NSTEMI and

antithrombotics
Dr. Gilbert Boucher
R4 Emergency Medicine
McGill


Goals

Reie! de"initions o" Non#ST#eleation

Myocardial in"raction and related items.

$rognostic "actors.

%urrent thera&ies.

S&ecial cases.




What's New?

October 4 , 2001
Practice Guidelines: Atherosclerotic Cardiovascular Disease

September 1 , 2001
Practice Guidelines: Atrial Fibrillation

April 27 , 2001
Practice Guidelines: Percutaneous Coronary Intervention

April 27 , 2001
E!ert Consensus Docu"ent: Catheteri#ation $aboratory %tandard

April 3 , 2001
Consensus Conference Report: Care of the Patient ith A!ult Con"enital #eart $isease

April 2 , 2001
%&pert Consensus $ocument: Stan!ar!s for Ac'uisition, (easurement an! Reportin" of )ntra*ascular +ltrasoun!
Stu!ies

(arch 1, 2001
,eachin" Sli!es: ACC-A#A .ui!elines for the (ana"ement of +nstable An"ina an! /on0S,0Se"ment %le*ation
(1ocar!ial )nfarction

2anuar1 1, 2001
Consensus Conference Report: (echanical Car!iac Support 2000: Current Applications an! 3uture ,rial $esi"n

/o*ember 1, 2000
Clinical Competence Statement: )n*asi*e %lectroph1siolo"1 Stu!ies, Catheter Ablation, an! Car!io*ersion

October 1, 2000
Clinical Competence Statement: Stress ,estin"

September 1, 2000
Practice .ui!elines: (ana"ement of Patients ith +nstable An"ina an! /on0S,0Se"ment %le*ation (1ocar!ial
)nfarction

September 1, 2000
Consensus Conference Report: (1ocar!ial )nfarction Re!efine!4A Consensus $ocument of the 2oint %uropean
Societ1 of Car!iolo"1-American Colle"e of Car!iolo"1 Committee for the Re!efinition of (1ocar!ial )nfarction

2ul1 1, 2000
%&pert Consensus $ocument: %lectron05eam Compute! ,omo"raph1 for the $ia"nosis an! Pro"nosis of Coronar1
Arter1 $isease

2une 1, 2000
,rainin" Statement: A!ult Car!io*ascular (e!icine 6COCA,S7 Re*ise! 8-00 ,as9 3orce :;: ,rainin" in /uclear
Car!iolo"1
!!!.acc.org


ACUTE CORONARY SYNDROME ACUTE CORONARY SYNDROME
No ST Elevation No ST Elevation
ST Elevation ST Elevation ST Elevation ST Elevation
Unstable Angina NQMI QwMI
Myocardial Inarction
NSTEMI


Myocardial in"arction'
acute( eoling( recent
Typical rise and gradual fall (troponin) or
more rapid rise and fall (CK-MB) of
biochemical markers of myocardial
necrosis with at least one of the following:

a) ischemic symptoms!

b) de"elopment of pathologic # wa"es on the

$C%!

c) $C% changes indicati"e of ischemia (&T

segment ele"ation or depression)! or

d) coronary artery inter"ention (e'g'( coronary

angio-plasty)'


)CC*)+) %uidelines
,
-&T$M. is an acute process of
myocardial ischemia with sufficient
se"erity and duration to result in
myocardial necrosis'
,
The initial $C% in patients with
-&T$M. does not show &T-segment
ele"ation'
,
-&T$M. is distinguished from /) by
the detection of cardiac markers
indicati"e of myocardial necrosis in
-&T$M. and the absence of abnormal
ele"ation of such biomarkers in
patients with /)'
De"inition' NSTEMI
De"inition' NSTEMI


De"inition' unstable angina

Unstable angina0an acute process of

myocardial ischemia that is not of
sufficient se"erity and duration to
result in myocardial necrosis.

1o not release biomarkers indicati"e of

myocardial necrosis into the blood'


UA!NSTEMI
" #RESENTATIONS
Rest Angina* Angina occurring at rest and prolonged,
usually > 20 minutes
New-onset Angina New-onset angina of at least CCS Class III
severity
Increasing Angina Previously diagnosed angina that has
become distinctly more frequent, longer in
duration, or lower in threshold (i.e.,
increased by > 1 CCS)class to at
least CCS Class III severity.
) $ts !ith NSTEMI usually &resent !ith angina at rest.
$ra%nwald
Circ%lation &'()*'+ *,&,


CAUSES O- UA!NSTEMI
T.ro/bosis
T.ro/bosis
Mec.anical
Obstr%ction
Mec.anical
Obstr%ction
Dyna/ic
Obstr%ction
Dyna/ic
Obstr%ction
Inla//ation!
Inection
Inla//ation!
Inection
M0O
1
M0O
1
$ra%nwald2 Circ%lation
,&(11*,2 *,,&
3
3




*ellens+ syndrome


The simplified criteria for Wellens' syndrome are as follows:
Prior history of chest pain
Little or no cardiac enzyme elevation
No pathologic precordial Q waves
Little or no ST-segment elevation
No loss of precordial waves
!iphasic T waves in leads "
#
and "
$
or symmetric% often
deeply inverted T waves in leads "
#
and "
$
&
Wellens' criteria are '(ite specific for left anterior descending
artery disease& )ll of the patients *n+,-./ in his ,0-- st(dy had
more than 1.2 narrowing of the left anterior descending artery
*mean+-12 narrowing/ with complete or near-complete
occl(sion in 102&


Tro&onins

I s T,
-
Tro&onin I does not accumulate in renal "ailure
-
Di""erent assays o" same tro&onin hae di""erent
alues due to di""erent isoto&es o" antibodies

.ery sensitie
-
Estimate that /01 o" &atients !ith 234 are no!
diagnosed !ith NSTEMI due to eleated tro&onins

5igh correlation !ith death( being &rimary

cardiac or not,






























F
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- $ngl 2 Med 3445!667:36894'


Tro&onemia

%lin %hem 6000 47' 780#789.

-
47 &ts !ith se&tic shoc:
-
/7#801 had ; tro&s
-
<6 &ts nonsuriors' negatie auto&sy "or necrosis
-
4ssociated !ith seere =. dys"unction.
%lin %hem 600< 49' 4<6#4<9
-
644 &ts( chronic hemodialysis( tro&onin T
-
5igher tro&s or increasing tro&s associated !ith
death.
71( 4/1( and 8>1 total death.
in 01( <41( and 641 cardiac death


Tro&onitis,

%lin %hem <>>>'National Academy of Clinical Biochemistry

Standards of Laboratory Practice: Recommendations for the Use of
Cardiac Markers in Coronary Artery Diseases

Tro&onin I can be "alsely eleated due to "ibrin

clot( hetero&hilic antibodies.

2se o" 6 cut#o""s &oint !ould re?uire too much

&hysician education,
-
454 needs to better de"ine NSTEMI due to im&ortant
im&lication o" being diagnosed !ith MI.



Figure 1. Plot of the appearance of cardiac mar3ers in 4lood vs
time after onset of symptoms&
Peak A% early release of myoglo4in or 56-7! isoforms after
)789 peak B% cardiac troponin after )789 peak C% 56-7! after
)789 peak D% cardiac troponin after (nsta4le angina& :ata are
plotted on a relative scale% where ,&. is set at the )78 c(toff
concentration&


@ther mar:ers

Delta alues at 6 hours could &roed to be ery

sensitie.
-
6 hour delta %A#MB BB1 sens s delta tro& I 7<1

S&eci"icity o" >71

Cearly mar:er "or more aggressie treatment

Am J Emerg Med # 6000 Dan

%R$' D4%% <>>B Dun out o" TIMI#<<a

-
Neg tro& but &os %R$ E 8.B1 death
-
Neg tro& and neg %R$ E 0./71 death
-
$os tro& and %R$ E >.<1 death








































F
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Ac
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isc
he
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a
pa
th
a
1<


Recommended

%lass I'
-
4s&irin( Nitrate( B#bloc:ers( mor&hine( @6 F&rnG.
-
Nondihydro&yridine FcardiHem3era&amilG.
-
4%Ei "or s&eci"ics.

%lass 6a'
-
4%Ei "or all.
-
=ong#acting %%B "or recurrent ischemia.
-
I4B$ i" all "ails.

%lass 6b'
-
EItended "orm o" Nondihydro&yridine.
-
Short acting dihydro&yridine in the &resence o" B#
bloc:er.


@Iygen

Jor'
-
%yanosis
-
Res& distress
-
5igh ris: "eatures

%onsume resources

Eidence is lac:ing.


Nitrates' Decr M.@6( incr coronaries
oIygenation
4ctions
-
Dilate enous bed' decr &reload and entricular !all
tension.
-
Smaller dilatation o" arterial system' decr a"terload
and entricular !all tension.

Need B#bloc:er
-
Dilatation o" atherosclerotic coronaries
-
Decreased &latelets adhesieness.

Jor
-
ischemia des&ite nitro K / and i B#bloc:ade
-
high#ris: &atients Fnon#hy&otensieG.

$rethrombolytics' /81 mortality reduction.

Mor&hine

$otent anIiolytic and analgesic action

$otentially bene"icial
-
.enous dilatation
- Decr 5R
-
Decr sB$ FDecr M.@6G
-
4ctiates neutral endo&e&tidases
4nn Emerg Med. May 600<L/9'448#44>.

Nausea and omiting in 601

5y&otension

Me&eridine i" allergic

Beta#bloc:ers

Decr sB$

Decr S4 node rate( contractility( 4. node

conduction.

Incr diastole "illing time.

i "orm "or high#ris: &ts3on going &ain.

@ral "or intermediate3lo! ris:s &atients.

No &re"erred agents eIce&t better i" B#bloc:er

!ithout IS4 Fmeto&rolol( atenolol( &ro&ramolol(
esmololG.


B#bloc:ers

%ontraindications FconsensusG'
-
<
st
degre 4. bloc: M64 msec
-
6
nd
or /
rd
degre 4. bloc: !ithout &acema:er
-
4sthma
- Seere =. dys"unction !ith %5J

%aution !ith'
-
%@$D
-
Bradycardia N80
-
5y&otension N>0

Goal is b&m o" 80#70 unless side#e""ects

B#bloc:ers

</1 reduction o" &rogression o" 24 to

4MI.

EItra&olate data "rom use in 4MI( recent

MI( stable angina( heart "ailure.


%alcium channel bloc:ers

Inhibit asculature SM contracture

-
%oronary asodilatation

Inhibit myocardial muscle contraction

4. bloc:

Slo! sinus node

%alcium channel bloc:ers

Dihydro&yridines' ni"edi&ine and amlodi&ine

-
&eri&heral asodilatation

.era&amil' D4.IT study F/600 &tsG

-
@nly "aorable trend

Ni"edi&ine' 5INT study F800 &tsG

-
Incr MI by <71( decr by 601 i" !ith meto&rolol
-
But, meto&rolol alone decr by 641OOO

DiltiaHem sho!ed trends o" im&roed outcome

-
%AMB leel( rein"arction rate
-
Same mortality
, eIce&t in =. dys"unction 4%S


%alcium channel bloc:ers

%onclusion'
-
Good sym&tom relieer
-
Trend o" im&roed outcome !ith non#
dihydro&yridine agents

To use i" unable to use B#bloc:ers

4nti&latelet agents

4s&irin 4S4$O
-
Thieno&yridine Fclo&idogrel or ticlo&idineG i"
hy&ersensitiity o" maPor GI intolerance


4s&irin

%yclooIygenase#< inhibitor
-
$reents thromboIane 46 "ormation

Dosing' <70 mg or /68 mg

-
Based on ISIS#6 !hich de"inetly established
its e""icacy.

%an use &r route.

4denosine di&hos&hate
inhibitors

%lo&idogrel acts "aster than ticlo&idine.

Ticlodi&ine' Gi se( neutro&enia( TT$

%lo&idogrel' minimal rash and diarrhea

-
<< TT$ !ithin <4 days F/ millions &tsG

%2RE study' NEDM 4ug 600<

-
<6000 &ts( &laiI /00mg &o
-
>./ s <<.4( <7.8 s <B.B
-
ST changes or ; mar:ers
-
No G$6b/a inh or angio

$laiI'
Sa"ety i" angio or used !ith
G&6b/4 inh

4ancet A%g%st 1''*( #CI5CURE st%dy

6700 &ts.

$laiI /00mg loading

No increased bleeding &roblem !hether

&laiI ;3# G$IIb3IIIa inh !ere used.

Better outcome be"ore an a"ter $%I.

@ther &o agents
,
&ulfinpyra:one
,
1ipyridamole
,
;rostacyclin
,
<ral %; ..B*...) inhibitor:

8 studies: 3 ;C.( 6 -&T$M.

, 9 increased mortality
,
-one presently recommended


4nticoagulants

2J5

=M* he&arin

5irudin


2J5

4ctiates antithrombin III

-
Inacties thrombin F"6G( ">a and "<0a

Molecular !eight' 8 000 to /0 000 D

Binds to arious &roteins( cells ( endothelium

2n&redictable.
-
*eight adPusted dosage
Incr need in DM and smo:ing( lo!er !ith age
,
Therou= et al' - $ngl 2 Med
34>>!634:33?733'

M. rate of 39@ down to ?'>@ in /)

=M* he&arin

Molecular !eight o" 4600 to 7000 D

Jactor Ka to thrombin inhibition ratio o"

<.> to /.B

@nly 68#801 hae M<B saccharides

-
both "6 and <0 inhibition
-
Rest inhibits only "actor Ka




=M* he&arin' C better
































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4lso,

%an only reerse about 701 o" anticoagulation

!ith &rotamine

Increase rate o" minor bleeding F>.<1 s 6.81G

%annot monitor 4%T during $%I( needs to sto&

<6 hours &re %4BG.

Not "or renal "ailure &atients FGJRN/0cc3minG

Decreased incidence o" 5IT.

M<00:g' CmaIimum o" dosing s study dosing

-
EnoIa&arin <00mg sc bid s !eight all the !ay as in
TIMI <<B


But going to cath lab,

Start 2J5 !ithout bolus 7 hours a"ter last

dose.

I" go to cath lab( consider &t "ully

anticoagulated !hen giing he&arin
boluses - unable to monitor.

I" on 2J5( !ait < hour then gie =M*

he&arin dose.




































5irudin

Direct thrombin inhibtor.

Jor &atients !ith 5IT or history o".

Binds directly to catalytic site o" thrombin

!ithout going through antithrombin III

TIMI 9' better than 4S4 alone in 24,

Mild im&roement com&ared to 2J5 but

increase in bleeding( no bene"it in STEMI.

Meta#analysis sho!s @R o" 0.>0

$latelet G$ IIb3IIIa Rece&tor 4ntagonists

4ctiation o" &latelets leads to

con"igurational change increasing a""inity
"or "ibrin and other ligands

Necessary "inal ste& to &latelets

aggregation.

Needs B01 bloc:ade to achiee &otent

antithrombotic e""ects




6# IIb!IIIa Rece7tor Antagonists3
,
)bci=imab (reopro): non-specific binding

/nclear significance
,
$ptifibatide (integrilin)( tirofiban
(aggrastat): "ery specific binding achie"e
A>?@ within 7 minutes
,
1ifferent antagonists can bind at different
sites and can parado=ically acti"ates the
%;..b*...a receptor

Bwhat is happening with the oral form'

6# IIb!IIIa Rece7tor Antagonists

4 main studies

6 &osities

5igh#ris: "eatures

<<.91 s B.91(

<8.91 s <4.61




Numbers,

$RISM';latelet Ceceptor .nhibition in

.schemic &yndrome Management'

heparin (non-weight based) "s tiroban D 8>hrs

$C% changes or en:ymes or "ery strong
h= of C)1
Composite end-point better at 8>hr but
only trend at 6? days'
M.*death: non-significant at 8> hrs but E
at 6? days (6'5 "s 9'6@)'
B;laying*fishing for numbers


$RISM' =ancet <>>>

;ig(re ,: )d<(sted hazard ratios *012
58/ for treatment with tirofi4an 4y
troponin 8 '(artiles

;ig(re #: =vent-rate c(rves
*mortality% myocardial
infarction/ for $.-day follow-
(p for patients with > troponin
8


Numbers,
,
;rism-plus: ;latelet Ceceptor .nhibition in
.schemic &yndrome Management in
;atients Fimited by /nstable &igns and
&ymptoms
,
T+$ study
,
&T changes or E en:ymes
,
Tiroban alone dropped due to too much
mortality

8'5@ "s 3'3 and 3'7@BBB (remember ;C.&M

study)
,
)t G days( composite end-point: 3G'4@ "s
39'4@
,
99@ C$; reduction at 6? days (absolute
6'>@)
,
34@ C$; reduction at 5 months (absolute
8'8@)
































F
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+


Numbers,
,
;/C&/.T: $ptifibatide

;latelet %lycoprotein ..b*...a in /nstable

)ngina:Ceceptor &uppression /sing .ntegrilin
Therapy'

33 ??? pts

E $C% changes or en:ymes rise

,
1eath or M. at 6? days: 37'G@ "s 38'9@

4'3@ "s G'5@ at 8 days

33'5@ "s 3?'3@ at G days

MaHor bleed increased by 3'7@

,
Cath rate o"erall: 5?@


Real NumbersO

G2ST@ I.'=ancet Dune 600<

4bciIimab' 9B00 &ts !ithout $%I

Same mortality at /0 days' B#>1

-
Des&ite all sorts o" subgrou& analysis,


4ntithrombotics'
<( 6 or / agentsCCC
=





%ardiogenic shoc:, B4DOOO
,
Circulation 3444: %/&T< ..b
,
9?? pts with -&T$M. and shock

.ncidence of 9'7@
,
G6@ mortality
,
But median time to shock G5 hrsI

4'5 hrs in &T$M.

=ast !ords'

Dournal o" Emergency Medicine

@ctober 6000'
-
QThe e""ect o" early ED treatment !ith
G$IIb3IIIa inhibitors has neer been "ormally
studied until no!R.
-
E4R=S trial !ill com&are early ED( s late
%%2 s catheteriHation laboratory


TIMI score
,
2)M)( )ugust 35( 9???
,
1atabases of $&&$-C$ and T.M.33B
,
39 "ariables( G significants

)ge A 57yo

6 risk factors for C)1

;rior coronary stenosis of A 7?@

&t de"iation

&e"ere angina symptoms

)&) use within G days

$le"ated serum cardiac markers

-ig%re *3 TIMI Ris8 Score

Rates o" all#cause mortality( myocardial in"arction( and seere recurrent ischemia &rom&ting urgent
reasculariHation through <4 days a"ter randomiHation !ere calculated "or arious &atient subgrou&s based on
the number o" ris: "actors &resent in the test cohort Fthe un"ractionated he&arin grou& in the Thrombolysis in
Myocardial In"arction TTIMIU <<B trialL n E <>89G Fsee Table <G. Eent rates increased signi"icantly as the TIMI ris:
score increased FPN.00< by
6
"or trendG.

G$ IIb3IIIa inh "or score 8 or aboeCCC

-ig%re 13 0alidation o TIMI Ris8 Score and Assess/ent o Treat/ent Eect According to Score

Rates o" all#cause mortality( myocardial in"arction( and seere recurrent ischemia &rom&ting urgent reasculariHation through <4 days
a"ter randomiHation !ere calculated "or the enoIa&arin and un"ractionated he&arin grou&s in the Thrombolysis in Myocardial In"arction
FTIMIG <<B trial and the E""icacy and Sa"ety o" Subcutaneous EnoIa&arin in 2nstable 4ngina and Non#V#*ae MI trial FESSEN%EG(
based on the TIMI ris: score. The &attern o" increasing eent rates !ith increasing TIMI ris: score !as con"irmed in all / alidation
cohorts FPN.00< by
6
"or trendG. % statistics !ere 0.78 "or the un"ractionated he&arin grou& and 0.7< "or the enoIa&arin grou& in TIMI
<<BL and 0.78 "or the un"ractionated he&arin grou& and 0.8> "or the enoIa&arin grou& in ESSEN%E. The rate o" increase in eents as
more ris: "actors !ere &resent !as signi"icantly lo!er in the enoIa&arin grou& in both studies F"or TIMI <<B( P E .0<L "or ESSEN%E( P E .
0/G. $ositie alues "or absolute ris: di""erence F4RDG and number needed to treat to &reent < eent FNNTG indicate calculations "aoring
enoIa&arin( !hile negatie alues indicate calculations "aoring un"ractionated he&arin.


4s Dr. =ang !ould said,

4uto#alidation on its o!n cohort

Retros&ectie

S&eci"ic Fbut largeG grou&

That !ould ma:e it a leel,4 i" !e !ant to use

it as a %linical decision rule to :no! !hether or
not to use G$ IIb3IIIa inhibitors.


TIMI Ris8 Calc%lator -or
Unstable Angina
In t.e bl%e col%/n2 7lease enter t.e 7atient9s
age2 and t.en answer eac. clinical :%estion
wit. a Y ;or yes< or an N ;or no<3 T.e 7atient9s
ris8 a77ears at t.e botto/ o t.e bl%e col%/n3
TIMI Ris8 Score or UA!NSTEMI Entry Score
4ge <
5istory o" 5y&ertension FS or NG 0
5istory o" Diabetes FS or NG 0
%urrent Smo:er FS or NG 0
5y&ercholesterolemia FS or NG 0
Jamily history o" %oronary 4rtery Disease FS or NG 0
$rior angiogra&hic stenosis M801 FS or NG 0
Seere anginal sym&toms FME 6 e&isodes rest &ain in &ast 64 hrsG FS or NG 0
2se o" as&irin !ithin the last 9 days FS or NG 0
Eleated cardiac mar:ers Feither %AMB or cardiac tro&oninG FS or NG 0
ST deiation FhoriHontal ST de&ression or transient ST eleation ME < mmG FS or NG 0
Total Ris8 Score ;'5=< *
Ris8 o Deat.!MI!Urgent Revasc%lari>ation by *) Days ;?< 4.901


%ost WWWW

Tiroban' >80W3/ days

4bciIimab' 6000W3treatment
-
But ho! come !e are almost neer using
stre&to:inase anymore, are !e
reasonableCCC


*hat about'
$laiI s G$ IIb3IIIaC
<B.B1 s <7.81
<9.> s <6.>1
D2ST a thought ,


But bac: to standard o" care,
The classics' 5o! do !e doC

In#hos&ital drugs treatment F1G( <>>B

2S4 %anada *orld
Intraenous he&arin 9> BB 9/
4s&irin >< >6 >6
B#bloc:ers 89 9/ 7/
%alcium antagonists 8> 8/ 8/
Intraenous nitrates 7B 40 8<


4ngio' stat or later

T4%TI%S' N Engl D Med 600<L /44'<B9>#<BB9( Dun

6<( 600<
6660 &atients( !ithin 4B hours s selectiely
all got 4S4( he&arin( G$IIb3IIIa inh
<8.>1 s <>.41 at 7 months
71 more %4BG( 860 eItra caths3<<00 &ts
MI' 4.B1 s 7.>1

$re G$IIb3IIIa inhibitors' TIMI/b F<>>8G

Early <B.<1 s <7.61 late

Decr length o" stay
,
J)-#K.&+ .n"estigators: 49? pts
Early 9.B1 s /./1 late at hos&ital discharge


More does not e?ual better

=ancet <>>BL /86' 809-<4

B 000 &ts( arious countries FBraHil( 2S4(

%anada( 4ustralia( 5ungary( $olandG
-
8>1 s 6<1 angio rate
-
Same oerall MI3death rate' 4.91 at 9 days

=ate angio' decreased rate o" oerall

cardioascular eent Fincluding stro:eG des&ite
higher recurrent angina


*hat do !e "ind any!ay on
angio,
,
Typically shows the following profile:

3) no se"ere epicardial stenosis in 3?@

to 9?@

9) 3-"essel stenosis in 6?@ to 67@

6) multi"essel stenosis in 8?@ to 7?@

8) significant ('7?@) left main stenosis

in 8@ to 3?@'


NeIt' early statinCCCOOO,

Myocardial Isc.e/ia Red%ction wit. Aggressive

C.olesterol 4owering ;MIRAC4<

D4M4 4&ril 600<

6000 &ts
4torastatin B0mg3d bet!een 64 and >7hrs o"
admission.

<9.41 s <4.B1 at 4 months( mostly recurrent

sym&tomatic ischemia re?uiring rehos&italiHation.


Ris: strati"ication
Noninvasive stress testing in low-risk
patients who have been free of ischemia
at rest or with low-level activity and of
CHF for a minimum of 1 to ! h" (Level
of Evidence: C)




Ris: strati"ication

#tress test only if free of$

%
#&-segment abnormalities
%
bundle-branch block
%
'( hypertrophy
%
)ntraventricular conduction defect
%
*aced rhythm
%
*ree+citation
%
,igo+in effect"
-therwise need imaging$ echo or
thallium.


S&ecial grou&s

*omen' more aty&ical sym&toms

-
Cbetter outcome in 24 then men

Elderly' More disease

Diabetics' Increased ris: "or any 4%S

$ost#%4BG' lo! threshold angio

4ll same &rotocols and numbers,

%ocaine users

%oronary asos&asms
-
*orsen by minimal atherosclerosis
-
Reersed by %%B
-
ST#changes in /B1 o" &ts in detoI centers

DetoIi"y by cholinesterase in lier and &lasma

-
=ess aailable in in"ants or elderly

Increased &latelets sensibility

Decrease antithrombin III and &rotein %

%ocaine users as &er 454

NTG and %%B "or ST changes

4ngio i" &ersistent ST eleation or i"

thrombus "ound
-
Thrombolysis i" not aailable

B#bloc:ers i" sB& M <80 or 5R M <00

-
=abetolol &re"erred


B#bloc:ers "or cocaine
usersCCC
Annals o" Internal Medicine. Dun <>>0
/0 olunteers

In cath lab

%ocaine "ollo!ed by &ro&ranolol

No change in 5r or B$ but'
-
801 incr in coronary resistance !ith 601 decr in "lo!
No mention o" benHosCCCCCCC


%onclusion

Tro&onemia is a bad sign.

=ots o" studies3numbers out there

Strati"ication is &robably the !ay to go to

target selected &o&ulation but can !e
rely on &resent eidences,


VuestionsC