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Approach to non-ST-segment elevation acute coronary syndrome
in the emergency department
Approach to non-ST-segment elevation acute coronary syndrome in the emergency department: risk stratification and treatment strategies.
Hosp Pract (Minneap). 2010 Apr;38(2):40-9.
Lefebvre CW, Hoekstra J.
Department of Emergency Medicine, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157-1089, USA.
Abstract
Cardiovascular disease remains a leading cause of morbidity and mortality among Americans. A significant share of all resources for health care is allocated for the diagnosis and treatment of acute coronary syndrome (ACS), including ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina. Because millions of patients visit emergency departments with chest pain and other symptoms that might indicate ACS, the clinician must be familiar with appropriate diagnostic and therapeutic treatment measures.
Non-ST-segment elevation (NSTE) ACS is a particularly challenging clinical entity due in part to limitations in the diagnostic tools employed to detect it and the wide range of therapeutic options available to treat it. Despite advances in the treatment of ACS and the dissemination of formal recommendations on approaches to managing NSTE ACS, pharmacologic and reperfusion therapy remain underused and often delayed. This results in an increase in adverse cardiac events for patients and rising health care costs for the public. The key to NSTE ACS management is rigorous adherence and application of evidence-based recommendations.
The American Heart Association (AHA) and the American College of Cardiology (ACC) have released comprehensive clinical practice guidelines to manage NSTE ACS. These include a process of risk stratification of patients presenting with NSTE ACS or possible NSTE ACS. Risk stratification can be performed using a number of scoring models, including the Thrombolysis in Myocardial Infarction (TIMI), the Global Registry of Acute Coronary Events (GRACE), and the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) scoring models.
Once a patient's risk for adverse cardiac events is determined, appropriate diagnostic and therapeutic modalities can be selected to match their level of risk. American College of Cardiology/AHA recommendations for the diagnosis and treatment of NSTE ACS include considerations regarding admission, antiplatelet therapy, anticoagulation, and early percutaneous coronary intervention/diagnostic angiography with the intent to perform revascularization. New information has emerged since the release of the 2007 updated ACC/AHA guidelines.
The 2009 update of the ACC/AHA guidelines includes new recommendations on antiplatelet therapy, early invasive therapy, and the timing of glycoprotein IIb/IIIa inhibitor therapy for patients with NSTE ACS. Considering this new information during the application of the ACC/AHA guidelines will enhance selecting the optimal treatment for the NSTE ACS patient and ensure appropriate use of health care resources.
Featured Angina| Acute Coronary Syndrome and Heart Disease Interviews
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Author Interview: Claes Held MD
Associate professor at Uppsala Clinical Research Center and the
Cardiology department at Uppsala University Hospital in Sweden
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Publication:
Physical activity levels, ownership of goods promoting sedentary behaviour and risk of myocardial infarction: results of the INTERHEART study
Eur Heart J first published online January 11, 2012 doi:10.1093/eurheartj/ehr432
2012 doi:10.1093/eurheartj/ehr432
Claes Held, Romaina Iqbal, Scott A. Lear, Annika Rosengren, Shofiqul Islam,James Mathew, and Salim Yusuf
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What are the main findings of the study?
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The main findings are he following:
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It is well known that physical inactivity is a risk factor for developing cardiovascular disease.
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Our study shows that being physically active reduces the risk of having a heart attack.
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Older studies have mostly studied people in the developed countries. This study which has a global perspective and includes 52 countries from all continents, shows that physical inactivity reduces the risk also in both low- middle-and high-income countries.
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We also found that ownership of a car and TV was associated with a more than doubled risk of being sedentary and that in low- and middle income the risk for a heart attack was increased with 27 %.
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We can however, not conclude from this study that there is a causal relationship but it is an interesting finding.
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Were any of the findings unexpected?
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We looked at the relationship between physical activity both at work and during leisure time.
A bit surprising was that people with heavy physical labor did not have a reduction in the risk of heart attacks, whereas people with both mild and moderate intensity did.
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What should clinicians and patients take away from this study?
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The main findings above and also that physical activity with duration below the recommended 30 minutes/day does seem to prevent from heart attacks as well although not as much as when you do it according to guidelines.
This may be a comfort to those who are completely sedentary and feel that it would be a too big step to move to the 30 minutes/day right away.
All PA does a good job for the heart as compared to not doing anything at all!
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What recommendations do you have for cardiology health care providers as a result of your study?
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It would be interesting to follow up on the ownership of car and TV and do a prospective study to see if the theory holds true.
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Abstract
Background— Despite data showing the benefits of implantable cardioverter-defibrillator (ICD) insertion for primary prevention in populations at risk for sudden death, professional society guidelines recommending primary prevention, and recognition by payers of the clinical value of ICDs in these populations, ICDs for primary prevention remain underused. We sought to determine whether implementing a screening tool would increase appropriate identification of patients showing clinical evidence of ICD benefit and prompt referral to an electrophysiologist for ICD implantation.
Methods and Results— Screening tools were affixed to medical records for patients seen in 2 outpatient cardiology offices that queried ejection fraction and whether referral to an electrophysiologist was made (N=6632).
The number of appropriate referrals in the screening period were compared with analogous data collected before implementation of the screening tool (control period) through retrospective record review (n=3606). Significantly more eligible patients were offered referral during the screening period than during the control period at both sites, 80% (8/10 eligible) versus 33% (5/15) at site 1 (P<0.02) and 100% (44/44) versus 60% (21/35) at site 2 (P<0.001). Of all patients offered referral, 41% (32/78) accepted.
Conclusions— The use of a screening tool increases referral to electrophysiology for patients in whom placement of an ICD confers the benefit of sudden cardiac death primary prevention. Barriers to referral include both physician and patient factors. Verification of these findings on a larger scale as well as studies defining the foundation of these barriers may further improve use of ICDs in patients for whom their mortality benefit is well described.
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Angina | Heart Disease Resourses
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Amazon.com 's Editorial Reviews
Angina: New Ways to Treat
Chronic Chest Pain
Part of the award winning public television series Healthy head
/Healthy Mind. It's one of the scariest medical symptoms for people who are generally healthy: a tightening, painful feeling in the chest known as Angina. In some cases this chest pain can be a serious warning that requires immediate treatment. But for the millions of people with chronic, stable angina the discomfort is something that can be readily managed with a variety of treatments. In this program we take a look at what generally causes angina, what can be done to prevent it and how it can be effectively treated with lifestyle changes, innovative drug therapies and medical procedures.
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Amazon.com Editorial Review:
Philips HeartStart Home Defibrillator (AED)
Be prepared for the unexpected.
When sudden cardiac arrest (SCA) strikes, the electrical system of the heart short circuits, causing the heart to quiver rather than pump in a normal rhythm. It typically results in the abnormal heart rhythm know as ventricular fibrillation (VF). It usually happens without warning and the majority of people have no previously recognized symptoms of heart disease. And it most often happens at home. For the best chance of survival from SCA caused by VF, a defibrillator should be used within 5 minutes. Yet, less than 1 in 20 people survive largely because a defibrillator does not arrive in time.
Just as seat belts or airbags do not save every life in a traffic accident, a defibrillator will not save every person who suffers a sudden cardiac arrest. Yet many lives could be saved if more people could be reached more quickly.
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