ST elevation Ml

COMMIT or CCS-2 (3 I), conducted in China and without a loading dose of clopidogrel, tried to determine whether adding clopidogrel to acetylsalicylic acid (ASA) can produce a further reduction in mortality and the risk of vascular events in hospital for patients admitted with ST-elevation Ml (STEMI). 

ACS can be classified into UA, myocardial infarction (Ml) without ST-segment elevation [non-ST-elevation Ml (NSTEMI)], or STEMI. The presence of cardiac troponin in ACS indicates worse prognosis than the absence of troponin (9). 

Fondaparinux is a chemically synthesized pentasaccharide that mimics the antithrombin-binding site of heparin and LMWH. Its molecular size (1728Da) is too small to bind to thrombin molecules while it is bound to antithrombin, Therefore, it is a pure anti-Xa inhibitor. It binds very little to platelets, proteins, or endothelium and is excreted in the urine, It does not form a complex with PF4 or other positively charged molecules. It is not neutralizable by protamine sulfate, Recent clinical trials have resulted in FDA approval for prophylaxis of deep vein thrombosis in orthopedic surgery, It has been shown to be effective and safe for the treatment of pulmonary embolism (20,21) and ACS (non-ST-elevation Ml) (OASIS 5—Michelangelo Trial) (17). 

Limited data are available to link clopidogrel nonresponsiveness to the occurrence of thrombotic events. Matetzky et al. studied clopidogrel responsiveness in patients undergoing stenting for acute ST-elevation Ml. They found that patients who exhibited the highest quartile of ADP-induced aggregation had a 40% probability for a recurrent cardiovascular... 

More recently, Fernandez-Aviles et al. (34) enrolled 20 patients with extensive ST-elevation Ml (>6mm), treated with primary or rescue angioplasty and stenting for treatment with bone marrow stem cells at median time of 13 days after... 

The only trial to date that was negative and failed to demonstrate any benefit of ABMSCs infusion was a small nonrandomized trial of five patients (36) with ST-elevation Ml treated within six hours with primary or rescue PCI after failed thrombolysis. Thirty million cells were injected in a single injection. There was no improvement in the EF from... 

Biochemical markers (creatine kinase [CK], CK-MB fraction, troponin I and troponin T) are elevated in Ml (ST-segment elevation Ml and non-ST-segment elevation Ml), but normal in chronic stable angina and unstable angina. 

A 59-year-old man with mild hemophilia A was given a test dose of desmopressin 30 micrograms (0.19 micrograms/kg) in 100 ml of saline by intravenous infusion over 30 minutes (29). Shortly afterwards, having had a cigarette, he developed chest pain. An electrocardiogram showed ST elevation, and a myocardial infarction was confirmed. 

Abbreviations AMI, acute myocardial infarction BM-MNC. bone marrow mononuclear cell BOOST, bone marrow transfer to enhance ST-elevation infarct regeneration CPC, circulating progenitor cells HF, heart failure LV, left ventricle LVED, left ventricular end-diastolic diameter LVEDV, left ventricular end-diastolic volume LVER left ventricular ejection fraction Ml. myocardial infarction TOPCARE-AMI, transplantation of progenitor cells and regeneration enhancement in acute myocardial infarction. Source From Ref. 21. 

Figure 44-14 The distinction between non-ST elevation myocardial infarction and unstable angina predicated on an increased cardiac troponin in patients presenting with ischemic discomfort. (Data from Brerinan ML, Penn MS,Viin Lente F, Nambi V, Shishehbor MH, Aviles RJ, etal. Prognostic value of myeloperoxidase in patients with chest pain. N Engl J Med 2003 349 1595-604.)...

Stable angina Non-ST elevation ACS ST elevation i CS evolving to Q-wave Ml... 

Mirror image - In general, yes. - Sometimes more prominent than the direct image Vi- V3 in some cases of lateral Ml. - In general, no. - ST elevation in VR and sometimes in Vi in case of non-complete occlusion of the left main trunk or equivalent and in 3 vessel disease. 

Aborted Ml with Q wave Acute coronary syndrome (ACS) with ST elevation (infarction in evolution) with early and efficient reperfusion. Rarely spontaneous thrombus resolution. Troponine level is decisive to separate unstable angina from Ml without Q wave. 

Acute Ml patients with ST Elevation or New LBBB, <6 hours of pain to qualifying EGG (n = 3000)... 

After you ve noted chara eristic lead changes in an acute Ml, use this table to identify the areas of damage. Match the lead changes (ST elevation, abnormal Q waves) in the second column with the affected wall in the first column and the artery involved in the third column. The fourth column shows reciprocal lead changes. ... 

Unstable Angina (UA) and Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) are important situations which may cause SCD or ML Treatment is aimed at the prevention of these events, mainly by revascularization after the immediate medical treatment. In this section, the medical therapy will be separately discussed for the hospital care and posthospital discharge care. 

Bertrand ME, Simoons ML, Fox KA, et al, Task force on the management of acute coronary syndromes of the European Society of Cardiology, Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation, Eur Heart J 2002 23 1 809-1 840. 

In the CURE study, 12,562 patients with acute coronary syndromes without ST-segment elevation have received ASA and clopidogrel 300 mg bolus, followed by 75 mg daily, versus ASA and placebo (50). The clopidogrel group had early reduction [within 24 hours of treatment—9.3% vs. I 1.4%, RR reduction 20% (p < 0.001) in the primary endpoint death from cardiovascular cause, nonfatal Ml, or stroke], which was sustained at one year, and was observed in all patients with acute coronary syndromes regardless of their level of risk. CURE patients who underwent PCI and were randomized to clopidogrel had a 31% RR reduction in death and Ml compared with placebo-treated PCI patients (51). 

The patient, a 63-year-old Caucasian female, was hospitalized on 4 April 2002 though 10 April 2002 for a non-ST segment elevation myocardial infarction (non-Q-wave MI per chart documentation). She had a negative adenosine stress test after the initial event. Her serum cardiac-specific troponin I (cTnl) concentration 24 hours after her onset of chest pain was 1.4 pg/L (upper limit of normal is 0.3 ng/mL), and her creatine kinase (CK) MB level was 12.5 pg/L (upper limit of normal 6.0 ng/mL). Three days post-event her cTnl level was 0.5 pg/L and her CK-MB level was 4.5 pg/L (Fig. 5-1). MB refers to one of the isoenzyme forms of CK found in serum. The form of the enzyme that occurs in brain (BB) does not usually get past the blood-brain barrier and therefore is not normally present in the serum. The MM and MB forms account for almost all of the CK in serum. Skeletal muscle contains mainly MM, with less than 2% of its CK in the MB form. MM is also the predominant myocardial creatine kinase and MB accounts for 10%-20% of creatine kinase in heart muscle. 

PE His initial vital signs were significant for BP 210/120 mm Hg, HR 80 beats/min, RR 18 breaths/min, and O2 saturation 98% on 6 liters oxygen by nasal cannula. In the ED, PB was started on IV infusions of nitroglycerin, metoprolol, and heparin. The patient was ruled in for acute Ml, with first creatine kinase (CK) of 137 lU/L, then peaking to 467 lU/L. Troponin was elevated at 0.95. ECG showed an ST segment elevation with no Q wave. 

Figure 4.67 (A) Acute Ml of anteroseptal zone due to occlusion of LAD proximal to D1 (ST-segment depression in III and VF) but distal to S1 (non-ST-segment elevation in VR and V1 and non-ST-segment depression in V6). (B) After some hours complete LBBB appears (see q in I, VL and V4 and polyphasic morphology in V3) (see the Sgarbossa...

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