy
•
.=B;1=L!E!,E K4>'<=!E1=L!E(E@/!E <$L!5"+06+";E>'<=!E1=L!E(E@/!E2J@$,'($@ 5"+09.E17L K!A'4$0(21=L!E <$L! KIJ/B+%+.4X9!L B'
•
R$64=K";1'L K!<>+A#<'"9>+I.E/49.
•
5"+07Z!6AEO
•
•
5"+04"$<"%A#=K;1<=+
•
M9+"%
•
5"+0P?E!%B"@$,'($@
•
R$6/5"+0*"@2;!@!%B"@$,'($@ 17B' 5"+0<=!E1=L!E2;!@1N?%G)=>' <$L!1=L!E94A9K1%L B!
•
6+";E>'R=<.92J@*> K@*? B; /? M;B;4? =K";1'L K!<>+A#<'"
•
Infiltrative diseases
17B' Sarcoidosis, Amyloidosis
•
<=!E1=L!E(E@R6R$'"$?
•
4"$!!44T=>@4"%!%B"@<'>4
•
=. B;1=L!E#"49T(<'B@!L B'!,E K4>'<=!E1=L!E(E@ R6R$'"$?
•
Endothelial dysfunction
H!@<=!E1=L!E(E@R6R$'"$?* B M;B ? ;%5"+0<=!E1=L!E(E@<>+A#EK+%6=L B'MWWK"<>+A#I.E)="E (6>E=!4#"4G$$:"',4$;(3)) "%@64C:)-#:-D (False positive) "%@64C::):-D (False negative) 5"+0 Early repolarization
4"$;?4=K";1'L K!<>+A#9"%$B+;4>G Q wave (=0/<$L! ST %49>+1E.;
Left bundle branch block
4"$4$09, K'<>+A#
4=, B;!"4"$ Pre-excitation J point elevation
Left bundle branch block
A'6=L B'MWWK"<>+A# 17B' Brugada syndrome
5"+01%L B!+A#(=0/<$L!4=K";1'L K!<>+A#!>412G =. B;1=L!E!,E K4>'*? B<=!E1=L!E(E@/!E 1=L!E!!4A9K1%L B!GR/(921P?%;A'1=L!E2J@ Cardiomyopathy
4"$9.E6=L B'MWWK"<>+A#2=>G KH>+ F,@'K TE?!4> 12G Persistent juvenile pattern
%" Tricyclic anti-depressants <$L! Phenothiazines 4"$9$+#6=L B'MWWK"<>+A#A'5"+0<=!E1=L!E(E@<>+A#1N?%G)=>' 6=L B'MWWK"<>+A#*? BGB@FC@ ST elevation MI(3) MEK(4B HC' : 9T(<'B@$!%9B!$0<+B"@ QRS complex (=0 ST segment(J point) 9.E9B!4>'!%B"@'K!% 1. 2B+'H!@ ST segment %49>+ K K7"%!"%,14.' 40 /? (!%B"@'K!% 2.5 ;.==.1;9$(0.25 mV) 2 leads 9B!1'L B!@4>'(=02J@!%B"@'K!% 2 ;.==.1;9$(0.2 mV) A'IJ A'IJ K7"%!"%,9 T4+B B " 40 /?)<$L! 1.5 ;.==.1;9$(0.15 mV) A'IJ K94. "$:&'K!%4+B") 3. 2B+'H!@ ST segment =E9>+!%B"@'K!% 0.5 ;.==.1;9$(0.05 mV) A' leads V1-4 !%B"@'K!% 2 lead 9B!1'L B!@4>'!"#GB@FC@ ST elevation MI H!@ posterior wall PC B@6+$%L'%>'EK+%4"$%49>+H!@ ST segment A' V7-9 !%B"@'K!% 1 ;.==.1;9$(0.1mV) <$L! 0.5 ;.==.1;9$(0.05mV) <"4!"%,'!K %4+B" 40 /? . .#N>%!L B'$B+; (Sgarbossa criteria) PC B@M;B2;GJ$:& E>@9B!M/'? K 4. 4$:? Left bundle branch block !"#).#"$:"EK+%14:Y&+' (<"4MEK60(''$+;;"44+B" 3 ;? R!4"21/S' ST elevation MI ;"44+B" 98%) a. ST segment %49>+!%B"@'K!% 1 ;.==.1;9$ (0.1 mV) A' lead *? B; ? QRS complex 1/S'G+4 '>G1/S' 5 60('' b. ST segment =E9>+=@!%B"@'K!% 1 ;.==.1;9$ (0.1 mV) A' lead V1-3 '>G1/S' 3 60('' c. ST segment =E9>+!%B"@'K!% 5 ;.==.1;9$ (0.5 mV) A' lead *? B;? QRS 1/S'=G '>G1/S' 2 60('' 6=L B'MWWK"<>+A#*? BGB@FC@ ST depression (=0 T inversion MEK(4B 2B+'H!@ ST segment =E9>+=@;"44+B" 0.5 7B!@ (0.05 mV) A'2!@ leads *? B9!B 1'L B!@4>' <$L! T wave 4=>G<>+(=0=C44+B" 10 7B!@1=S4 (0.1mV) A' lead *? B R wave 1EB'<$L!2>E2B+'H!@ R/S ;"44+B" 1 !%B"@M$4SE4? "$(/=I=6+";I.E/49.H!@ ST segment !"#M;B#T1)"09B!5"+04=K";1'L K!<>+A#H"E1=L!E<"4A'G"@5"+017B' 4=, B;!"4"$ Pre-excitation, Dilated cardiomyopathy <$L! Stress cardiomyopathy, Cardiac Amyloidosis, Left bundle branch K!<>+A#+ (M;B+"B #01/S'HK"@PK"%<$L!H+"), 4=K";1'L K!<>+A#!>412G, block, Left anterior hemi(fascicular) block, 4=K";1'L K@(GG1N?%G)=>'(=01$L K!$>@) '!4#"4'? K%@> ;? R$6/5"+0!L B'*? B!"#;?=>4D:06=L B'MWWK"6=K"%6=C@4=K";1'L K! Cor pulmonale ( *> <>+A#9"%!?4 E>@9"$"@*? B 2
4"$9$+#$0E>G Cardiac Biomarkers A'5"+0<=!E1=L!E(E@<>+A#1N?%G)=>' EK+%+.*%"4"$/>##,G>'1$"2";"$F9$+#$0E>G Cardiac Biomarkers MEK;"4;"%1)L B!<"<=>43"'H!@4"$G"E1#SGH!@4=K";1'L K! <>+A#(4=K";1'L K!<>+A#9"%), 4"$4$09, K'4"$(HS@9>+H!@1=L!E, 4$0G+'4"$!>412G $+;FC@4"$4$09, K'$0GG/$02"*!>9R';>9. (=0[!$& R;'(neurohormonal activation) #C@;?/$0R%7'&!%B"@;"A'5"+0<=!E1=L!E(E@<>+A#1N?%G)=>' 1$")G+B"4"$9$+#*? B;? /$0R%7'&2J@2,E6L!4"$9$+#<"<=>43"'H!@4=K";1'L K!<>+A#9"%PC B@2";"$F#T(%44=, B;*? B;6? +";12? B%@2J@ (=0)%"4$:&!9> $"9"%*? B 30 +>'M/#'FC@ 1 /? MEK(1) A'!E?94"$9$+#$0E>G1!'MP;& Creatinine phosphokinase *> K@7'.E$+;(=01N)"0 isoform MB A'1=L!E 1/S'<=>4 (9B9!B ;")G+B" KIJ* B?;4? =K";1'L K!<>+A#G"E1#SG1)?%@1=S4'K!%!"#;?$0E>G1!'MP;&/49.(9BE+K %4"$9$+#$0E>G Cardiac Troponin PC B@1/S'2"$/$04!G5"%A'1P==&4=K";1'L K!<>+A##02";"$F9$+#)G<=>43"'H!@4=K";1'L K!G"E1#SGMEK1). B; KHC'($"+ 28%)(1) (=02";"$F#T(%44=, B;12? B%@MEKE KH? C'!?4 (9B1$"M;B MEK).#"$:"1)?%@$0E>GH!@ biomarkers (9B9K!@EJ=>4D:04"$1/=? B%'(/=@EK+% RE%1$")G+B"A'5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'#0;?$0E>G1). B; KHC'#"41E.;5"%A'1+=" 3-4 7> B+R;@<=>@;?4"$9?G9>' H!@<=!E1=L!E(E@ (=0A'4"$9$+# Troponin 6+";M+2J@6+$)G4"$1/=? B%'(/=@%&'() *+ , -*$2 troponin %.'- 20% /+2 /34#$5(0%678(9-:672;<1%/- (9B A'2"1<9,! BL'(9"$"@*? B1) #0;?$0E>G6@*? B<$L!1/=? B%'(/=@M;B14.' 20% E>@5")*? B 8 <"44"$9$+#A'9!'($4M;B)G6+";I.E/49.(=0;?!"4"$;"14.' 6 7> B+R;@ 1$"#T1/S'9K!@$>G KIJ/B+%M+K1)L B!(%4+B" #01/S'4=, B;*? B;1? )?%@ K!<>+A#9"%#$.@A'5"%<=>@ (Non ST elevation MI) EK+%4"$9.E9";$0E>G Cardiac biomarkers Unstable angina <$L!;?4=K";1'L PC B@<"4M;B)G 6+";I.E/49.1$"6+$*T4"$%L'%>'4"$+.'.#N>%(=0/$01;.'6+";12? B%@EK+%4"$9$+#2;$$F5") <=!E1=L!E(E@<>+A# K/B+%*? B;$? 0E>G markers [email protected]/49.4 AE1#'<$L!M;B (stress test) E>@('+*"@A'5")*? B 8 <"4IJ RE%IJ K/B+%5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'6+$;?4"$1/=? B%'(/=@$0E>G Cardiac biomarkers !%B"@7>E1#' (9B A'4=, B;*? B;$? 0E>G2J@(9B6@$0E>G9B!1'L B!@4S6+$2LG<"2"1<9,! BL''!4#"4<=!E1=L!E<>+A#9?G 2B+'IJ K* B?$0E>G Troponin /49.(=0;?!"4"$M;B'"'14.' 6 7> B+R;@6+$MEK$>G4"$9$+#%L'%>'PK T5"%A' 3 7> B+R;@PC B@!"#9$+#)G$0E>G Troponin 1/S'/49. RE%1N)"0!%B"@%. B@ 3-4 7> B+R;@($4<=>@;?!"4"$ (9B#09$+#)GMEK<=>@ 6 7> B+R;@#C@('0'TA B+R;@ (9B<"4M;B; ? Troponin 1$"%>@A7K4"$9$+# Creatinine phosphokinase isoform MB *E(*' '!41<'L!#"44"$9$+#$0E>G Troponin (=K+1$"%>@;?4"$9$+#*? B;/? $0R%7'& A'4"$)%"4$:&!>9$"4"$12?% .7?+9. <$L!4"$4=>GPK T H!@4=K";1'L K!<>+A#9"%H"E1=L!E 5"%A'1+=" 30 +>' <$L! 1 /? EK+%4"$9$+# N terminal-pro B-type Natriuretic peptide(NT-BNP) (*? B A7K A'4"$9$+#<"<=>43"'H!@<>+A#=K;1<=+) <$L! C-reactive protein(CRP) (1)L B!/$01;.'4"$<=>43"'H!@<=!E1=L!E(E@) PC B@ > !>9$"4"$12?%7?+9. (=04"$4=K";1'L K!<>+A#9"%PK T*? B 30 +>'(=0 1 /? (9B CRP NT-ProBNP *? B2J@2>;)>'Q&4G *? B2J@2>;)>'Q&4G> !>9$"4"$12?% .7?+9. *? B 1 /?1*B" K'>'(5) !%B"@M$4SE/? >##,G>'1$"/$01;.'6+";12? B%@EK+%4"$$+G$+;HK!;J=*,4O!%B"@ /$04!G4>G biomarkers (=K+4T<'E1/S'60('' 17B' TIMI risk score(6) <$L! GRACE risk score(5")*? B 9)(1) PC B@E?4+B"!"8>%HK!;J=!%B"@AE!%B"@<'C B@ (=0)G+B" GRACE risk score ;?6+";(;B'%T4+B"A'4"$)%"4$:&!>9$"4"$12?%7?+9. *? B 6 1EL!'(7)
5")*? B 7 (2E@1/=? B%'(/=@ Cardiac Biomarkers 7'.E9B"@O <=>@#"44=K";1'L K!<>+A#9"%H"E1=L!E 9>@(9B<=!E1=L!E(E@R6R$'"$? (<'B+%1/S'#T'+'1*B"H!@6B"/49.2J@2,E multiples of cutoff limit) 9";$0%01+="'>G K !,E9>'(<'B+%1+="7> B+R;@) (2E@AG Cardiac biomarkers (9B=07'.EMEK(4B Myoglobin, Creatinine Phosphokinase Isoforms 9B"@O (=0 Creatinine Phosphokinase isoform MB, Troponin )G+B" Myoglobin (=0 Creatinine HC'4+B"/49. MEK4!B ' biomarkers 9>+!L B'(1-2 7> B+R;@) #"4'> K'$0E>G biomarkers Phosphokinase isoforms 9B"@O #01). B; K 9>+!L B'!>'MEK(4B Creatinine Phosphokinase isoform MB (=0 Troponin #0FJ49$+#MEK9";;" *> K@ K'? Myoglobin (=0 Creatinine Phosphokinase isoform MB #0;?$0E>G=E=@#'9$+#+>EM;B MEK 5"%<=>@#"4<=!E1=L!E!,E9>' 24-72 7> B+R;@ (9B Troponin #01$. B;FJ49$+##>GMEK<=>@#"4 Myoglobin RE%1$. B;)G$"+ 3-4 7> B+R;@M/(=K+ (=0;?$0E>G2J@4+B"/49. M/!%B"@'K!% 2 2>/E"<& RE%$0E>G K!*? B9"% PC B@A'4=, B;*? B;4? =K";1'L K!9"%H'"EAG2J@4+B"4=, B;*? B;H? '"E4=K";1'L K!9"%'K!%4+B"(small MI ) (MGB = Myoglobin, CPK = Creatinine phosphokinase, CPKMB = Creatinine phosphokinase isoform MB) ( 6>E=!4#"4G$$:"',4$;(8))
5")*? B 8 (2E@('+*"@(%4R$6A'5"+0 Non ST elevation Acute Coronary syndrome EK+%4"$9$+#+>E Troponin 6+";M+2J@ IJ/B+%9";I=9$+# Troponin ($4$>G (high sensitivity Troponin-hsTn) $B+;4>G4"$/$01;.' Grace risk score RE%(GB@ K <"4)G$0E>G Troponin 2J@4+B"/49. (> Upper limits of normal) A B+R;@9B!;"1;L B!EJ+"B ;?4"$1/=? B%'(/=@ !%B"@7>E1#'<$L!M;B <"4M;B1/=? B%'(/=@4S AE1#' <$L!6B"2J@;"4 (=0/<$L!;?!"4"$*"@6=.'4. 1HK"MEK A4D"(GG5"+0<=!E1=L!E(E@ <>+A#1N?%G)=>'EK+%('+*"@ invasive 2B+'A'4=, B;*? B6"B Troponin M;B2J@4+B"/49.6+$/$01;.'+B";?!"4"$('B'!4;"14.' 6 7> B+R;@<$L!M;B A'4=, B;*? B;?!"4"$;"M;B14.' 6 7> B+R;@6+$9$+#9.E9";PK T!?4 3 7> B+R;@1)L B!EJ+"B ;?4"$1/=? B%'(/=@<$L!M;B6=K"%4>'4>GA'4=, B;*? B;$? 0E>G2J@(9B1$. B;($4 <"4)G$0E>G1/=? B%'(/=@!%B"@7>E1#'(4$,:"!B"'A'1'L K!6+";)4S AGM;B1/=? B%'(/=@1). B; KHC'A4D"9";$0E>G GRACE risk score PC B@A'4=, B;*? B GRACE score 9B TA4D"(GG4=, B;*? B;?6+";12? B%@9B T (=02B@9$+#%L'%>'(GG5"%'!49B!M/ (9B<"4;?5"+0!L B'*? B1HK"MEK;"44+B"4S A4D"9";R$6<$L!5"+0'> K'O 2B+'A'4=, B;*? B6"B Troponin M;[email protected]/49.1=%(=0;"<=>@#"4 6 7> B+R;@M/(=K+4S2";"$F(%45"+04=K";1'L K!<>+A#9"%H"E1=L!E!!4M/MEK(6>E=!4#"4G$$:"',4$;(1)) 1;L B!).#"$:"#"4*? B4=B"+M/HK"@9K'4"$EJ(=IJ K/B+%5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'*? B M;B;? ST elevation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elevation <$L! bundle branch block #0FJ4EJ(=9";('+*"@H!@5"+0<>+A# 9"%H"E1=L!E*? B; ? ST elevation $0<+B"@'? K6+$;?4"$9$+#*"@<>!@/V.G>94. "$MEK(4B 4"$9$+#$0E>G[? R;R4=G.', Cardiac biomarkers(6+$1/S' Troponin 6+";M+2J@), $0E>G4=J R62A'1=L!E, $0E>G6$?!0*.'.' $B+;M/4>G4"$9$+# blood chemistry
2.
3.
4.
5.
!L B'#"4'> K' KIJ/B+%*? B6E. FC@ 5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'6+$MEK$>G4"$EJ(=9B!A'E KHC').18D17B' . N>% Chest pain unit <$L! Intensive Cardiac Care Unit 1)L B!A'4"$+.'# <=>@#"4IB"'H> K'9!'($4(=0MEK$>G%"9K"'14$SE1=L!E(=09K"'4"$(HS@9>+H!@1=L!E(=K+ 4"$EJ(=#0;, B@1'K'A' 5 /$01ES'<=>4MEK(4B 1. 4"$=E!"4"$1#SG!4 2. 4"$9$+#9.E9"; Cardiac biomarkers PK T5"%A' 3-6 7> B+R;@9";(9B4$:? 3. 4"$9$+#9.E9";6=L B'MWWK"<>+A# . EK+% Risk score ('.%;A7K GRACE risk score) 4. 4"$/$01;.'$0E>G6+";12? B%@9B!4"$12?%7?+9 5. 4"$9$+#5")6=L B'12?%@20*K!'5")<>+A#6+";F? B2J@ (Echocardiography) 6. 4"$9$+#+.'.#N>%1)L B!(%4R$6<$L!5"+0!L B' 7. 4"$/$01;.'$0E>G6+";12? B%@9B!4"$14.E1=L!E!!4EK+% CRUSADE bleeding risk score 4"$9$+#2+'<=!E1=L!E1=L!E(E@<>+A#(Coronary arteriography) <=>@#"4IB"'H> K'9!'*? B 2 1$"#02";"$F%L'%>' 4"$+.'.#N>%MEK(=0A4D"#T1)"09";R$6*? B1/S'2"1<9, A'4=, B;*? B1HK"MEK4G> 5"+0<=!E1=L!E(E@<>+A#(=0;?6+"; 12? B%@2J@ (=0).#"$:"*T4"$9$+#2+'<=!E1=L!E(E@<>+A#RE%=TE>G6+";1$B@EB+'9";6+";12? B%@ PC B@#0MEK4=B"+9B!M/ 4"$(4K MH5"+0<=!E1=L!E(E@R6R$'"$?9?G9>'(Coronary Revascularization) A'4=, B; KIJ/B+%*? B M;B; ? ST elevation (=0!"4"$6@*? B K'>'1$";, B@1'K'(4K MH<=!E1=L!E(E@R6R$'"$?!%B"@6$GFK+'1/S'<=>4 #C@+"@(I'M;B9B"@#"4IJ K/B+% 4$:? M;B1$B@EB+' 1<=B" K'?; K9? @> (9B4"$FB"@H%"%<=!E1=L!E(E@#'FC@4"$IB"9>E*T*"@1G? B%@<=!E1=L!E(E@R6R$'"$? 1'L B!@EK+%R$6<=!E1=L!E(E@R6R$'"$?9!K @MEK$>G4"$6+G6,;/>##>%12? B%@9B"@O!%B"@9B!1'L B!@1)L B!/K!@4>'4"$4=>GPK T <"41$"A'(Coronary Revascularization) !%B"@6$GFK+'(9B1$. B;($4(=K+ KIJ/B+%4S2";"$F4=>GGK"'1)L B!4=>G;"$>G4"$9.E9";EJ(=!%B"@9B!1'L B!@(GGIJ K/B+%'!4MEK 1'L B!@#"4IJ K/B+%1<=B" K'?#0;?6+";12? B%@=E=@!%B"@;"4<=>@4"$(4K MH
#"4'? K#0MEK4=B"+FC@$"%=01!?%EH!@(9B=0H> K'9!'A'4"$EJ(=$+;FC@6T('0'T*? B$+G$+;#"4*> K@ American Heart Association(AHA) $B+;4>G American College of Cardiology(ACC)(6) (=0 European Society Cardiology(ESC)(1) PC B@;?$"%=0!?%EE>@ K'? 4"$EJ(=1GL K!@9K' 1GL K!@9K' KIJ/B+%*,4$"%*? B;!? "4"$*? B2@2>%5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'6+$MEK$>G4"$EJ(=1$B@EB+' 1)L B!$0G,4=, B;*? B;6? +"; 12? B%@2J@(=0A4D"!%B"@*>'*B+@*?(E>@9"$"@*? B 3) KIJ/B+%*? B6E. FC@5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'6+$MEK$G> 4"$$>4D" 1GL K!@9K'EK+%%"9K"'!"4"$4=K";1'L K!<>+A#H"E1=L!E %"9K"'14$SE1=L!E (=0!"#).#"$:"%"4=, B; Anticoagulant $B+;EK+% RE%;?$"%7L B!%"$+;FC@H'"E*? B1<;"02; E>@9"$"@*? B 4 PC B@;?('+*"@A'4"$A7K%"4=, B; K'?E>@9"$"@*? B 5-8 9"$"@*? B 3 (2E@6T('0'TA'4"$EJ(=IJ K/B+%5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'1GL K!@9K' (6>E=!4#"4G$$:"',4$;(1)(6)) 6T('0'T KIJ AG6T('0'T KIJ/B+%*? BFJ42@2>%5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'*? B M;B;? ST %49>+ 6+$MEK$>G4"$+.'.#N>%(=0/$01;.'6+";12? B%@9B!I=(*$4PK!' (=04"$14.E1=L!E!!4$,'($@ !%B"@6$GFK+'#"4/$0+>9. 4"$9$+#$B"@4"% 6=L B'MWWK"<>+A# $B+;4>G4"$9$+# biomarkers
*> K@ ESC (=0 ACC/AHA
KIJ/B+%5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'6+$$>GM+K K@ ESC (=0 ACC/AHA <$L! Coronary Care unit (Intensive Cardiac Care unit A'2<$>3\ ACC/AHA)
I
6,:5")<=>43"' A
I
6,:5")<=>43"' C
6+$/$01;.'6+";12? B%@9B!I=(*$4PK!' (=04"$14.E1=L!E!!4$,'($@EK+%
ESC
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' C
ESC
I
6,:5")<=>43"' A
ESC
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' C
ACC/AHA
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' C
I
6,:5")<=>43"' A
risk score
KIJ/B+%6+$MEK$>G4"$9$+#6=L B'MWWK"<>+A#5"%A' 10 '"*?<=>@#"4 First medical contact $+;FC@4"$(/=I=EK+%()*%&!%B"@$+E1$S+ (=0*TPK T<"4;?!"4"$ <$L!!%B"@'K!%5"%A' 6-9 7> B+R;@(=0 24 7> B+R;@ (=04B!'4=>GGK"' <"4HK!;J=M;B1)?%@)! !"#).#"$:"9$+#6=L B'MWWK"<>+A#A' V3 , V4 (=0 V7-9 1). B;19.; R
R
KIJ/B+%6+$MEK$>G4"$9$+#<"$0E>G Cardiac Biomarkers !%B"@$+E1$S+ (=0MEK$>GI=5"%A' 60 '"*? (=06+$MEK$>G4"$9$+#PK T<"4M;B('B7>E (6-9 (=0 12-24 7> B+R;@<"4%>@6@2@2>%!%J B) 2";"$F9$+#PK TMEK1$S+4+B" (($4$>G(=0 3 7> B+R;@5"%<=>@) 1;L B!A7K4"$9$+# high sensitive Cardiac Troponin
('0'TA+A#(Echocardiography) 1)L B!/$0R%7'& A'4"$+.'#. N>% (=0+.'.#N>%(%4R$6!L B' ? 4> D:0*? BGB@+B";?6+";12? B%@2J@!L B'O ACC/AHA) (<"4M;B;= 4"$9$+#<=!E1=L!E(E@R6R$'"$?EK+%4"$N?E2?2";"$F7B+%#T('46+"; I.E/49.H!@<=!E1=L!E(E@R6R$'"$?* B?*TA+A# 1N?%G)=>'(culprit lesion) (=0$!%R$6!L B'<"4;?HK!GB@A7K A'IJ K* B M;B ? ;!? "4"$1#SG!4PK T 6=L B'MWWK"<>+A#<$L! Cardiac biomarkers /49. 6+$MEK$>G4"$9$+# Stress test 4B!'4"$9>E2.'A#*T4"$9$+#(GG$,4=K T!L B' 2";"$FA7K4"$9$+#EK+% Coronary CT angiography (*'4"$9$+#<=!E1=L!E(E@R6R$'"$?E+K %4"$N?E2? A'IJ K* B?;6? +";12? B%@/"' 4="@<$L!9B T PC B@I=4"$9$+#6=L B'MWWK"<>+A# (=0 Biomarkers M;B('B7>E 6+$).#"$:"/$01;.'6+";12? B%@EK+% stress test <"4MEK$>G4"$9$+#EK+% 6=L B'12?%@6+";F? B2J@20*K!'<>+A#(Echocardiography) (=K+)G+B" Left
ESC
(=0 ACC/AHA ESC
IIa
6,:5")<=>43"' B
ACC/AHA
IIa
6,:5")<=>43"' B
ACC/AHA
IIa
6,:5")<=>43"' B
Ventricular Ejection Fraction > 0.4
6+$).#"$:"9$+#2+'<=!E1=L!E(E@R6R$'"$?<"44"$9$+#6=L B'12?%@6+"; F? B2J@20*K!'<>+A#(Echocardiography) (=K+)G+B"4"$*T@"' H!@<>+A#
9"$"@*? B 4 (2E@$"%7L B!(=0H'"EH!@%"*? B A7K A'4"$$>4D"IJ K/B+%5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'*? B M;B;? ST %49>+ >*K@4=, B;*? B;?(=0M;B;(? I'$>G4"$9$+#2+'<=!E1=L!E(E@R6R$'"$? (E>E(/=@#"4G$$:"',4$;(1) (6)) /< 5" A,%2
E%B;%,!#&F2!:<"2 Aspirin
;.==.4$>; $J/ non enteric coat 16? K%+(=K+4=L'*"@/"4(<$L!<=!E1=L!EET) #"4'> K'$>G/$0*"'9B!1'L B!@A'H'"E 75-100 ;.==.4$>;9B!+>'
Aspirin 150-300
E%#:1 56 P2Y12 inhibitors Clopidogrel
• •
Ticagrelor
• •
Prasugrel
•
A'*? A'H'"E 300 ;.==.4$>;*"@/"4 (loading dose) (=K+9";EK+%H'"E 75 ;.==.4$>;+>'=0 1 6$> K@9B!1'L B!@!%B"@'K!% 1 /? A;*"@/"4 (supplymentary loading dose) <"416%MEK loading dose ;"4B!'<'K"*>'*?* B?;(? I'#0FB"@H%"%<=!E1=L!E(E@R6R$'"$? *>'*? A'H'"E 180 ;.==.4$>;*"@/"44B!'<$L!H:0*T4"$FB"@H%"%<=!E1=L!E(E@R6R$'"$? FC@(;K#016%MEK Clopidogrel ;"4B!'<'K"<$L!M;B49S "; #"4'> K'$>G/$0*"'9B!A'H'"E 90 ;.==.4$>; +>'=0 2 6$> K@ *>'*? A'H'"E 60 ;.==.4$>;*"@/"44B!'<$L!H:0*T Primary PCI #"4'> K'$>G/$0*"'9B!A'H'"E 10 ;.==.4$>; +>'=0 1 6$> K@ %=&03"09>8(?<1@'- A/>B.0"4(02*909!7$1%7#$1%>(0-< , C)(:-3-BA!, .($->"0DE7.0"?"5/@5-!7$1%7#$1:12!<5A/ !"#$6"3%)'- .095'F 0G*$2 !7$1%7#$1:12HGH"-0"8:7, 5 (coronary anatomy) :73&+2 "35<2.0"A;, Prasugrel A-EI , >8(- B!-< , .?<5-, $9.5(0 60 .'H 7."<) !"#$)8H"G!7$1%7#$1@)$2
E%B;%,#%&GAFDB>-A"D!:<"2 Fondaparinux
• • • •
Enoxaparin
• • •
Unfractionated heparin
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nti-Xa activity M;B6+$A7K2=>G4>G Unfractionated heparin
."J8>(C8 )(C1, "B.0"4(02*909!7$1%7#$1:12HGH"-0"8 1$. B;A; (M;B14.' 5000 %J'.9) (=K+<%E*"@<=!E1=L!EETA'H'"E 12-15 • %J'.99B!4. R=4$>;9B!7> B+R;@( M;B14.' 1000 %J'9. ) (=K+9.E9";6B" aPTT 1)L B!AG 1.5-2 1*B" 9B!M/!%B"@'K!% 48 7> B+R;@<$L!#'4+B"MEK$G> 4"$FB"@H%"%<=!E1=L!E(E@R6R$'"$? <"4MEK$>G Fondaparinux ;"4B!' 1$. B;A; (=0/$>;9"; Activated Clotting time • . 9B!4. R=4$>;<"4AG Glycoprotein IIb/IIIa inhibitors (ACT), <$L! 60 %J'9 .($-.0"4(02*909!7$1%7#$1:12HGH"-0"8
Bivalirudin
A;, ."J8>()8 :8 E->B.0"4(02*909!7$1%7#$1:12HGH"-0"8 1)L B!*E(*' Unfractionated heparin RE%1N)"0$"%*? B; R!4"214. ? E1=L!E!!42J@ K'A'*? A'H'"E 0.75 ;.==.4$>;9B!4. R=4$>; #"4'> ;.==.4$>;9B!4. R=4$>;9B!7> B+R;@1/S'1+=" 4 7> B+R;@ (!"#A;9B!4. R=4$>; <"4#T1/S') • >K..7K().0">B20-*$2C?@0)0"4A!, G"< , 2:".A-*-01%>(0.<-(9B).#"$:"/$>GH'"E9B!1'L B!@E>@ K'? . 30-59 ;.==.=9. $9B!'"*?) • A'4=, B;*? B4"$*T@"'M9G4)$B!@M;B;"4(6B"4"$H#>E6$?!0*.'' 2";"$FAE6$?!0*.''. 9B T4+B" 30 ;.==.9$9B!'"*?) • 6+$=EH'"E9B!1'L B!@1<=L! 1 ;.==.4$>;9B!4. R=4$>;9B!7> B+R;@ (=0A'4=, B;*? B MEK$>G4"$W!4M9A;9B!4. R=4$>;9B!7> B+R;@ •
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
ACC/AHA
I
6,:5")<=>43"' C
ACC/AHA
I
6,:5")<=>43"' B 6,:5")<=>43"' C
ESC
(=0 ACC/AHA
I
ESC
(=0 ACC/AHA
I
6,:5")<=>43"' C (6,:5")<=>43"' B
ACC/AHA)
('0'TAG/$0*"'5"%A' 24 7> B+R;@($4<"4M;B;H? K!G/$0*"'%"4=, B; ! blocker 1E.;M;B6+$<%,E%"1+K'(9B;!? "4"$ H!@5"+0<>+A#=K;1<=+$,'($@ (Killip $0E>G III KHC'M/) KIJ/B+%*? B;?4"$*T@"'<>+A#G%"4=, B; B blocker J/$>G/$0*"'*,4$"%*? B M;B;?HK!G%"4=, B; ! blocker $B+;4>G Nitrates !%J B(=K+('0'TAG%" ! blocker $B+;4>G Nitrates !%B"@19S;*? B(=K+!"4"$M;BE K (=0M;B;H? K!+A#
ACC/AHA) ACC/AHA
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' B
ACC/AHA
IIa
6,:5")<=>43"' C
('0'TA+A#'R=<.9=E9B T=@
ACC/AHA
I
6,:5")<=>43"' A
ACC/AHA
I
6,:5")<=>43"' A
ESC
I
6,:5")<=>43"' C
ACC/AHA
I
6,:5")<=>43"' C
ESC
IIa
6,:5")<=>43"' C
ACC/AHA
IIa
6,:5")<=>43"' B
ACC/AHA
IIa
6,:5")<=>43"' B
ACC/AHA
IIa
6,:5")<=>43"' B
ACC/AHA
IIa
6,:5")<=>43"' C
ACC/AHA
IIa
6,:5")<=>43"' C
ACC/AHA
IIa
6,:5")<=>43"' C
ESC
III
$
('0'TA+A#=K;1<=+<$L!;?4"$*T@"' H!@<>+A#
('0'TA412G*> K@ steroids (=0 nonsteroidal antiinflammatory drug 1+K'(9B Aspirin 6+$A7K%"4=, B; ! blocker J/<%E*"@<=!E1=L!EETH:0($4$>GM+K$>4D"A'IJ K/B+%*? B$0GGM<=1+?%'6@*? B (Killip $0E>G < III) 1;L B!;?7?)#$1$S+<$L!6+";E>'R=<.92J@ 6+$).#"$:"A@#"4MEK$>G%" Nitrates (=K+ <"4M;B;H? K!'R=<.92J@ (=0M;B;H? K!+A#'R=<.9=E9B T=@ (5"%A' 24 7> B+R;@($4) $
6+$).#"$:"A4D"EK+%!!4P.1#'(4B KIJ/B+%A' 6 7> B+R;@($4<=>@;?!"4"$ 6+$).#"$:"A K @;?!"4"$1#SG('B'<'K"!4 !%J B4!B ''T2B@R$@)%"G"= 6+$).#"$:"A7K=4J R/B@1). B;4"$M<=1+?%'<=!E1=L!E<>+A#(Intra-aortic K* B?;!? "4"$1#SG('B'<'K"!49B!1'L B!@ Balloon Pump counterpulsation) A'IJ <$L!4=>GPK T<=>@MEK%"19S;*? B $B+;4>G$0GGM<=1+?%'R=<.9M;B6@*? B4!B '<$L!<=>@ 4"$9$+#2+'<=!E1=L!E(E@R6R$'"$?
C)(:-3-B Nifedipine <$L!%"<;J B Dihydropyridines !L B'<"4C)(C1, "+A#=K;1<=+, HK!
ACC/AHA
6,:5")<=>43"' B III 6,:5")<=>43"' A
ACC/AHA
III
6,:5")<=>43"' A
ACC/AHA
III
6,:5")<=>43"' B
$
C)(:-3-B %"4=, B; Angiotensin Converting Enzyme inhibitor *"@<=!E1=L!EET5"%A' 24 7> B+R;@1'L B!@#"41). B;R!4"214.E6+";E>'R=<.9 =E9B T=@
ACC/AHA III 6,:5")<=>43"' C C)(:-3-B %"4=, B; Nitrates <"4;?HK!+A#G%"4=, B; Phosphodiesterase III inhibitor ;"4B!'(Sildenafil 5"%A' 24 7> B+R;@, Tadalafil 5"%A' 48 7> B+R;@) K!%B"@'K!% 1 HK! 1)!"4"$(2E@H!@<>+A#=K;1<=+ 2)=>4D:0GB@ cardiac output 9B T 3);?6+";12? B%@9B!5"+07Z!6 *;?5"+09B!M/'? #"4<>+A# MEK(4B !"%,14.' 70 /?, 7?)#$9B T4+B" 60 <$L!14.' 110 6$> K@9B!'"*? (=06+";E>'P.2R9=?9 T+B B " 120 ;.==.1;9$/$!* 4);?HK!'P.2R9=?9 T4+B B " 100 ;.==.1;9$/$!*<$L!9B T4+B"/49.14.' 30 ;.==.1;9$/$!* $
nd
rd
9"$"@*? B 6 (2E@6T('0'TA'4"$A+A#1N?%G)=>'*? B M;B;? ST %49>+ (E>E(/=@#"4G$$:"',4$;(1,6)) *+G,(,+ CH ; ?=;*+G,(,+ &(2>)*+G,(,+ ('0'TAG4"$$>4D"(GGAE(4B KIJ/B+%*,4$"% *? B M;B;?H!K G/$0*"'(4B KIJ* B M;B ? 2";"$F >G/$0*"'%" Aspirin MEK (Clopidogrel <$L! Ticagrelor <$L! Prasugrel <"4;?(I'FB"@H%"%<=!E1=L!ER6R$'"$? )A'H'"E loading ('0'TAG Aspirin(Dual Anti-Platelet ? K!8()8G50)%@8(9260-.702!"#$@I2 ) ('0'TAG Aspirin(Dual Anti-Platelet therapy <$L! DAPT) H:0*T4"$FB"@H%"%<=!E1=L!E(E@<>+A# ('0'TAG%"9K"'14$SE1=L!E$B+;4>' Omeprazole) $B+;M/EK+%A'IJ 2!@7'.E<"4;?/$0+>99. 41=L!EA'*"@1E.'!"<"$, ;?(I= peptic (=0IJ K* B;? ?/>##>%12? B%@(9.E17L K! Helicobacter pylori , !"%, 65/? KHC'M/ <$L!MEK$>G%"9K"'1=L!E(HS@9>+<$L! steroid $B+;) ('0'TA@#"4;?!"4"$!>'1/S'1<9, AG(I'4"$$>4D" <$L!16%MEK$>G%" Clopidogrel ;"4B!'M;B(1)L B!A7K(*' Clopidogrel) ('0'TAG Clopidogrel ;"4B!' A'4$:?* B?1/S'4=, B;6+";12? B%@2J@<=>@#"4MEK$>G4"$/$01;.'4"%+.5"6H!@ <=!E1=L!E(E@R6R$'"$?(=K+1*B" K'>' RE%9K!@M;B;H? K!;) 1;L B!M;B2";"$FA
ESC
(=0 ACC/AHA
I
6,:5")<=>43"' A
ACC/AHA
I
6,:5")<=>43"' C
ESC
I
6,:5")<=>43"' A
ACC/AHA
I
6,:5")<=>43"' A
ACC/AHA
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' C
ESC
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' A
('0'TA;) <"49K!@4"$*T4"$9$+#2+'<=!E1=L!E(E@R6R$'"$?((=0A; supplementary loading dose <"416%MEK$>G;"4B!' 300 ;.==.4$>;) 1;L B!M;B2";"$FAG Aspirin(Dual Anti-Platelet therapy <$L! DAPT) 9B!1'L B!@M/!%B"@'K!% 12 1EL!'1;L B!;?(I' A4D"(GGM;B$,4=K T(conservative therapy) ('0'TAG Aspirin <"41E.;A4D" (GGM;B$,4=K T(=K+M;B1/S'I=<$L!;?!"4"$4T1$.G4B!'4"$9$+#2+' <=!E1=L!E(E@R6R$'"$? KIJ* B?#T1/S'9K!@MEK$>G4"$$>4D"EK+%4"$IB"9>E*T*"@1G? B%@<=!E1=L!E(E@ R6R$'"$?6+$MEK$>G4"$<%,E%" Clopidogrel <$L! Ticagrelor !%B"@'K!% 5 +>'<$L!!%B"@'K!% 7 +>'<"4MEK$>G Prasugrel <"41/S'M/MEK(=0R!4"2 12? B%@9B!4"$14.E4=K";1'L K!<>+A#H"E1=L!EM;B2J@#'14.'M/
ESC
I
6,:5")<=>43"' B
ACC/AHA
I
6,:5")<=>43"' B
ESC
6,:5")<=>43"' C IIa 6,:5")<=>43"' C
ESC
IIa
6,:5")<=>43"' B
ESC
IIa
6,:5")<=>43"' B
IIb
6,:5")<=>43"' B
ESC
III
6,:5")<=>43"' C
ACC/AHA
III
6,:5")<=>43"' B
ACC/AHA
6+$1$. B; Ticagrelor <$L! Clopidogrel A<;B<=>@4"$IB"9>E*T*"@1G? B%@ <=!E1=L!E(E@R6R$'"$? A'*>'*?* B?2";"$FA%
C)(('0'T%"4=, B; NSAID(*> K@*? B#T1)"0<$L!M;B#T1)"09B!1!'MP;& Cyclooxygenase-2) $B+;4>G Aspirin C)(('0'TAG Aspirin A'IJ K* B?16%;? R$6<=!E1=L!E2;!@;"4B!'
B
ACC/AHA
A'4=, B;*? B12? B%@9B!1=L!E!!4'K!%*? B MEK$>G Clopidogrel 6+$).#"$:" A;9B!+>')<=>@MEK$G> 4"$FB"@ H%"%<=!E1=L!E(E@R6R$'"$?1N)"0 7 +>'($4
!"#).#"$:"9$+#)>'Q,4$$;(=0/<$L!4"$*T@"'H!@14$SE1=L!E1/S'G"@ "%1)L B!/$>GH'"E%" Clopidogrel (9B M;B('0'TA4D")
6,:5")<=>43"'
I
ESC
(=0 ACC/AHA
I
9"$"@*? B 7 (2E@6T('0'TA'4"$A7K%" Glycoprotein IIb/IIIa inhibitor A'IJ K/B+%5"+0<=!E1=L!E(E@R6R$'"$?1N?%G)=>'*? B M;B; ? ST %49>+(E>E(/=@#"4G$$:"',4$;(1,6)) *+G,(,+ CH ; ?=;*+G,(,+ &(2>)*+G,(,+ 4"$9>E2.'A#1=L!4A7K%"9K"'14$SE1=L!E, %"9K"'4"$(HS@9>+H!@1=L!E (=0%" Glycoprotein IIb/IIIa inhibitor ).#"$:"9";4=, B;12? B%@(=0 R!4"214.E14.E1=L!E!!4 ('0'TAG Dual Anti-Platelet therapy <$L! ? +"; DAPT !%J B(=K+*? B$>G4"$FB"@H%"%<=!E1=L!E(E@R6R$'"$? (9B;6 12? B%@2J@(17B'1G Troponin 1). B;2J@) (=0;? R!4"214.E1=L!E!!49B T
ESC
I
6,:5")<=>43"' C
ESC
I
6,:5")<=>43"' B
6+$).#"$:"AG Aspirin 4B!'4"$ FB"@H%"%<=!E1=L!E(E@R6R$'"$? A'4=, B;6+";12? B%@/"'4="@<$L!2J@ *? B M;B16%MEK$>G%"4=, B; P2Y12 inhibitor 6+$).#"$:"AG Aspirin H:0FB"@H%"%<=!E1=L!E(E@R6R$'"$? A'4=, B;6+";12? B%@2J@*? B M;B16%MEK >G%"4=, B; P2Y12 inhibitor ( !"#$%G9C1, "G%"4=, B; P2Y12 inhibitor $B+;4>G Aspirin(Dual Anti-Platelet therapy <$L! DAPT);"4B!')$K!;M/4>G%"9K"'4"$(HS@9>+H!@1=L!E$0<+B"@4"$FB"@ H%"%<=!E1=L!E(E@R6R$'"$? ( !0.%G9C1, "G%"4=, B; P2Y12 inhibitor $B+;4>G Aspirin(Dual Anti-Platelet therapy <$L! DAPT);"4B!'$B+;M/4>'4>G Bivalirudin $0<+B"@4"$FB"@H%"% <=!E1=L!E(E@R6R$'"$? ( !0.%G9C1, "
ACC/AHA ESC
6,:5")<=>43"' A
ACC/AHA
I
ACC/AHA
IIa
6,:5")<=>43"' C
ACC/AHA
IIa
6,:5")<=>43"' C
ESC
IIb
6,:5")<=>43"' C
ESC
III
6,:5")<=>43"' A
ESC
III
6,:5")<=>43"' A
ACC/AHA
III
6,:5")<=>43"' A
ACC/AHA
III
6,:5")<=>43"' B
!"#).#"$:"AG Dual Anti-Platelet therapy <$L! DAPT 4B!'4"$9$+#2+'<=!E1=L!E(E@R6R$'"$? A'4=, B; 6+";12? B%@2J@*? B%>@;?!"4"$1#SG('B'!49B!1'L B!@(9B R!4"21=L!E!!49B T
C) B('0'TA4D"(GGM;B$,4=K T(Conservative treatment) C)(('0'T Abciximab H:0FB"@H%"%<=!E1=L!E(E@R6R$'"$? C)(('0'TAG%" Dual Anti-Platelet therapy <$L! DAPT 4B!'4"$9$+#2+' <=!E1=L!E(E@R6R$'"$?
6,:5")<=>43"' B IIa 6,:5")<=>43"' C I
9"$"@*? B 8 (2E@6T('0'TA'4"$A7K%"9K"'4"$(HS@9>+H!@1=L!EA'IJ K/B+%5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'*? B M;B; ? ST %49>+ (E>E(/=@#"4G$$:"',4$;(1,6)) *+G,(,+ CH ; ?=;*+G,(,+ &(2>)*+G,(,+ ('0'TA+H!@1=L!E$B+;4>G%"9K"'14$SE1=L!EA'IJ K/B+% *,4$"% ('0'TA9$"4"$14.E1=L!E!!4 B+;M/4>G/$02.*Q.5")(=0I=HK"@16?%@H!@%"(9B=09>+
ESC
(=0 ACC/AHA
I
6,:5")<=>43"' A,B
ESC
I
6,:5")<=>43"' C
('0'TA;9B!+>'1'L B!@#"4 /$02.*Q.5")E?* B?2,E(=0!>9$"4"$14.E1=L!E!!49B T*? B2,E (<"41=L!4(I'4"$$>4D"(GGM;B$,4=K T (=06+";12? B%@9B!1=L!E!!42J@)
!0.EI , 6(59C1, "'*?*"@<=!E1=L!EET$B+; H:0*T4"$FB"@H%"% <=!E1=L!E(E@<>+A# ('0'TA;9B!4. R=4$>; 2 6$> K@9B!+>'4$:? M;B; ? Fondaparinux 4$:?* B M;B ? ;*? K>@ Fondaparinux (=0 Enoxaparin ('0'TA;AG aPTT !%J B$0<+B"@ 50-70 +.'"*? <$L!A7K Low molecular weight heparin !L B'O ('0'TAG Glycoprotein IIb/IIIa inhibitors 9";2;6+$."J8?, $2.0">B.0"4(02*909!7$1%7#$1:12HGH"-0"8 (*' Unfractionated heparin $B+;4>G Glycoprotein IIb/IIIa inhibitors RE%1N)"04=, B;*? B12? B%@2J@9B!4"$14.E1=L!E!!4 ('0'TA+H!@1=L!E#'4$0*> B@!!4#"4R$@)%"G"=A' KIJ* B A4D"(GGM;B$,4=K T!%B"@1E?%+(purely conservative therapy) ('0'TA+H!@1=L!E$B+;M/4>G%"9K"'14$SE1=L!E*>'*?* B? +"@(I'4"$$>4D":DD"K.7, B Unfractionated heparin (=0 Enoxaparin Bivalirudin (=0 Fondaparinux •
ESC
I
6,:5")<=>43"' A
ACC/AHA
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' C
ESC
I
6,:5")<=>43"' B
ESC
I
6,:5")<=>43"' A
ACC/AHA
•
('0'TA+H!@1=L!E$B+;M/4>G%"9K"'14$SE1=L!EA'4=, B; *? B+"@(I'4"$$>4D":DDC)("K.7, B Enoxaparin <$L! Unfractionated heparin Fondaparinux ( RE%1N)"0;?6+";12? B%@9B!1=L!E!!42J@) •
ACC/AHA
•
A'IJ K* B?FJ4/$01;.'EK+% stress test +B"1/S'4=, B;6+";12? B%@9B T6+$;?4"$ +"@(I'%"9K"'4"$(HS@9>+H!@1=L!E$0<+B"@!%J B A'R$@)%"G"=E>@ K'? 48 7> B+R;@ 2T<$>G Unfractionated heparin 9=!E1+="*? B'!'R$@)%"G"=<$L!#'6$G 8 +>'2T<$>G Enoxaparin <$L! Fondaparinux •
ACC/AHA
•
('0'T).#"$:"<%,E%"9K"'4"$(HS@9>+H!@1=L!E<=>@#"44"$$>4D" (GG$,4=K T(invasive treatment) 4$:? M;B;?I=(*$4PK!'
ACC/AHA ESC
6,:5")<=>43"' A I 6,:5")<=>43"' B I
6,:5")<=>43"' A I 6,:5")<=>43"' B I
6,:5")<=>43"' A I 6,:5")<=>43"' B (2T<$>G Fondaparinux) I
6,:5")<=>43"' B IIa 6,:5")<=>43"' C I
A'IJ K* B?9K!@$>G4"$IB"9>E*T*"@1G? B%@<=!E1=L!E(E@R6R$'"$?* B MEK ? $>G %"9K"'4"$(HS@9>+H!@1=L!E$B+;('0'T).#"$:"4"$<%,E%"E>@ K'? A B+R;@4B!'*T (=0A O Unfractionated heparin 9";('+*"@/V.G>9.H!@*? B K <%,E Fondaparinux 24 7> B+R;@4B!'*T (=0A O Unfractionated heparin 9";('+*"@/V.G>9.H!@*? B K <%,E Bivalirudin 3 7> B+R;@4B!'*T (=0A O heparin 9";('+*"@/V.G>9.H!@*? B K
ACC/AHA
I
6,:5")<=>43"' B
ACC/AHA
I
6,:5")<=>43"' B
• •
•
•
('0'TA4D":DDC)("K.7, B (9B 1$. B;($4 (1+K'(9B#T1/S'9K!@IB"9>E*T*"@1G? B%@<=!E1=L!E(E@R6R$'"$? 5"%A' 24 7> B+R;@) M;B('0'TAG4>G Enoxaparin
ESC
IIa
6,:5")<=>43"' B
III
6,:5")<=>43"' B
#"4*? B4=B"+;"(=K+#01E1#'+B" 4"$$>4D"AU(4B4"$AG P2Y12 inhibitor (=0%"9K"'4"$(HS@9>+H!@1=L!E1)L B!/K!@4>'I=(*$4PK!'9B"@O PC B@;?6T('0'TAG4"$FB"@H%"%<=!E1=L!E(E@R6R$'"$? <"4#T1/S'PC B@!"#AG 4"$$>4D"(GG$,4=K T(invasive therapy) PC B@1<=B" K'?1). B;R!4"214.E1=L!E!!4$,'($@;"4HC K' PC B@;?6T('0'TA;)>'Q&4G> 4"$14.E1=L!E!!4*? B'K!%4+B"%"4=, B;1E.;!%B"@7>E1#' (=02";"$F=E6+";#T1/S'H!@%"4=, B; Glycoprotein IIb/IIIa inhibitor =@M/MEKE+K % !%B"@M$4SE;? 1? )?%@%"9K"'14$SE1=L!E *? B#T1/S'9K!@A7K9B!<=>@4"$1/.E<=!E1=L!E(E@R6R$'"$? 2B+'%"9K"'4"$(HS@9>+H!@1=L!E2";"$F<%,EMEK<"4MEK$>G 4"$1/.E<=!E1=L!E(E@(=K+ 4"$1=L!4A7K%"9K"'(HS@9>+H!@1=L!E;?) KL'3"';"#"4;?4"$8C4D"H'"EA9$" 4"$14.E1=L!E!!49B T<"4).#"$:"A4D"(GGM;B$,4=K T 6L! Fondaparinux 1;L B!1*?%G4>G%"!L B' (9B;/? >U<"2T6>U6L! M;B2";"$FA7KH:0*T4"$FB"@H%"%<=!E1=L!EMEK#C@9K!@1/=? B%'1/S' Unfractionated heparin (9B%"*? BEH? :0FB"@H%"% <=!E1=L!E(E@R6R$'"$?6!L Bivalirudin 2B+' Unfractionated heparin (=0 Enoxaprin 4S;/? $02.*Q.5")$!@=@;" !%B"@M$4SE?;H? K!2>@149,6!L <"4;?(I'A'4"$$>4D"(GGM;B$,4=K T Enoxaparin #0;?6+";20E+4+B" Unfractionated heparin 1'L B!@#"4M;B9!K @9$+#9.E9";$0E>G4"$(HS@9>+H!@1=L!E (9B9K!@/$>GH'"E%"9";4"$*T@"'H!@M9 (=0M;B6+$A7K Unfractionated heparin 2=>GM/;"4>G Enoxaparin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rgent <$L! < 2 7> B+R;@) A'4=, B;*? B6+";12? B%@2J@;"4 MEK(4B ? "4"$1#SG('B'!4!%B"@9B!1'L B!@M;B9!G2'!@9B!4"$$>4D" i. 4=, B;*? B;!
ii. iii. iv. 2.
;?!"4"$1#SG!4PK T$B+;4>G6=L B'MWWK"<>+A#1/=? B%'(/=@$B+;A' ST-T segment <$L! T wave ;?=4> D:07Z!6<$L!5"+0<>+A#=K;1<=+$B+; 7?)#$19K'I.E#>@<+07'.E$K"%($@(Life threatening arrhythmias)
EB+' i.
ii.
*T5"%A'1+=" 24 7> B+R;@<=>@#"4$>GM+K A'4=, B;*? B;6? +";12? B%@2J@ GRACE risk score > 140 (=0/<$L! ;?/>##>%12? B%@ Primary HK!AEHK!<'C B@9B!M/'? K 1. ;?$0E>G Troponin 1). B;<$L!=E=@!%B"@7>E1#'$B+;4>G=>4D:0*? B1HK"MEK 2. 6=L B'MWWK"<>+A#1/=? B%'(/=@9";!"4"$1#SG('B'!4 *T5"%A'1+=" 72 7> B+R;@A'4=, B;*? B;/? >##>%12? B%@ Secondary HK!AEHK!<'C B@9B!M/'? K 1. ;? R$61G"<+"'1E.; 2. ;?4"$*T@"'M912L B!; (GFR < 60 mL/min/1.73 m ) 3. 4"$*T@"'H!@<>+A#G4"$FB"@H%"%<=!E1=L!E(E@R6R$'"$?;"M;B'"' 6. 16%MEK$>G4"$IB"9>E*T*"@1G? B%@<=!E1=L!E(E@R6R$'"$?;"4B!' 2
7.
3.
Intermediate GRACE risk score (109-140)
KIJ/B+%1<=B" K'?!"4"$;>46@*? B*TAE;"*T4"$9$+#2+'<>+A# (GGM;B1$B@EB+' A'6T('0'TH!@ ACC/AHA (6)$0G,4=, B;6+";12? B%@2J@*? B6+$MEK$>G4"$$>4D"(GG$,4=K T(invasive '? 1) )8$0.0".7, 0)%-# , $!<5A/*01%7#$1N, therapy) M+KE@> K B:), C1, "8 ( 8)Ventricular tachycardia ?($%-#($2 stress test D(25(0)8G50)%@8(92@I2 7) "3DDC!7%589-H7!'? 9) %G9C1, "B>02%D8(92!7$1%7#$1:12HGH"-0"8)0.($- !"#$"B20-*$2C?D.&"($260-.702 4+2 )0. 12) )8H"G%D0!50-"(5) 13) .0">B20-*$2!<5A/!, $2N, 097(02D.&"($2 (LVEF -, $9.5(0", $973 40) M;B*T1=%<$L!M;B1$B@EB+' A'IJ K/B+%*? B6+";12? B%@9B TPC B@;?=4> D:06$GFK+'E>@9B!M/'? K i. M;B)G!"4"$1#SG!4PK T ii. M;B;?5"+0<>+A#=K;1<=+ K!@9K'(=05"%<=>@1/S'/49. iii. 6=L B'MWWK"<>+A#1GL iv. $0E>G Cardiac biomarkers 1/S'/49. K!<>+A#H"E1=L!E#"44"$9$+# stress test ( M;B; ? inducible ischemia) v. M;B;?4=K";1'L
5")*? B 9 (2E@H> K'9!'4"$EJ(=IJ K/B+%EK+%!"4"$1#SG!4 PC B@#0;?4"$+.'.#N>%(%44=, B;9";R$6*? B'B"#01/S'!!41/S' Acute Coronary syndrome (ACS)(=02"1<9,! BL' PC B@1/S'4"$#T('41)L B!4"$1=L!44"$EJ(=*? B1<;"02;(Operational term) PC B@A'4=, B;*? B; ? ST %49>+ (ST elevation Acute coronary syndrome) #T1/S'9K!@$>G4"$1/.E<=!E1=L!EN,41N.' 2B+'4=, B;*? B M;B;? ? +";12? B%@2J@<$L!2J@;"46+$MEK$G> 4"$9$+# ST %49>+#T1/S'9K!@;?4"$9$+#%L'%>'1). B;19.;(=0/$01;.'6+";12? B%@ A'4=, B;*? B;6 %L'%>'EK+%4"$2+'<=!E1=L!E(E@<>+A#9";6+";1$B@EB+' 1)L B!+"@(I'4"$$>4D"9B!M/ 2B+'4=, B;*? B;6? +";12? B%@'K!% 6+$MEK$>G4"$%L'%>'!?46$> K@EK+%4"$/$01;.'2;$$F5")<=!E1=L!E(E@<>+A# <$L!9$+#2+'<=!E1=L!E(E@<>+A#A'5"%<=>@ (=04=, B;*? B)G2"1<9,! B'L *? B M;B14? B%+HK!@4S A4D"9";2"1<9, (1))
9"$"@*? B 9 (2E@4"$#>E=TE>G6+";12? B%@H!@IJ K/B+%5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'*? B M;B; ? ST %49>+ 9"; TIMI (=0GRACE risk score PC B@1$?%@9";!>9$"4"$12?%7?+.9A'R$@)%"G"=(E>E(/=@#"4G$$:"',4$;(5) (9) (1)) $0E>G6+";12? B%@ $0E>G60('' !>9$"4"$12?%7?+9. $0E>G60('' GRACE !>9$"4"$12?%7?+9. K!<>+A#9"%/ A'R$@)%"G"=($K!%=0) TIMI risk score /4=K";1'L risk score 4"$1/.E<=!E1=L!E<>+A# 5"%A' 14 +>'(%) 9B T
0-2
7.7
<109
<1
/"'4="@
3-4
32.7
109-140
1-3
2J@
5-7
56.6
> 140
>3
9"$"@*? B 10 (2E@4"$#>E=TE>G6+";12? B%@H!@IJ K/B+%5"+0<=!E1=L!E(E@<>+A#N>G)=>'*? B M;B; ? ST %49>+ 9"; GRACE risk score PC B@1$?%@9";!>9$"4"$12?%7?+.9<=>@#"4!!4R$@)%"G"=M/FC@ 6 1EL!' (6>E=!4#"4G$$:"',4$;(9)) $0E>G6+";12? B%@ $0E>G60('' GRACE risk score !>9$"4"$12?%7?+9. *? B 6 1EL!'($K!%=0) 9B T
<89
<3
/"'4="@
89-118
3-8
2J@
> 118
>8
9"$"@*? B 11 (2E@/>##>%9B"@O*? B A7K/$01;.' TIMI risk score 2T<$>G KIJ/B+%EK+%5"+0<=!E1=L!E(E@<>+A#1N?%G)=>'*? B M;B;? ST %49>+ RE%'T60(''#"4(9B=0/>##>%;"/$01;.'$+;4>'E>@9"$"@*? B 4 (6>E=!4#"4G$$:"',4$;(5)) />##>%12? B%@ 60('' !"%, > 65 /?
1
/>##>%12? B%@9B!R$6<=!E1=L!E(E@<>+A# ] 3 HK!
#
1
4"$A7K Aspirin ;"5"%A' 7 +>'
1
/$0+>9 R$6<=!E1=L . !E(E@<>+A#;"4B!' (4"$9?G(6G!%B"@'K!% 50%)
1
;?!"4"$1#SG('B'!414.' 1 6$> K@5"%A'1+="'K!%4+B" 24 7> B+R;@
1
;? ST segment 1/=? B%'(/=@
1
;?$0E>G Biomarkers (Troponin) I.E/49.
1
9"$"@*? B 12 (2E@/>##>%9B"@O*? B A7K/$01;.' GRACE risk score *> K@7B+@A'R$@)%"G"= (=0<=>@#"4!!4R$@)%"G"=#'FC@ 6 1EL!'2T<$>G KIJ/B+%EK+%5"+0<=!E1=L!E(E@<>+A#*? B M;B;? ST %49>+ (6>E=!4#"4G$$:"',4$;(9, 10)) GRACE (In hospital)
/>##>%12? B%@ !"%, (/?)
7?)#$ (6$> K@/'"*?)
GRACE (post discharge to 6 month)
60('' ^ 29
0
30-39
/>##>%12? B%@ !"%, (/?)
60('' ^ 29
0
8
30-39
0
40-49
25
40-49
18
50-59
41
50-59
36
60-69
55
60-69
55
70-79
75
70-79
73
80-89
91
80-89
91
] 90
100
] 90
100
< 50
0
^ 49.9
0
50-69
3
50-69.9
3
70-89
9
70-89.9
9
7?)#$ (6$> K@/'"*?)
6+";E>'R=<.9(P.2R9=?)
6$?!0*.''. ($4$>G . $) (;.==.4$>;/1EP.=9
!"4"$H!@5"+0<>+A# =K;1<=+ (Killip classification)
90-109
15
90-109.9
14
110-149
24
110-149.9
23
150-199
38
150-199.9
35
> 200
46
> 200
43
< 80
58
< 80
24
81-99
53
80-99.9
22
100-119
43
100-119.9
18
120-139
34
120-139.9
14
140-159
24
140-159.9
10
160-199
10
160-199.9
4
] 200
0
] 200
0
0-0.39
1
0-0.39
1
0.4-0.79
4
0.4-0.79
3
0.8-1.19
7
0.8-1.19
5
1.2-1.59
10
1.2-1.59
7
1.6-1.99
13
1.6-1.99
9
2-3.99
21
2-3.99
15
>4
28
>4
20
Class I
0
Class II
20
Class III
39
Class IV
59
6+";E>'R=<.9(P.2R9=?)
6$?!0*.''. ($4$>G . $) (;.==.4$>;/1EP.=9
/$0+>9.4=K";1'L K!<>+A# 9"%H"E1=L!E1E.; /$0+>9.5"+0<>+A#=K;1<=+
12
24
/$0+>9.5"+0 Cardiac arrest H:0;"FC@
39
Cardiac Biomarkers
14
Cardiac Biomarkers
I.E/49. ST segment
15
I.E/49. 1/=? B%'(/=@
28
ST segment
1/=? B%'(/=@
11
/$01;.'6+";12? B%@RE%A7K60(''$+;9";4=, B;(=K+#T('4E>@9"$"@*? B 9-10
*
9"$"@*? B 13 (2E@9>+(/$9B"@O*? B A7K/$04!G4"$6T'+: CRUSADE bleeding risk score PC B@2";"$F)%"4$:& R!4"214.E1=L!E!!4$,'($@$0<+B"@'!'R$@)%"G"=EK+%5"+0<=!E1=L!E(E@<>+A#1N?%G)=>' RE%'T;"6T'+:IB"' www.crusadebleedingscore.org ( 6>E=!4#"4G$$:"',4$;(1)) B>-G'& &(2>) *(G,, B>-G'& 6B"[?;"R96$.91$. B;9K' ($K!%=0)
6B"4"$H#>E6$?!0*.''. . $9B!'"*?) (;.==.=9
^70
0
7
71–80
1
34–36.9
3
81–90
3
37–39.9
2
91–100
6
]40
0
101–110
8
^15
39
111–120
10
>15–30
35
]121
11
>30–60
28
7"%
0
>60–90
17
8
M;B;?
0
;?
6
M;B;?
0
;?
6
M;B;?
0
;?
7
<31
9
31–33.9
>90–120 >120
6+";E>'P.2R9=? (;.==.1;9$/$!*)
!>9$"7?)#$ (6$> K@9B!'"*?)
*(G,,
1)8
7 0
^90
10
91–100
8
101–120
5
121–180
1
181–200
3
]201
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