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A more detailed discussion of the interaction between clopidogrel and proton pump inhibitors may be found in Chapter 6. As described earlier (see “Beta-Adrenoceptor Blockers”), they should be used routinely in patients without contraindications. Therefore, dual antiplatelet therapy is indicated for a longer period of time following PCI with a drug-eluting stent. An algorithm for selection of patients who warrant prophylactic implantation of an ICD is shown in Fig. 35-6. Soon after STEMI, the left ventricle begins to dilate. Strict control of blood glucose in diabetic patients with STEMI has been shown to reduce the mortality rate. Nitrate administration is contraindicated in patients who have received oral phosphodiesterase-5 inhibitors, such as sildenafil and vardenafil, within the last 24 hours, and tadalafil within the last 48 hours. 2. To diagnose ACS, blood tests or an ECG can be used. CHARACTER- pressure sensation, fullness, or squeezing in the midportion. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: The PCI-CURE study. High probability include ST segment elevation in two contiguous. Recognition of a depressed LV ejection fraction by echo-cardiography or radionuclide ventriculography identifies patients who should receive medications to inhibit the renin-angiotensin-aldosterone system. The pain is deep and visceral; adjectives commonly used to describe it are heavy, squeezing, and crushing, although, occasionally, it is described as stabbing or burning ( Chap. 4 ). It is similar in character to the discomfort of angina pectoris ( Chap. 33 ) but commonly occurs at rest, is usually more severe, and lasts longer. Thereafter, a single antiplatelet agent, either clopidogrel or low-dose ASA, is recommended in addition to warfarin. 100. Bleeding complications with the P2Y12 receptor antagonists clopidogrel and ticagrelor in the PLATelet inhibition and patient outcome trial. While troponins and CK-MB appear in the blood within 6 hours of infarction, troponins stay elevated for up to 10 days while CK-MB returns to normal values within 48 hours. Most episodes of AIVR do not require treatment if the patient is monitored carefully, as degeneration into a more serious arrhythmia is rare. Currently, there are no data to support that the more selective, more expensive eplerenone is superior to, or should be preferred to, the less expensive generic spironolactone unless a patient has experienced gynecomastia, breast pain, or impotence while receiving spironolactone. Histologic studies indicate that the coronary plaques prone to disruption are those with a rich lipid core and a thin fibrous cap ( Chap. 30 ). After an initial platelet monolayer forms at the site of the disrupted plaque, various agonists (collagen, ADP, epinephrine, serotonin) promote platelet activation. Serum magnesium should be measured in all patients on admission, and any demonstrated deficits should be corrected to minimize the risk of arrhythmias. Acute coronary syndromes can also be due to secondary. Owing to the risk of catheter thrombosis, fondaparinux should not be used alone at the time of coronary angiography and PCI but should be combined with another anticoagulant with anti-thrombin activity such as UFH or bivalirudin. It is unclear whether or not bivalirudin requires dose adjustment for patients with significant renal dysfunction. Clinical Pharmacogenetics Implementation Consortium guidelines for cytochrome P450-2C19 (CYP2C19) genotype and clopidogrel therapy. Transport time to the hospital is variable from case to case, but the goal is to keep total ischemic time within 120 min. In some patients with severely compromised LV function, the loss of appropriately timed atrial systole results in a marked reduction of cardiac output. Compared with clopidogrel, either prasugrel or ticagrelor lowers the risk of CV death, MI, or stroke by an additional 20% to 30% depending on the patient population studied. In a large clinical trial, 114 eplerenone significantly reduced mortality as well as hospitalization for HF in post-MI patients with an LVEF less than 40% (0.40) and symptoms of HF at any time during hospitalization. No monitoring of coagulation is recommended for bivalirudin and fondaparinux. The antiplatelet drugs segment is further segmented into aspirin, clopidogrel, prasugrel, and others.
Acutely, this results from expansion of the infarct, i.e., slippage of muscle bundles, disruption of normal myocardial cells, and tissue loss within the necrotic zone, resulting in disproportionate thinning and elongation of the infarct zone. These hemodynamic disturbances usually respond promptly to elevation of the legs, but in some patients volume expansion with intravenous saline is required. To diagnose ACS, blood tests or an ECG can be used. Validity of a risk-prediction tool for hospital mortality: The Global Registry of Acute Coronary Events. Strict control of blood glucose in diabetic patients with STEMI has been shown to reduce the mortality rate. However, patients who have had a stent implanted and have an indication for anticoagulation should receive dual antiplatelet therapies in combination with warfarin. Coordinating Committee of the National Cholesterol Education Program, endorsed by the National Heart, Lung, and Blood Institute, American College of Cardiology Foundation, and American Heart Association. This can be attributed to the low per capita healthcare expenditure and stringent government policies, especially within the African region. GERIATRIC PHARMACOLOGY Geriatric pharmacology is a specialized field focusing. Initial treatment of STE MI should proceed without evaluation of the troponins because these patients have a greater than 97% chance of having an MI subsequently diagnosed with biochemical markers. Typical rise and gradual fall (troponin) or more rapid rise and fall (CK-MB) of. Many drugs used in the coronary care unit, such as atropine, H 2 blockers, and narcotics, can produce delirium, particularly in the elderly. Morphine also has a vagotonic effect and may cause bradycardia or advanced degrees of heart block, particularly in patients with inferior infarction. Once converted to its functional state, this receptor develops a high affinity for soluble adhesive proteins (i.e., integrins) such as fibrinogen. GERIATRIC PHARMACOLOGY Geriatric pharmacology is a specialized field focusing. Some of the most important factors include persistent ischemia (spontaneous or provoked), depressed LV ejection fraction ( 75, diabetes mellitus, prolonged sinus tachycardia, hypotension, ST-segment changes at rest without angina (“silent ischemia”), an abnormal signal-averaged ECG, nonpatency of the infarct-related coronary artery (if angiography is undertaken), and persistent advanced heart block or a new intraventricular conduction abnormality on the ECG. In some patients with severely compromised LV function, the loss of appropriately timed atrial systole results in a marked reduction of cardiac output. In this trial, ticagrelor significantly reduced the rate of the CV death, MI, stroke, and stent thrombosis compared with clopidogrel. 55 Although no increase in study-defined major bleeding was noted with ticagrelor, the frequency of non-CABG major bleeding was increased compared with clopidogrel. Contrary to prior belief, it is safe to perform a gentle rectal examination on patients with STEMI. ISIS-4: A randomised factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58,050 patients with suspected acute myocardial infarction. Since ECG can be inconclusive, biomarkers are frequently used to. ACS registry data indicate, however, that the frequency of heparin-induced thrombocytopenia is rare (less than 0.5%). 79 Bivalirudin would be a preferred anticoagulant for patients with a history of heparin-induced thrombocytopenia undergoing PCI. 2, 5. Clopidogrel should be continued for at least 14 days in patients with STE MI in patients not undergoing PCI. He was Editor of the Indian Heart Journal from 2012 to 2014. N Engl J Med 346:2079, 2002 and AS Jaffe et al: Biomarkers in acute cardiac disease: The present and the future. Please see: Acute coronary syndromes - October 30, 2015. Arterial blood that is at its maximum oxygen-carrying capacity can potentially. Some will eventually be diagnosed with nonischemic chest discomfort. CVS pathology 3 - ischemic heart disease, angina and myocardial infarction 20. The extent of infarction correlates well with the degree of pump failure and with mortality, both early (within 10 days of infarction) and later.
Since little gadolinium enters normal myocardium, where there are tightly packed myocytes, but does percolate into the expanded intercellular region of the infarct zone, there is a bright signal in areas of infarction that appears in stark contrast to the dark areas of normal myocardium.
Echocardiographic estimation of left ventricular (LV) function is useful prognostically; detection of reduced function serves as an indication for therapy with an inhibitor of the renin-angiotensinaldosterone system. CVS pathology 3 - ischemic heart disease, angina and myocardial infarction 20. Defibrillators, respirators, noninvasive transthoracic pacemakers, and facilities for introducing pacing catheters and flow-directed balloon-tipped catheters are also usually available. The expanded Global Registry of Acute Coronary Events: Baseline characteristics, management practices and outcomes of patients with acute coronary syndromes. Many drugs used in the coronary care unit, such as atropine, H 2 blockers, and narcotics, can produce delirium, particularly in the elderly. Inclusion of platelets gives the clot a white appearance. Acutely, this results from expansion of the infarct, i.e., slippage of muscle bundles, disruption of normal myocardial cells, and tissue loss within the necrotic zone, resulting in disproportionate thinning and elongation of the infarct zone. Coronary artery bypass surgery should be reserved for patients whose coronary anatomy is unsuited to PCI but in whom revascularization appears to be advisable because of extensive jeopardized myocardium or recurrent ischemia. If patients have been previously prescribed SL NTG and ischemic chest discomfort persists for more than 5 minutes after the first dose, the patient should be instructed to contact emergency medical services before self-administering subsequent doses to activate emergency care sooner. Reperfusion, either pharmacologically (by fibrinolysis) or by PCI, accelerates the opening of infarctrelated arteries in those patients in whom spontaneous fibrinolysis ultimately would have occurred and also greatly increases the number of patients in whom restoration of flow in the infarct-related artery is accomplished. Evolution of antithrombotic therapy used in acute coronary syndromes. However, we may send you emails based on your report interest from time to time. Two trials compared alteplase with reteplase and alteplase with tenecteplase and found similar mortality between agents. 31, 32 Therefore, alteplase, reteplase, and tenecteplase are acceptable as first-line agents. The degree to which antiplatelet and anticoagulant therapy achieves these goals partly determines how effectively it reduces the risk of mortality from STEMI. However, the rate of nonCABG surgery-associated bleeding is higher with both prasugrel and ticagrelor compared with clopidogrel. Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group. The frequency of stent thrombosis following PCI is also lower with prasugrel or ticagrelor compared with clopidogrel. Supraventricular tachyarrhythmias, including sinus tachycardia. Because recurrent or persistent ischemia often heralds extension of the original infarct or reinfarction in a new myocardial zone and is associated with a near tripling of mortality after STEMI, patients with these symptoms should be referred for prompt coronary arteriography and mechanical revascularization. Clinical Pharmacogenetics Implementation Consortium guidelines for cytochrome P450-2C19 (CYP2C19) genotype and clopidogrel therapy. Unstable angina an acute process of myocardial ischemia that is not of. The clinical significance of serum markers will be discussed in greater detail in later sections of this chapter. The remainder of the convalescent phase may be accomplished at home. Decline in rates of death and heart failure in acute coronary syndromes, 1999-2006. Therefore, the clot is composed of cross-linked platelets and fibrin strands. 9, 11. As a consequence, clinical manifestations are dependent upon the severity of obstruction in the affected coronary artery (fig 1), the presence or absence of collateral perfusion, and the volume and myocardial oxygen demand within the affected territory. Effects of pretreatment with clopidogrel and aspirin followed by longterm therapy in patients undergoing percutaneous coronary intervention: The PCI-CURE study. Fibrinolytic therapy is preferred over primary PCI where there is no cardiac catheterization laboratory or there would be a delay in “door-to-primary PCI” of more than 90 minutes (of first medical contact) within the institution or 120 minutes (of first medical contact) if the patient is transferred. Nitroglycerin is considered a cornerstone of anti-anginal therapy.