Emergent tx in ACS; STEMI

1. anticoagulants

1.1. unfractioned heparin; enoxaparin; fondaparinux

1.2. used simultaneously with tPA etc; need additional anticoag during PCI if fondaparinux is used

2. ace inhibitor

2.1. used in first 24hrs after admission in pts w/ stable BP after fibrinolytic agent

3. GPIIb/IIIa inhibitor

3.1. role in stemi changes often

3.2. give IB before PCI

3.3. lowers mortality, higher patency, better LVEF

3.4. AE: monitor for bleeding

4. MONA and beta blocker

4.1. same as UA and nstemi

5. reperfusion (asap)

5.1. PCI

5.1.1. percutaneous coronary intervention

5.1.1.1. PREFERRED

5.1.2. PCI capable: treat w/in 90min, ASAP, w/anticoag and GPIIB/IIIA inhibitor

5.1.3. not PCI capable: evaluate/tx with fibrinolysis w/in 30min of presentation

5.1.4. AE: lower short term mortality; less nonfatal reinfarction and recurrent ischemia; less hemorrhagic stroke

5.2. fibrinolysis

5.2.1. tPA; rPA; TNKase "clot busters"

5.2.2. eligibility: ST elevation +12 hrs of pain; start w/in 30 min of arival; up to 50% reduction in mortality

5.2.3. AE: major bleeding: intracranial hemorrhage=most feared complication occurring in 1st 24hrs; watch for: changes in mental status, focal neuro deficits, HA, papilledema

5.2.4. Absolute contraindications: previous hemorrhagic stroke, other strokes, or CVA w/in 1 yr; known intracranial neoplasm; active internal bleeding; suspected aortic dissection

6. evaluation of outcome

6.1. st elevation should normalize

6.2. CP relief

6.3. Onset of ventricular arrhythmias->lidocaine or cardioversion if necessary