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

ST elevation MI (<12 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.

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

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  1. ST elevation MI(<12 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 time<60’, ischemia >3u Pro thrombolysis: transfer time>60’, ischemia<3u Primary PCI * First medical contact-to-balloon time < 9030 min Consider IIB-IIIa antagonists Failed Rescue PCI * Consider pre-PCI lytic therapy if transfer time>60 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(<72h) Non-invasive testing * Increased bleeding risk = elderly women(>75j), renal failure (GFR<60 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)

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