执业医师心梗图片

我是30号题第一站防护服的穿脱二氧化碳采样，选择仪器，怎样操作首先选择消毒剂，配一个2%浓度的消毒剂，怎么配第二站临床操作锁骨上淋巴结检查肝脏触摸（单手）胸外按压术（都要说的细点）第三站亚硝酸盐中毒，病人的救治原则毛巾微生物采样空气中氨的采样

谁有51号题

2017年执业医师考试知识点：循环系统 　　执业医师应当具备良好的职业道德和医疗执业水平，发扬人道主义精神，履行防病治病、救死扶伤、保护人民健康的神圣职责。全社会应当尊重医师。医师依法履行职责，受法律保护。下面是我为大家带来的执业医师考试循环系统的知识点。欢迎阅读。　　第一节 心力衰竭　　一、基本知识 　　(一)心力衰竭的基本病因及诱因 　　1、基本病因：记忆：前夫(前负荷)，后夫(后负荷)，不给力(心肌收缩力减弱)。 　　(1)心肌收缩力减弱：冠心病最为常见 　　(2)后负荷(压力负荷)增加：动脉压力增高。如高血压(体循环高血压)、主动脉瓣狭窄(左心室后负荷)、肺动脉高压和肺动脉瓣狭窄(右心室后负荷) 　　记忆：后夫(后负荷)提(高血压)刀宰(狭窄)肥(肺动脉高压)羊 　　后负荷的原因：动脉压力增高。记忆：落后了就有压力了。就是狭窄+压力增加。 　　(3)前负荷(容量负荷)增加： 　　1)心脏瓣膜关闭不全如二尖瓣关闭不全，主动脉瓣关闭不全 　　2)左，右心或者动静脉分流性先心病如间隔缺损，动脉导管未闭，动静脉瘘等。 　　3)伴有全身血容量增多或者循环血容量增多的疾病如慢性贫血，甲亢等。心脏的容量 　　负荷也必然增加。 　　记忆：关(关闭不全)心(先心病)前夫(前负荷)评(贫血)价(甲亢) 　　2诱因：感染、心律失常和治疗不当依次是心力衰竭最主要的诱因。呼吸道感染是最常见，最重要的诱因。 　　3、发病的基本机制：心室重构。记忆：新室重构 　　(二)心功能分级 　　1、Killip分级(急性心梗用)： 　　Ⅰ级：无肺部啰音和第三心音; 　　Ⅱ级：肺部啰音<12肺野;有左心衰竭 　　Ⅲ级：肺部啰音>12(急性肺水肿); 　　Ⅳ级：心源性休克(血压小于9060mmHg) 　　Killip分级记忆：1无2啰半;3肿4休克; 　　2、用NYHA分级(非急性心梗)：没有心梗或者不是急性的就是NO心梗，为NYHA。 　　Ⅰ级：患者有心脏病，但体力活动不受限制。一般体力活动不引起过度疲劳、心悸、气喘或心绞痛。 　　【爬楼能爬顶楼】 　　Ⅱ级(心衰Ⅰ度)：患者有心脏病，以致体力活动轻度受限制。休息时无症状，一般体力活动(每天日常活动)引起过度疲劳、心悸、气喘或心绞痛。 【爬楼梯到3楼】 　　Ⅲ级(心衰Ⅱ度)：患者有心脏病，以致体力活动明显受限制。休息时无症状，但小于一般体力活动，或从事一般家务活动即可引起过度疲劳、心悸、气喘或心绞痛。 【爬楼梯到2楼】 　　Ⅳ级(心衰Ⅲ度)：患者有心脏病，休息时也有心功能不全或心绞痛症状，进行任何体力活动均使不适增加。 【在底楼喘气】 　　NYHA分级记忆：一无二轻三明显;四级不动也困难(不能平卧) 　　注意：心梗的临床表现：最早出现疼痛。必须有这个症状。 　　二、慢性心力衰竭 　　(一)临床表现 　　1、左心衰： 　　症状：主要为肺淤血的表现。 　　临床表现： 　　1)呼吸困难：表现为劳力性呼吸困难、夜间阵发性呼吸困难(心源性哮喘)和端坐呼吸，严重时可出现急性肺水肿。劳力性呼吸困难可为首发症状(最早出现)。随着病情的发展演化成夜间阵发性呼吸困难(心源性哮喘)。 　　2)咳嗽可粉红色泡沫痰(或者白色泡沫痰) 　　3) 两肺底湿啰音和喘鸣音;两肺底常可闻及湿啰音(中小水泡音)和喘鸣音。心脏听诊可闻及肺动脉第二心音亢进，舒张期S3奔马律(心衰特有体征之一) 　　心源性哮喘(也叫夜间阵发性呼吸困难)有高血压史，禁用肾上腺素;支气管哮喘无高血压史，禁用吗啡(抑制呼吸);氨茶碱两者都可用。 　　2、右心衰： 　　(1)症状：体循环淤血。食欲不振、恶心、呕吐、腹胀、腹痛和尿少、夜尿增多等。 　　(2)体征：肝颈静脉回流征阳性，颈静脉充盈或怒张;下垂性对称性水肿(双下肢)，右心奔马律(胸骨左缘第3、4肋间闻及舒张期奔马律)。 　　右心衰引起淤血的主要器官;肝，脾，胃肠道。 　　左心衰的病人一般有高血压病史，因为体循环高压。 　　高血压+劳力性呼吸困难=左心衰 　　左心衰+右心衰=全心衰 　　3、全心衰： 　　左、右心衰的临表同时存在可考虑全心衰。继发于左心衰而形成的全心衰，当右心衰出现后，左心衰肺淤血的症状反较单纯性左心衰时减轻。 　　(二)诊断：心衰诊断首选超声心动图，用于心室的收缩和舒张。 　　1、收缩功能：评价心脏收缩功能的主要指标是射血分数(EF)正常左室射血分数(LVEF)>50%，运动时至少增加5%;右心室射血分数(RVEF)应>40%; 　　2、舒张功能：评价心脏舒张功能的主要指标是EA【记忆：恩爱(EA)舒服(舒张功能)】，心动周期中舒张早期心室充盈速度最大值为E峰，舒张晚期(心房收缩)心室充盈最大值为A峰，正常时EA>2。 【E早A晚】 　　3、血浆脑利钠肽(BNP)测定：有助于心衰诊断和预后判断，对未经治疗的患者，如其水平正常，则可排除心力衰竭的诊断。 　　4、心衰时，心室壁张力增加，心室肌内不仅BNP分泌增加，ANP的'分泌也明显增加，使血浆中ANP及BNP水平升高，其增高的程度与心衰的严重程度呈正相关。为此，血浆ANP及BNP水平可作为评定心衰的进程和判断预后的指标。 　　(三)治疗 　　1、首先控制感染。 　　2、药物治疗 　　(1)利尿剂：1、噻嗪类：痛风患者和高血糖患者禁用(因其可引起高尿酸血症和高血糖等)。2、速尿：降低有效循环血量，减轻前负荷。3、螺内酯(安体舒通)：高钾禁用。 　　(2)血管扩张剂： 　　1)硝普钠：同时扩张动脉和静脉，降低心室的前、后负荷。主要用于以心排出量降低、左心室充盈压和体循环阻力增高为特征的晚期心力衰竭患者。起始剂量3ug(Kin)，最大不超过10 ug(Kin)。最常见的副作用是低血压。 　　2)硝酸酯类(硝酸甘油)：主要扩张静脉和肺小动脉。降低前负荷 。初始滴速为10 ugmin。 　　3)酚妥拉明：主要扩张动脉，降低后负荷 　　4)ACEI(普利家族)： 　　所有慢性收缩性心衰患者都必须使用ACEI，且需要终身使用。 　　低血压、双肾动脉狭窄、无尿性肾衰竭(血肌酐>225umolL)、血钾>5mmolL、妊娠哺乳期妇女禁用。(肾衰，肾窄，高钾，低压，孕妇)两肾一高低+孕妇 　　ACEI类适用：1、心衰伴有高血糖; 　　2、逆转心肌肥厚(左心室); 　　3、慢性收缩性心衰患者。 　　5)血管紧张素Ⅱ受体拮抗剂(ARB)：一般不引起咳嗽，可用于不能耐受ACEI的患者，替代ACEI治疗。 　　?对于那些依赖升高的左室充盈压来维持心排血量的阻塞性心瓣膜病，如二尖瓣狭窄、主动脉瓣狭窄及左心室流出道梗阻的患者不宜应用强效血管扩张剂。 　　(3)洋地黄类(正性肌力药) 　　心衰+房颤——洋地黄(西地兰);心衰+伴心脏扩大——洋地黄(西地兰) 　　a、※※禁忌症： 　　①预激合并房颤; 　　②二度或高度房室传导阻滞; 　　③病窦; 　　④单纯性舒张性 如肥厚型心肌病; 　　⑤单纯性重度二尖瓣狭窄伴窦性心律而无右心衰的患者; 　　⑥急性心梗24小时内，除非合并房颤或(和)心腔扩大; 　　⑦洋地黄中毒或过敏时; 　　⑧血钾低于5mmolL;⑨心率低于60次分。 　　肥厚肺心二尖窄，急性心梗伴心衰，二度高度房室阻， 　　预激病窦不应该，低钾缓率也不该。 　　b、1、洋地黄中毒------特征性表现：快速性心律失常+伴有房室传导阻滞。 　　2、洋地黄中毒最常见----心律失常(室性期前收缩(室早二联率)常见) 　　c、ECG见鱼钩样改变只说明患者使用过洋地黄类制剂，不能认为中毒。 　　d、洋地黄的毒性反应：胃肠道反应(厌食是最早的表现);心电图(快速房性心律失常伴传导阻滞，此外有ST-T改变鱼钩样改变);中枢神经系统症状(黄视，绿视) 　　e、中毒处理： 　　①立即停用; 　　②快速心律失常者，血钾不低用利多卡因(室性心动过速适用)或苯妥英钠(阵发性室速适用)，血钾低者用静脉补钾; 　　③严禁使用电复律，因易导致心室颤动; 　　④有房室传导阻滞、缓慢心律失常者可用阿托品，一般不需要安置临时心脏起搏器。 　　(4)其他正性肌力药物: 　　1)多巴酚丁胺：增加室性心律失常和死亡率。 　　2)米力农：有增加心脏猝死的可能性，不宜长期用于心衰的治疗。 　　3)钙增敏剂 　　(5)β阻滞剂：临床常用美托洛尔等 　　①目前认为其治疗心衰的机制为：降低心脏的交感神经张力、延长舒张期、上调β-肾上腺素能受体。 　　②副作用：1、心肌抑制，心力衰竭恶化; 　　2、诱发哮喘和外周血管收缩。 　　③禁忌症：支气管哮喘、心动过缓、二度及二度以上房阻。 　　三、顽固性心衰的定义及对策 　　1、定义：顽固性心衰又称难治性心衰，是指尽管经ACEI合(或)其他血管扩张剂，以及利尿剂和洋地黄系统治疗，症状仍不能缓解。 　　2、顽固性心衰处置的第一步是努力寻找导致顽固性心衰的可能病因，并设法纠正。 　　三、急性心力衰竭----广泛前壁心肌梗死最常见 　　1、临表：咳粉红色泡沫痰(左心衰)，两肺可闻干啰音、喘鸣音、细湿啰音。 　　2、急性左心衰抢救措施： 　　(1)患者取坐位，双腿下垂，以减少静脉回流。 　　(2)高流量吸氧(10~20mlmin纯氧吸入)。 　　(3)吗啡3~5mg静注，仍是治疗急性肺水肿的极为有效的措施;但对伴有颅内出血、神志障碍、慢性肺功能不全者，属禁忌。 　　(4)呋塞米20~40mg静注，于2分钟内推完，也是主要方法。 　　(5)应用血管扩张剂，选用硝普钠(高血压引起的急性左心衰首选硝普钠)，如有低血压，宜与多巴酚丁胺合用。 　　(6)西地兰：心衰加房颤——洋地黄(西地兰);心衰加伴有心脏扩大的——洋地黄(西地兰),急性心梗24小时内禁用洋地黄。 　　(7)氨茶碱25g静滴，缓解支气管痉挛等。 　　3、ACEI的药物(普利)不能用于急性左心衰时的抢救。 　　端坐吸氧腿下垂，强心利尿打吗啡，血管扩张硝普钠。;

General TreatmentMonitoring, O2 Bed rest initially, with early ambulationLow-salt, low-fat dietStool softeners, anxiolytics as neededDrugsAspirin Some Trade Names BUFFERINECOTRINGENACOTEClick for Drug Monograph , clopidogrel Some Trade Names PLAVIXClick for Drug Monograph , or bothβ-BlockerGlycoprotein IIbIIIa inhibitor for patients undergoing PCI and for those at high risk (eg, with markedly elevated cardiac markers, TIMI risk score ≥ 4, persistent symptoms)A heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph (unfractionated or low mol wt heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph )IV nitroglycerin Some Trade Names NITRO-BIDNITRO-DURNITROLNITROQUICKClick for Drug Monograph (unless low-risk, uncomplicated MI)Fibrinolytics for select patients with STEMI when timely PCI unavailableACE inhibitor (as early as possible) and statinAntiplatelet and antithrombotic drugs, which stop clots from forming, are usedAnti-ischemic drugs (eg, β-blockers, IV nitroglycerin Some Trade Names NITRO-BIDNITRO-DURNITROLNITROQUICKClick for Drug Monograph ) are frequently added, particularly when chest pain or hypertension is present (see Table 3: Coronary Artery Disease: Drugs for Coronary Artery Disease ) Fibrinolytics should be used if not contraindicated for STEMI if primary PCI is not immediately available but worsen outcome for unstable angina and NSTEMIChest pain can be treated with morphine Some Trade Names DURAMORPHMS CONTINMSIRROXANOLClick for Drug Monograph or nitroglycerin Some Trade Names NITRO-BIDNITRO-DURNITROLNITROQUICKClick for Drug MonographMorphine Some Trade Names DURAMORPHMS CONTINMSIRROXANOLClick for Drug Monograph 2 to 4 mg IV, repeated q 15 min as needed, is highly effective but can depress respiration, can reduce myocardial contractility, and is a potent venousHypotension and bradycardia secondary to morphine Some Trade Names DURAMORPHMS CONTINMSIRROXANOLClick for Drug Monograph can usually be overcome by prompt elevation of the lowerNitroglycerin Some Trade Names NITRO-BIDNITRO-DURNITROLNITROQUICKClick for Drug Monograph is initially given sublingually, followed by continuous IV drip if BP is normal or slightly elevated in most patients on arrival at the emergency department; BP gradually falls over the next severalContinued hypertension requires treatment with antihypertensives, preferably IV nitroglycerin Some Trade Names NITRO-BIDNITRO-DURNITROLNITROQUICKClick for Drug Monograph , to lower BP and reduce cardiacSevere hypotension or other signs of shock are ominous and must be treated aggressively with IV fluids and sometimes vasopressors (see Shock and Fluid Resuscitation: Prognosis and Treatment)Antiplatelet drugs: Aspirin Some Trade Names BUFFERINECOTRINGENACOTEClick for Drug Monograph , clopidogrel Some Trade Names PLAVIXClick for Drug Monograph , ticlopidine Some Trade Names TICLIDClick for Drug Monograph , and glycoprotein (GP) IIbIIIa inhibitors areAll patients are given aspirin Some Trade Names BUFFERINECOTRINGENACOTEClick for Drug Monograph 160 to 325 mg (not enteric-coated), if not contraindicated, at presentation and 81 mg onceday indefinitelyChewing the first dose before swallowing quickensAspirin Some Trade Names BUFFERINECOTRINGENACOTEClick for Drug Monograph reduces short- and long-term mortalityIf aspirin Some Trade Names BUFFERINECOTRINGENACOTEClick for Drug Monograph cannot be taken, clopidogrel Some Trade Names PLAVIXClick for Drug Monograph 75 mg onceday or ticlopidine Some Trade Names TICLIDClick for Drug Monograph 250 mg bid may beClopidogrel Some Trade Names PLAVIXClick for Drug Monograph has largely replaced ticlopidine Some Trade Names TICLIDClick for Drug Monograph for routine use because neutropenia is a risk with ticlopidine Some Trade Names TICLIDClick for Drug Monograph and WBC must be monitoredPatients with unstable angina or NSTEMI in whom intervention is not possible or recommended are given both aspirin Some Trade Names BUFFERINECOTRINGENACOTEClick for Drug Monograph and clopidogrel Some Trade Names PLAVIXClick for Drug Monograph for at least 1The optimal duration of double antiplatelet therapy for these patients is the subject of ongoing In patients undergoing PCI, a clopidogrel Some Trade Names PLAVIXClick for Drug Monograph loading dose (300 to 600 mg po once) improves outcomes, particularly when administered 24 h inHowever, delaying PCI for 24 h is not appropriate for manyFurther, such a loading dose increases risk of perioperative bleeding in patients who require coronary artery bypass grafting (CABG) because their coronary anatomy proves unfavorable for PCI Thus, many clinicians administer a clopidogrel Some Trade Names PLAVIXClick for Drug Monograph loading dose only in the catheterization laboratory once coronary anatomy and lesions have been proven to be amenable to PCIFor patients receiving a stent for revascularization, aspirin Some Trade Names BUFFERINECOTRINGENACOTEClick for Drug Monograph is continued indefinitely, and clopidogrel Some Trade Names PLAVIXClick for Drug Monograph should be used for at least 1 mo in patients with a bare-metalPatients with a drug-eluting stent have a prolonged risk of thrombosis and may benefit from 12 mo of clopidogrel Some Trade Names PLAVIXClick for Drug Monograph treatment, although the recommended duration is still GP IIbIIIa inhibitors ( abciximab Some Trade Names REOPROClick for Drug Monograph , tirofiban Some Trade Names AGGRASTATClick for Drug Monograph , eptifibatide Some Trade Names INTEGRILINClick for Drug Monograph ) are potent antiplatelet drugs that must be given IV Patients undergoing PCI should receive a GP IIbIIIa inhibitor; results appear to be better if the drug is initiated at least 6 h before PCI and continued for 18 to 24 hIf PCI is not being done, a GP IIbIIIa inhibitor is given to all high-risk patients (eg, those with markedly elevated cardiac markers, a TIMI risk score ≥ 4, or persistent symptoms despite adequate drug therapy) The GP IIbIIIa inhibitor is continued for 24 to 36 h, and angiography is done before the infusion period isRoutine use of GP IIbIIIa inhibitors with fibrinolytics is not recommended at thisAlthough abciximab Some Trade Names REOPROClick for Drug Monograph is the drug recommended in most published guidelines, eptifibatide Some Trade Names INTEGRILINClick for Drug Monograph is cheaper and is thought to have comparable efficacy and is thus oftenStudies continue to investigate the comparative efficacy of the different GP IIbIIIa Anticoagulant drugs: Either a low mol wt heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph (LMWH) or unfractionated heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph is given routinely to patients with ACS unless contraindicated (eg, by active bleeding or planned use of streptokinase Some Trade Names STREPTASEor anistreplase) Choice of agent is somewhat Unfractionated heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph is more complicated to use because it requires frequent (q 6 h) dosing adjustments to achieve an activated PTT (aPTT) 5 to 2 times the controlIn those undergoing angiography, further dosing adjustment is performed to achieve an activated clotting time (ACT) of 200 to 250 sec if the patient is treated with a GP IIbIIIa inhibitor and 250 to 300 sec if a GP IIbIIIa inhibitor is not beingHowever, the effects of unfractionated heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph are shorter and can be reversed (with prompt discontinuation of heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph infusion and with administration of protamine sulfate Some Trade Names No US trade nameClick for Drug Monograph ) if bleeding develops following The LMWHs have better bioavailability, are given by simple weight-based dose without monitoring aPTT and dose titration, and have lower risk of heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph -inducedThey also may produce an incremental benefit in outcomes relative to unfractionated in patients with ACS Of the LMWHs, enoxaparin Some Trade Names LOVENOXClick for Drug Monograph appears to be superior to dalteparin Some Trade Names FRAGMINClick for Drug Monograph or nadroparin Some Trade Names No US trade nameClick for Drug MonographHowever, enoxaparin Some Trade Names LOVENOXClick for Drug Monograph may pose a higher bleeding risk in patients with STEMI who are > 75, and its effects are not completely reversible with Thus, taking all into account, many published guidelines recommend LMWH (eg, enoxaparin Some Trade Names LOVENOXClick for Drug Monograph ) over unfractionated heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph in patients with unstable angina or NSTEMI and in patients < 75 with STEMI who are not undergoing PCI By contrast, unfractionated heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph is recommended when emergency PCI is performed (eg, patients with acute STEMI who proceed to the catheterization laboratory), when CABG is indicated within the next 24 h, and in patients at high risk for bleeding complications (eg, history of GI bleeding within the last 6 mo) or with creatinine clearance < 30 mL Ongoing studies should help clarify the choice between LMWH and unfractionated heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph For those undergoing PCI, post-procedure heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph is no longer recommended unless patients are at high risk of thromboembolic events (eg, those with large anterior MI, known LV thrombus, atrial fibrillation), as post-procedure ischemic events have decreased with the use of stents and antiplateletFor those not undergoing PCI, heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph is continued for 48 h (or longer if symptoms persist)The difficulties with the heparins (including bleeding complications, the possibility of heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph -induced thrombocytopenia, and, with unfractionated heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph , the need for dosing adjustments) have led to the search for betterThe direct thrombin inhibitors, bivalirudin Some Trade Names ANGIOMAXClick for Drug Monograph and argatroban Some Trade Names No US trade nameClick for Drug Monograph , may have a lower incidence of major bleeding and improved outcomes, particularly in patients with renal insufficiency (hirudin, another direct thrombin inhibitor, appears to cause more bleeding than the other drugs) The factor Xa inhibitor, fondaparinux Some Trade Names ARIXTRAClick for Drug Monograph , reduces mortality and reinfarction in patients with NSTEMI who undergo PCI without increasing bleeding but may result in worse outcomes than unfractionated heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph in patients with STEMI Although routine use of these alternative anticoagulants is thus not currently recommended, they should be used in place of unfractionated heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph or LMWH in patients with a known or suspected history of heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph -induced Patients at high risk of systemic emboli also require long-term therapy with oral warfarin Some Trade Names COUMADINClick for Drug MonographConversion to warfarin Some Trade Names COUMADINClick for Drug Monograph should begin 48 h after symptom resolution or PCIβ-Blockers: These drugs are recommended unless contraindicated (eg, by bradycardia, heart block, hypotension, or asthma), especially for high-riskβ-Blockers reduce heart rate, arterial pressure, and contractility, thereby reducing cardiac workload and O2IV β-blockers given within the first few hours improve prognosis by reducing infarct size, recurrence rate, incidence of ventricular fibrillation, and mortalityInfarct size largely determines cardiac performance after Heart rate and BP must be carefully monitored during treatment with β- Dosage is reduced if bradycardia or hypotensionExcessive adverse effects may be reversed by infusion of the β-adrenergic agonist isoproterenol Some Trade Names ISUPRELClick for Drug Monograph 1 to 5 μgNitrates: A short-acting nitrate, nitroglycerin Some Trade Names NITRO-BIDNITRO-DURNITROLNITROQUICKClick for Drug Monograph , is used to reduce cardiac workload in selectedNitroglycerin Some Trade Names NITRO-BIDNITRO-DURNITROLNITROQUICKClick for Drug Monograph dilates veins, arteries, and arterioles, reducing LV preload andAs a result, myocardial O2 demand is reduced, lesseningIV nitroglycerin Some Trade Names NITRO-BIDNITRO-DURNITROLNITROQUICKClick for Drug Monograph is recommended during the first 24 to 48 h for patients with heart failure, large anterior MI, persistent chest discomfort, orBP can be reduced by 10 to 20 mm Hg but not to < 80 to 90 mm HgLonger use may benefit patients with recurrent chest pain or persistent pulmonaryIn high-risk patients, nitroglycerin Some Trade Names NITRO-BIDNITRO-DURNITROLNITROQUICKClick for Drug Monograph given in the first few hours reduces infarct size and short-term and possibly long-term mortalityNitroglycerin Some Trade Names NITRO-BIDNITRO-DURNITROLNITROQUICKClick for Drug Monograph is not routinely given to low-risk patients with uncomplicated MIFibrinolytics: Tenecteplase Some Trade Names TNKASEClick for Drug Monograph (TNK), alteplase Some Trade Names ACTIVASEClick for Drug Monograph (rTPA), reteplase Some Trade Names RETAVASEClick for Drug Monograph (rPA), streptokinase Some Trade Names STREPTASE, and anistreplase (anisoylated plasminogen activator complex—APSAC), all given IV, are plasminogenThey convert single chain plasminogen to double chain plasminogen, which has fibrinolyticThey have different characteristics and dosing regimens (see Table 7: Coronary Artery Disease: IV Fibrinolytic Drugs Available in the US) and are appropriate only for selected patients with STEMI (see below)Tenecteplase Some Trade Names TNKASEClick for Drug Monograph and reteplase Some Trade Names RETAVASEClick for Drug Monograph are recommended most often because of their simplicity of administration; tenecteplase Some Trade Names TNKASEClick for Drug Monograph is given as a single bolus over 5 sec and reteplase Some Trade Names RETAVASEClick for Drug Monograph as a double bolus 30 minAdministration time and drug errors are reduced compared with otherTenecteplase Some Trade Names TNKASEClick for Drug Monograph , like alteplase Some Trade Names ACTIVASEClick for Drug Monograph , has an intermediate risk of intracranial hemorrhage, has a higher rate of recanalization than other fibrinolytics, and isReteplase Some Trade Names RETAVASEClick for Drug Monograph has the highest risk of intracranial hemorrhage and a recanalization rate similar to that of tenecteplase Some Trade Names TNKASEClick for Drug Monograph , and it is Streptokinase Some Trade Names STREPTASEmay induce allergic reactions, especially if it has been used previously, and must be given by infusion over 30 to 60 min; however, it has a low incidence of intracerebral hemorrhage and is relativelyAnistreplase, related to streptokinase Some Trade Names STREPTASE, is similarly allergenic and slightly more expensive but can be given as a singleNeither requires concomitant heparin Some Trade Names HEPFLUSH-10Click for Drug MonographFor both, recanalization rate is lower than that with other plasminogenBecause of the possibility of allergic reaction, patients who previously received streptokinase Some Trade Names STREPTASEor anistreplase are not given that Alteplase Some Trade Names ACTIVASEClick for Drug Monograph is given in an accelerated or front-loaded dosage over 90Alteplase Some Trade Names ACTIVASEClick for Drug Monograph with concomitant IV heparin Some Trade Names HEPFLUSH-10Click for Drug Monograph improves patency, is nonallergenic, has a higher recanalization rate than other fibrinolytics, and isTable 7IV Fibrinolytic Drugs Available in the USThis table is presented as a PDF and requires the free Adobe PDFGet Adobe ReaderOther drugs: ACE inhibitors appear to reduce mortality risk in MI patients, especially in those with anterior infarction, heart failure, orThe greatest benefit occurs in the highest-risk patients early duringACE inhibitors are given > 24 h after thrombolysis stabilization and, because of continued beneficial effect, may be prescribed long-Angiotensin II receptor blockers may be an effective alternative for patients who cannot tolerate ACE inhibitors (eg, because of cough) Currently, they are not first-line treatment after MI Contraindications include hypotension, renal failure, bilateral renal artery stenosis, and known HMG-CoA reductase inhibitors (statins) have long been used for prevention of CAD and ACS, but there is now increasing evidence that they also have short-term benefits, such as stabilizing plaque, reversing endothelial dysfunction, decreasing thrombogenicity, and reducingThus, all patients without contraindications to therapy should receive a statin as early as possible following ACS LDL levels of 70 to 80 mgdL (81 to 07 mmolL) are the recommended ultimate

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