ST elevation MI (<12 h after onset of pain)

1
ST elevation MI (lt12 h after onset of pain)
Aspirin heparin
nitrate
Admission in PCI-center
Admission in non-PCI-center or first medical
contact outside hospital

• Hemodynamic instability
• (shock / cardiac failure/ malignant
  arrythmias)
• contra-indication thrombolysis

YES
Transfer PCI center
NO
Thrombolysis start
clopidogrel
Transfer to PCI center
OR
Pro transfer transfer timelt60,
ischemia gt3u Pro
thrombolysis transfer timegt60,
ischemialt3u
Primary PCI First medical contact-to-balloon
time lt 90?30 min Consider IIB-IIIa antagonists
Failed
Rescue PCI
Consider pre-PCI lytic therapy if transfer
timegt60 min
2
Acute coronary syndrome without ST elevation
Aspirin - Heparin (enoxaparin )
Clopidogrel - Nitrate - Beta-blocker
HIGH RISK
Recurrent ischemia (e.g. dynamic ST changes)
Elevated troponin Early post-infarct
angina Diabetes mellitus
Hemodynamic instability major arrhythmias
NO
YES
Second troponin
negative
Positive
GP IIb / IIIa antagonist Coronarography(lt72h)
Non-invasive testing
Increased bleeding risk elderly women(gt75j),
renal failure (GFRlt60 ml/min), prior stroke
urgent procedures consider Bivalirudin (in
stead of enox GP IIb / IIIa antagonist)
non-urgent situations consider fondaparinux (
in stead of enox)