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However, CABG remains indicated for cardiogenic shock, failed PCI, high-risk anatomy, surgical repair of a mechanical complication of STEMI eg, ventricular septal rupture, free-wall rupture, or severe mitral regurgitation from papillary muscle dysfunction or rupture.
Different anticoagulation agents are available; the utility of each agent depends on the clinical context, taking into account the method of reperfusion. Fondaparinux is not used in this setting because of the increased risk of catheter thrombosis. Bivalirudin may Treatment of acute mi a journal used for patients who develop or have a history of heparin-induced thrombocytopenia HIT and require anticoagulation.
Other antiplatelet agents used for dual antiplatelet therapy are the P2Y12 receptor inhibitors eg, clopidogrel, ticagrelor, prasugrel ; a loading dose of these agents is given before or at the time of reperfusion and an extended duration maintenance dose is administered thereafter, depending on the method of reperfusion.
For patients undergoing primary PCI, a loading dose of mg of clopidogrel, mg of ticagrelor, or 60 mg of prasugrel should be given as early as possible or at the time of primary PCI.
A daily dose of 75 mg clopidogrel, 90 mg ticagrelor twice dailyor 10 mg prasugrel is recommended. It is reasonable to discontinue P2Y12 receptor inhibitor agents prior to 1 year for patients who receive a BMS if there is evidence of increased bleeding.
The use of prasugrel is not recommended for patients with a history of stroke or transient ischemic attack TIA. The use of other P2Y12 receptor inhibitor agents in patients treated with fibrinolysis has not been prospectively studied.
There are two alternative management strategies, either an early invasive strategy with angiography, with intent for revascularization with percutaneous coronary intervention PCI or coronary artery bypass grafting CABGor a conservative strategy with initial medical therapy and noninvasive cardiovascular imaging.
Regardless of the strategy, both entail aggressive utility of medications such as anticoagulants, antiplatelet agents, beta blockers, statins, and possible use of angiotensin-converting enzyme ACE inhibitors for appropriate patient populations.
An immediate early invasive strategy is also recommended for patient who are stable but at a high risk for clinical events. For patients who fall outside this category, a delayed invasive strategy within 25 to 72 hours of admission versus a conservative ischemia-guided strategy may be considered.
They also play an important role in reduction of reinfarction and complex ventricular arrhythmias. In patients with chronic obstructive lung disease or chronic asthma, beta-1 selective beta blockers are preferred and should be initiated at low doses. Calcium channel blockers Non-dihydropyridine calcium channel blockers eg, verapamil or diltiazem should be given for recurrent myocardial ischemia only if there are contraindications to using beta blockers.
Similar to beta blockers, use of non-dihydropyridine calcium channel blockers can also increase the likelihood of developing cardiogenic shock, thus, similar caution should be used when considering the use of these drugs.
A maintenance dose of aspirin mg daily should be continued indefinitely. Clopidogrel Ticagrelor Prasugrel All three agents are given with an initial loading dose, followed by a daily maintenance dose up to 12 months for all patients treated for NSTE ACS with either early invasive or conservative strategies.
With the wider use of new generation drug-eluting stents DESa shorter duration of P2Y12 receptor inhibitors of months can be considered in patients who are at high bleeding risk.
Clopidogrel A oading dose of clopidogrel mg is recommended, followed by a maintenance dose of 75 mg daily. A loading dose of ticagrelor mg is recommended, followed by a maintenance dose of 90 mg twice daily. Prasugrel A loading dose of prasugrel 60 mg is recommended, followed by a maintenance dose of 10 mg daily.
However, there was a concern of an increased bleeding risk in individuals treated with prasugrel. Patients undergoing an early invasive strategy who received dual antiplatelet therapy with high-risk features are considered candidates to receive either of these two agents. Anticoagulant therapy Anticoagulant agents are recommended to be given to all patients with NSTE-ACS, regardless of the initial treatment strategy, in addition to antiplatelet therapy.
The following agents may be considered as treatment options from this group of medications. This regimen is continued for 48 hours or until PCI is performed. A major disadvantage of the use of unfractionated heparin is the large interindividual variability and narrow therapeutic window.
It should be continued for the duration of hospitalization or until PCI is performed. A dose reduction is required for patients with impaired kidney function. Enoxaparin results in a more predictable and efficient anticoagulation compared to unfractionated heparin, leading to reduction in recurrent MI events  ; however, there is possibly a higher bleeding risk in patients undergoing PCI.
This regimen is continued until diagnostic angiography or PCI. This agent is given as a once-daily SC injection of 2. In addition, in patients undergoing PCI, administer another anticoagulant agent eg, unfractionated heparin or bivalirudinas fondaparinux is associated with a higher risk of catheter thrombosis; this was demonstrated in the Fifth Organization to Assess Strategies in Ischemic Syndromes OASIS-5 trial.
Additional Aspects of Management and Late Hospital Care After the initial management and stabilization of the patient in the early and critical phase of acute myocardial infarction MIthe goals of care for these patients is to restore normal activities, prevent long-term complications, as well as aggressively modify lifestyle and risk factors.
This multifaceted goal is achieved with the implementation of important key elements, including the use of cardioprotective medications and cardiac rehabilitation, as well as physical activity, diet, and patient education.
Current clinical practice guidelines recommend use of one of three beta blocker agents proven to reduce mortality in patients with heart failure: Statins All patients with an acute MI should be started on high-potency statin therapy and continued indefinitely. Current clinical practice guidelines, high potency statins such as atorvastatin 40 mg or 80 mg, or rosuvastatin 20 mg are recommended.
Lifestyle modifications and cardiac rehabilitation Much emphasis has been placed on postdischarge care for patients after MI. Several lifestyle modifications have been strongly linked to a reduction in recurrent MI and prevention of further progression of cardiovascular disease.
These modification include dietary changes that adopt a low-fat and low-salt diet with dietary counseling, smoking cessation, up-to-date vaccination, and an increase in physical activity and exercise.The American Journal of Geriatric Cardiology.
Treatment of Acute Myocardial Infarction. Michael W. Rich, MD, The Cardiovascular Division, Washington University School of Medicine, St. Louis, MO. Objective To evaluate the safety and efficacy of sertraline treatment of MDD in patients hospitalized for acute myocardial infarction (MI) or unstable angina and free of other life-threatening medical conditions.
BackgroundVasodilatory shock that does not respond to high-dose vasopressors is associated with high mortality.
We investigated the effectiveness of angiotensin II for the treatment of patients. Patients who present with non-ST elevation acute coronary syndromes (ACS) are a heterogeneous group with diverse short- and long-term timberdesignmag.com, early risk stratification and individualization of medical or invasive treatment is mandatory to achieve optimal therapeutic results.
Over the past 3 decades, mortality rates for acute myocardial infarction (MI) have declined significantly in large part due to improved evidence-based revascularization . Myocardial infarction (MI) is a painful condition with tightness, pressure, or squeezing pain in the chest for approximately 75% of patients who experience it.
This pain often radiates to the arms, jaw, or back.