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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
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

acute coronary syndrome without st elevation
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)