(Level of Evidence: C), An ACE inhibitor should be administered orally during convalescence from STEMI in patients who tolerate this class of medication, and it should be continued over the long term. Consequently, it is expected that primarily descriptive or retrospective observational study methodologies will be uncovered. The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website www.escardio.org/guidelines In patients whose clinical condition necessitates prolonged bed rest and/or minimized activities, it is reasonable that treatment be continued until the patient is ambulatory. Appropriate hypoglycemic therapy to achieve near-normal fasting plasma glucose, as indicated by A1C. All but low-risk patients without a clear contraindication to -adrenoceptor blocker therapy. WebAcute myocardial infarction (MI) and its sequelae are leading causes of morbidity and mortality worldwide. When should I not take a nitrate medication? Read the latest: Get new journal Tables of Contents sent right to your email inbox, https://www.uptodate.com/contents/angina-pectoris-chest-pain-caused-by-fixed-epicardial-coronary-artery-obstruction, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=172839, Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review protocol, Incidence of severe infection in patients with rheumatoid arthritis taking biologic agents: a systematic review, Wants and needs for involvement experienced by relatives of patients with an acquired brain injury: a scoping review, Articles in PubMed by Matt Wilkinson-Stokes, Articles in Google Scholar by Matt Wilkinson-Stokes, Other articles in this journal by Matt Wilkinson-Stokes. The search strategy will aim to locate both published and unpublished studies, as well as relevant gray literature. More recent data is less clear as to whether the risk of profound hypotension with nitrate use in right-sided MI is as great as we think. 1999 ACC/AHA Expert Consensus Document all support the following to be contraindications This review will consider studies published in English. Wenowprovide abstracts in languages other than English for select reviews. Lipid management: (TG 200 mg per dL or greater) Primary goal is non-HDL-C* substantially lower than 130 mg per dL (3.36 mmol per L). Strongly encourage patient and family to stop smoking and to avoid secondhand smoke. Often they get better once you've been using the medicine for a few weeks. The 2013 ACC/AHA STEMI Guidelines, in particular, highlight the following as contraindications to the use of NTG for ongoing chest pain in STEMI (1): Marked Angina pectoris: Chest pain caused by fixed epicardial coronary artery obstruction. The studies investigating this are limited and this is an area that certainly warrants further investigation. Available from: 25. We now report the results of the NACIAM trial (N-Acetylcysteine in Acute Myocardial Infarction), which was designed to evaluate the efficacy of adding intravenous high-dose NAC to low-dose nitroglycerin to reduce infarct size in patients with STEMI and to explore the mechanism (s) of putative beneficial effects of NAC. (Level of Evidence: C), Patients with diabetes who have STEMI should have an appropriate food group balance and caloric intake. Following diagnosis, initial treatment with analgesics, nitrates and anti-platelet agents forms the initial approach. WebOther contraindications include: PDE-5 inhibitors (avanafil, sildenafil, tadalafil, vardenafil) : If you take nitrites or nitrates, be cautious when taking these medications. Although the overall mechanism is complex, NTG serves as a pro-drug which is converted to nitric oxide, a potent vasodilator, which ultimately leads to venodilation (dose-dependent, lower dosages) and arteriodilation (dose-dependent at higher dosages). Allergy to nitrates. Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP. (Level of Evidence: C), The predischarge risk assessment and planned work-up should be reviewed and continued. Available from: 23. Blood Webread more and non-ST elevation myocardial infarction (NSTEMI). No further benefit was observed with nitrate therapy beyond this point. Start and continue indefinitely aspirin 75 to 162 mg per day if not contraindicated. (Level of Evidence: C), Patients and their families should be asked if they are interested in cardiopulmonary resuscitation training after the patient is discharged from the hospital. As well as a textual description of each included study, tables and figures providing a comparison of the discussed points to aid in data presentation will be included where appropriate.30. This effect is rare but may be deadly if it happens. All of these serve to reduce oxygen demand and increase supply of oxygen and other nutrients. IV morphine boluses titrated to clinical effect: 2.5 to 5mg the patient with fluid resuscitation and -adrenergic agonists if needed. Consider clopidogrel 75 mg per day or warfarin if aspirin is contraindicated. Rapid diagnosis of STEMI The rapid diagnosis of STEMI only requires the presence of symptoms suspicious for an ACS (eg, chest discomfort, dyspnea, sudden death) and a confirmatory ECG; it does not require evidence of (Level of Evidence: C), Critical pathways and protocols and other quality-improvement tools (such as the ACC Guidelines Applied in Practice and the AHAs Get with the Guidelines) should be used to improve the application of evidence-based treatments by patients with STEMI, caregivers, and institutions. Six databases will be systematically searched: the Cochrane CENTRAL Register, PubMed, Embase, MEDLINE Complete, CINAHL, and Google Scholar. Diagnosis. More recent and comprehensive research from 2014, 2016, 2018, and 2019 conflicts with the conclusions from the 1989 study, suggesting instead that nitrate administration during right ventricular myocardial infarction results in no significant difference in the rate of adverse events. With the spray under the tongue: a slight burning or tingling sensation under the tongue. (Level of Evidence: B), Intravenous unfractionated heparin (bolus of 60 U per kg, maximum 4,000 U IV; initial infusion 12 U per kg per hour, maximum of 1,000 U per hour) or low-molecular-weight heparin (LMWH) should be used in patients after STEMI who are at high risk for systemic emboli (large or anterior myocardial infarction, atrial fibrillation, previous embolus, known left ventricular thrombus, or cardiogenic shock). Non-ST elevation myocardial infarction (NSTEMI) is a recognized diagnostic entity that has an unacceptable mortality rate when it goes unrecognized. Consequently, it is expected that primarily descriptive or retrospective observational study methodologies will be uncovered; therefore, a PEO search strategy rather than a PICOT search strategy will be adopted.22. This content is owned by the AAFP. Use of sildenafil (Viagra) in patients with Keyword Highlighting Treatment of other risks (such as physical activity, weight management, blood pressure, and cholesterol management). A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and the JBI Database of Systematic Reviews and Implementation Reports was conducted and no current systematic reviews on the topic were identified. 12. Copyright 2004 by the American Academy of Family Physicians. This series is coordinated by Michael J. Arnold, MD, contributing editor. Right ventricular infarction: a haemodynamic diagnosis. WebPMID: 3304958. Sodium nitroprusside causes direct venous and arterial vasodilation, is a potent pulmonary vasodilator, and is an inhibitor of hypoxia-induced pulmonary vasoconstriction ( 66 ). WebThe study will include both experimental and observational (descriptive and analytical) study designs that discuss the occurrence of adverse events from the administration of nitrates during a known right ventricular myocardial infarction. In Cohn JN, Guiha NH, Broder MI, Limas CJ. http://www.acc.org/clinical/guidelines/stemi/index.htm. Until two decades ago nitroglycerin was contraindicated in acute myocardial infarction (MI). Up to 60% of patients with inferior wall acute myocardial infarction (AMI) develop hypotension. To test the hypothesis that this hypotensive response to nitroglycerin may be related to right ventricular (RV) . 1. Lancet 1988. The primary concern for the use of nitrates in this population is the potential for causing profound hypotension when preload is reduced and, therefore, the focus has been on fluid loading in this population. Chest pain can be treated with nitroglycerin or sometimes morphine. However, there are benefits to symptom control in the management of these patients, such as reduction in the stimulation of the sympathetic nervous system, thereby decreasing myocardial oxygen demand with reduced chronotropy and inotropy. Definitions of the evidence levels are as follows: Level A: Data derived from multiple randomized clinical trials or meta-analyses. (Level of Evidence: C), A plan for appropriate recognition and response to a potential acute cardiac event, including the phone number to access emergency medical services, generally 9-1-1. Signs of methemoglobinemia like a blue or gray color of the lips, nails, or skin; a heartbeat that does not feel normal; seizures; very bad dizziness or passing out; very bad headache; feeling very sleepy; feeling tired or weak; or shortness of breath. (Level of Evidence: A), In patients with STEMI who tolerate ACE inhibitors, an ARB can be useful as an alternative to ACE inhibitors provided there are either clinical or radiologic signs of heart failure or LVEF is less than 0.40. Thadani U, Rodgers T. Side effects of using nitrates to treat angina. There is ubiquitous belief that right ventricular myocardial infarction (RVMI) patients are pre-load dependent, and that administering nitrates to this cohort may cause adverse events most notably hypotension. Dylan Kellogg, MD , in particular, highlight the following as contraindications to the use of NTG for ongoing chest pain in STEMI (1): Marked hypotension (generally systolic <90mmHg or >30mmHg drop from baseline), Use of a 5 phosphodiesterase inhibitor within the previous 24 to 48 hours, ST elevation in V1 and ST depression in V2 (highly specific for RV infarction), Isoelectric ST segment in V1 with marked ST depression in V2, Much of the research surrounding the use of nitroglycerin in myocardial infarction occurred in the 1980s and 1990s, including the ISIS-4 and GISSI-3 studies, which were examined in a, that showed only modest mortality benefit for nitrates when used within 24 hours at day 2 (RR 0.81, 95% CI [0.74,0.89], p<0.0001). (6), Kinch and Ryan (1994): In a review of the literature, the authors point out that animal studies of induced right ventricular infarction resulted in acute RV dilatation, an increase in right-sided filling pressures, and a decrease in RV systolic and end-diastolic pressure. Due to the acute nature of the management of myocardial infarctions, experimental and often also prospective observational study designs are rarely practical or ethical. angina after sildenafil use, other nonnitrate antianginal agents, such as In the November 1, 2004, issue of American Family Physician, a Practice Guideline discussed management before STEMI and initial recognition and management in the emergency department sections of this guideline. Moher D, Liberati A, Tetzlaff J, Altman DG. The accompanying table provides recommended interventions for secondary prevention for patients with STEMI. The databases to be searched include: Cochrane CENTRAL Register (Cochrane Library), PubMed (PubMed; 1946present), Embase (Ovid; 1883present), MEDLINE Complete (Ovid; 1946present), CINAHL (EBSCO; 1961present), and Google Scholar (Google). NSTEMI is diagnosed in patients determined to have symptoms consistent with ACS and troponin elevation but without ECG changes consistent with STEMI. (Level of Evidence: B), The continued use of nitrate therapy beyond the first 24 to 48 hours in the absence of continued or recurrent angina or CHF may be helpful, although the benefit is likely to be small and is not well established in contemporary practice. Reference: Cheitlin MD, et al. There were five duplicates between the two lists, leaving 18 articles in total. Kinch JW, Ryan TJ. e.g. As Jaton (2017) points out in his review, even if these rare adverse events such as hypotension or arrhythmia occur, NTG has a short half-life (in vivo 3 minutes) which will resolve transient hypotension and bradycardia with minimal detriment. WebIn the absence of these indications, use of nitrates should be carefully considered, especially when lower blood pressure precludes the use of other agents shown to be effective in reducing morbidity and mortality, eg, -blockers and angiotensin-converting enzyme (ACE) inhibitors (ACEIs). This subsequent loss in atrial pressure and reduced RV contractility was theorized to be the primary cause of reduced cardiac output and aortic pressure in patients with RVMI. Sudden onset of heart failure or presence of a new murmur herald increased risk and suggest the need for rapid intervention. This systematic review will include patients who experienced an acute myocardial infarction of any region (as confirmed by any indicators, such as cardiac enzyme levels, angiography, ECG, ultrasound, or discharge diagnosis) where the infarcted region is identified, and where RVMI is present in a proportion of the sample. WebThecurrent 2014 ACC/AHA NSTEMI and 2013 ACC/AHA STEMI Guidelines as well as the1999 ACC/AHA Expert Consensus Document all support the following to be contraindicationsto the use of any form of nitroglycerin include: Hypotension(usually reported to be a systolic Because of NTG venodilation at doses typically used by emergency healthcare personnel (0.4 mg sublingually or up to 40 mg/min IV), it was suggested that a reduction in this preload would cause further decreased cardiac output and worsening cardiogenic shock, coronary perfusion, and increased cardiac oxygen demand. All but low-risk patients without a clear contraindication to Consider omega-3 fatty acids as adjunct for high TG. WebThe one true contraindication to giving nitrates in patients with chest pain is hypotension. This systemic vasodilation reduces left ventricular systolic wall stress. Lawrence DW. If the patient had already used nitrates Part 10: Special circumstances of resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. not be given to patients with hypotension, marked bradycardia or tachycardia, RV In this population it is still necessary to assess volume status (and fluid resuscitate or use vasoactive agents as indicated) and consider the use of pain medications that can alleviate symptoms without causing the same degree of hypotension, such as fentanyl. Available from: 24. to maintaining your privacy and will not share your personal information without The combination of recommended practice based on 30-year-old evidence and the emergence of recent challenging evidence suggest that this topic merits systematic review. Class IIb: Procedure or treatment may be considered (additional studies with broad objectives needed; additional registry data would be helpful). National Heart Foundation of Australia; Cardiac Society of Australia and New Zealand: Australian Clinical guidelines for the management of acute coronary syndromes 2016. As noted in the ACC/AHA STEMI Guidelines, although nitroglycerin can ameliorate symptoms and signs of myocardial ischemia by reducing [left ventricular] preload and increasing coronary blood flow, it generally does not attenuate the myocardial injury associated with epicardial coronary artery occlusion unless vasospasm plays a significant role. (1), Right-Ventricular Electrocardiography and Physiology. (Class III, Level of Evidence: B), 2013 AHA/ACC STEMI Guidelines: High-intensity statins are categorized as having a class I indication, and statin therapy should be initiated as soon as possible unless contraindicated based on ACC/AHA Morphine: Indications: Only if pain refractory to all anti-ischemic agents There is ubiquitous belief that right ventricular myocardial infarction (RVMI) patients are pre-load dependent, and that administering nitrates to this cohort may cause adverse events most notably hypotension. The only difference is that nitrates are Most of the published data come from patients with myocardial infarction (MI), but the conclusions would apply to patients with unstable angina. Level C: Only consensus opinion of experts, case studies, or standard-of-care. 24 hours, the administration of a nitrate may be considered, but once again, Nitroglycerin (glyceryl trinitrate [GTN]) remains a first-line treatment for angina pectoris and acute MI. Nitroglycerin achieves its benefit by giving rise to nitric oxide (NO), which causes v . 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Accessed at: https://litfl.com/right-ventricular-infarction-ecg-library/. Nitrates are contraindicated when patients have taken a phosphodiesterase-5 (PDE-5) inhibitor within 24 hours (48 hours for tadalafil). -blockers, should be considered. Hypotension occurred post NTG in 38/466 inferior STEMIs and 30/339 non-inferior STEMIs, 8.2% vs. 8.9%, p = 0.73. WebConsider intravenous nitrates; Consider morphine; Beta-blockers (if no contraindications) Statin therapy; Non-ST elevation ACS (unstable angina or non-ST elevation myocardial infarction (NSTEMI)) Antiplatelet therapy Aspirin; Platelet P2Y12 receptor blocker; Anticoagulation; Admit to monitored bed; Consult Cardiology Valsartan and candesartan have established efficacy for this recommendation. If blood pressure is 140/90 mm Hg or greater or 130/80 mm Hg or greater for individuals with chronic kidney disease or diabetes: Add blood pressure medications, emphasizing the use of beta blockers and inhibition of the renin-angiotensin-aldosterone system. You may be trying to access this site from a secured browser on the server. Clinical diagnosis and differentiation from cardiac tamponade and pericardial constriction. The reduction in tone and consequential increase in lumen diameter may also promote circulation through the coronary collaterals, increase perfusion and, in turn, increase myocardial supply (MD02). UpToDate [internet]. Worked examples of alternative methods for the synthesis of qualitative and quantitative research in systematic reviews. Bosson N, Isakson B, Morgan JA, Kaji AH, Uner A, Hurley K, et al. Prehosp Emerg Care. Right Life in the Fast Lane (February 8, 2021). Secondly, the text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy tested on PubMed on February 27, 2020 (see Appendix I). Copyright 2023 American Academy of Family Physicians. While experimental studies, and in particular randomized control trials, remain ideal, due to the acute nature of the management of myocardial infarctions, experimental (and often also prospective observational) study designs are rarely practical or ethical. Blood pressure control: Goal is less than 140/90 mm Hg or less than 130/80 mm Hg if chronic kidney disease or diabetes. WebA patient with possible STEMI has ongoing chest discomfort. 16. The ability to increase cardiac output appears to be greatest in those patients with the most severe left ventricular failure. Part 9. (Level of Evidence: B), Sodium intake should be restricted in STEMI patients with hypertension or heart failure. Treatment should begin within a few days of the event (if not initiated acutely) and continue indefinitely. WebPMID: 6421532 Abstract The use of nitrates in treating acute myocardial infarction is reviewed; proposed mechanisms of action and pertinent pathophysiology are discussed. WebBecause nitroglycerin is a vasodilator, it is contraindicated as standard treatment, or must be given with extreme care. 2020 [cited 2020 Feb 14]. Physical activity: minimum goal is 30 minutes, three to four days per week; optimal is daily. We now report the results of the NACIAM trial (N-Acetylcysteine in Acute Myocardial Infarction), which was designed to evaluate the efficacy of adding intravenous (Level of Evidence: C), The patients list of current medications should be reevaluated in a follow-up visit, and appropriate titration of ACE inhibitors, beta blockers, and statins should be undertaken. Right ventricular infarction: clinical and hemodynamic features. Acute right ventricular myocardial infarction. Cochrane Database Syst Rev 2009. (Level of Evidence: C), 1. hours. vasodilation. time interval should be avoided. your express consent. Nitrates are a class of medications that increase the release of nitric oxide (NO) in vascular smooth muscle cells, leading to smooth muscle relaxation and subsequent vasodilation. Thankfully these side-effects are unpleasant but not serious. Most of the published data come from patients (Level of Evidence: B), For patients who have undergone diagnostic cardiac catheterization and for whom percutaneous coronary intervention (PCI) is planned, clopidogrel should be started and continued for at least one month after bare metal stent implantation (three months for sirolimus, six months for paclitaxel) and up to 12 months in patients who are not at high risk for bleeding. One therapy, the use of nitrates such as nitroglycerin (NTG), continues to be used in the management of acute ischemic chest pain due to ST-elevation myocardial infarction (STEMI). Unstable angina and NSTEMI differ primarily in the presence or absence of The guidelines discuss the five major modalities that apply to measuring myocardial infarction, including electrocardiographic techniques, cardiac biomarker methods, radionuclide imaging, echocardiography, and magnetic resonance imaging. report of the American College of Cardiology Foundation/American Heart Abstract. Wilkinson-Stokes M, Colbeck M, Stewart S. Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review protocol [internet] PROSPERO; 2020 [cited 2020 May 11]. (5) Yusuf, et al. Nitrates, along with antiplatelet and additional analgesic therapies, form the basis of initial acute myocardial infarction treatment with primary percutaneous coronary intervention, thrombolysis, or (less commonly, at around 5% of acute infarctions) bypass surgery as definitive reperfusion treatment.1. This systematic review will include all forms of adverse events, including hypotension defined as a systolic blood pressure under 100 mmHg in a patient whose pre-administration blood pressure was over 100 mmHg or as a drop in systolic blood pressure of greater than one third of their pre-administration blood pressure, all dysrhythmias, syncope, death, and any other adverse events that may be discovered during the literature review. Right Ventricular Infarction. IV morphine boluses titrated to clinical effect: 2.5 to 5mg IV as an initial dose, then titrated to effect every 5 to 10 minutes Encourage increased consumption of omega-3 fatty acids. appropriate caution with careful monitoring of initial dosages must be used. Parekh P, Agrawal N, Vasavada A. Long-Term -Adrenoceptor Blocker Therapy in Survivors of Myocardial Infarction. "Nitrates should Studies in the canine model demonstrated that low-dose intravenous (i.v.) 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. For more information, please refer to our Privacy Policy. All three will be considered in forming final recommendations for practice and research. (Level of Evidence: C), Supplemental oxygen therapy should be continued beyond the first six hours in STEMI patients with arterial oxygen desaturation(SaO2 less than 90 percent) or overt pulmonary congestion. A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide. (Level of Evidence: B) Wolters Kluwer Health (Level of Evidence: C), The advisability of calling 9-1-1 if symptoms are unimproved or worsening after five minutes, despite feelings of uncertainty about the symptoms and fear of potential embarrassment. were subsequently affirmed by a single case study in 197412 and two small retrospective cohort studies totaling 32 people in 1979 and 1981.13,14 Over 40 years later, these physiological principles remain widely accepted.15,16, An informal literature search revealed five primary research articles discussing the safety of nitrate administration during right ventricular infarction (or right coronary artery occlusion): a 1989 cohort study17; a 2014 case study18; and larger cohort studies in 2016,19 2017,20 and 2019.21 Of these, the original 1989 study of 28 patients concluded there was an increased risk of hypotension, and stated this is likely due to impaired right ventricular ejection fraction reducing left ventricular preload.17 Conversely, the 2014, 2016, 2017, and 2019 studies, collectively containing over 1000 patients, all concluded nitrates had no increased risk of adverse events when given to right ventricular infarcts, inferior infarcts, or right coronary artery occlusions.18-21 However, despite this updated evidence, the existing view against the use of nitrates remains orthodoxy: the current American Heart Association guidelines on nitrate use state RVMI is a contraindication.16. WebThe incidence of acute ST-elevation myocardial infarction (AMI) is decreasing in many European countries; 1 however, the incidence of non-STEMI acute coronary syndrome (non-STEMI ACS) is increasing. e.g. Nitrates are catalyzed by sulfhydryl to form nitric oxide in the tunica media, leading to increased cyclic guanosine monophosphate production, reducing intracellular calcium, causing smooth muscle relaxation and consequential vasodilation.2 The increased vascular pooling decreases both preload and afterload, reducing stimulation of the Frank-Starling mechanism, reducing force of contraction, and therefore reducing myocardial oxygen demand (MV02). With the spray under the tongue: a slight burning or tingling sensation under the tongue. Significance of, 18. WebWhat are the contraindications for nitrate administration? Hemodynamic spectrum of dominant right ventricular infarction in 19 patients. Class IIa: It is reasonable to perform procedure or administer treatment (additional studies with focused objectives needed). Class IIa. As inferior ST-elevation may be used as a diagnostic proxy for RVMI in some systems, studies considering inferior wall myocardial infarction patients will be considered for inclusion where there is sufficient evidence to indicate concomitant RVMI. (Level of Evidence: C), Treatment with cognitive-behavioral therapy and selective serotonin reuptake inhibitors can be useful for STEMI patients with depression that occurs in the year after hospital discharge. Studies have demonstrated benefits of their use in patients with and without concomitant fibrinolytic therapy, both early and late after STEMI. Generations of medical students and paramedic students have been educated on the use of NTG to alleviate chest pain as well as the contraindications to its use. Monitor response of BMI and waist circumference to therapy. patients in whom the half-life of sildenafil may be prolonged, such as in renal 1. practice guidelines including, where appropriate, primary 2013 Jan 29;127(4):e362-425. Definitive evidence is currently lacking, but it is WebCoronary Artery Disease - STEMI Topic Review | Learn the Heart - Healio NSTEMI is diagnosed in patients determined to have symptoms consistent with ACS and troponin elevation but without ECG changes consistent with STEMI. Signs of methemoglobinemia like a blue or gray color of the lips, nails, or skin; a heartbeat that does not feel normal; seizures; very bad dizziness or passing infarction, or 5'phosphodiesterase inhibitor use within the previous 24 to 48 I Sh*t You Not, Differentiating Peak and Plateau Pressures, Sodium Bicarbonate for cardiac arrest: Time to put it away. Share your thoughts in the comment box below. Assess fasting lipid profile in all patients, preferably within 24 hours of STEMI. WebAlthough the overall incidence of cocaine-associated MI varies between studies from 0.7% to 6% of those presenting with chest pain after cocaine ingestion (some of the variance may relate to differences in MI diagnostic criteria), cocaine appears to be an important contributor to MI among the young. This article will partially contribute towards a postgraduate thesis for MW-S. Prehospital, 20. Rapid diagnosis of STEMI The rapid diagnosis of STEMI only requires the presence of symptoms suspicious for an ACS (eg, chest discomfort, dyspnea, sudden 2020 [cited 2020 May 11]. ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a Frequency and severity of adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review protocol [internet]. The results of critical appraisal will be reported in narrative form and in a table. Circulation 2013;127(4):e362-425. Data is temporarily unavailable. (Level of Evidence: C), Prophylaxis for deep venous thrombosis (DVT) with subcutaneous LMWH (dosed appropriately for specific agent) or with subcutaneous unfractionated heparin, 7,500 U to 12,500 U twice per day until completely ambulatory, may be useful, but the effectiveness of such a strategy is not well established in the contemporary era of routine aspirin use and early mobilization.
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