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ASAMs7@ASAClopidogrelEnoxaparinEarly InvasiveGP IIb/IIIa (small molecule)123450.20.41.02.46.90.81.93.37.317.4 012345678>=9 0.81.62.24.47.312.416.123.426.835.9 0.70.92.23.75.710.015.018.023.035.0 2.13.56.810.014.019.022.024.025.029.00/123456/70-23-45-70-34-70-23-45-7335712195813202641581320264149141520294258142323569168183182761622620691551357959122031162513162013195101571457125105.711.420.74.19.815.9 ASA - Initial dose of 162-325 mg (nonenteric) then 75-160 mg/d of enteric coated or nonenteric; or Clopidogrel for ASA if sensitivity or GI intolerance. Clopidogrel: loading dose 4-8 tablets (300-600 mg) if rapid onset of action required, then 75 mg/d. IV UFH bolus 60 U/kg (max 4,000 U) IV followed by infusion of 12 U/kg/h (max 1,000 U/h) titrated to aPTT 50-70 sec Oxygen to maintain SAO2 > 90% SL NTG (Except RV MI or SBP < 90) Analgesia (e.g. MSO4) B-blockers IV followed by oral (Except HR < 60, PR > 0.24 sec, SBP < 90 Oxygen to maintain SAO2 > 90% IV NTG 24 - 48 hours (Except RV MI or SBP < 90) Analgesia (e.g. MSO4) B-blockers IV followed by oral (Except HR < 60, PR > 0.24 sec, SBP < 90) ACE-Inhibitors oralReperfusion therapy is recommended for all patients with ST segment elevation MI. Thrombolysis or primary percutaneous coronary intervention (PCI) is recommended, with the latter if the patient has a contraindication to thrombolysis. Beta-Blockers, oral ACEI for control of HTN or LVD, after MI Bed rest with continuous ECG monitoring Bed rest with continuous ECG monitoring Add O2 to maintain SaO2>90% NTG IV b-Blockers, oral or IV MSO4 IV for pain, anxiety or pulmonary congestion IABP if ischemia or hemodynamic instability persists ACEI for control of HTN or LVD, after MI Initial medical therapy with cath if recurrent ischemia at rest or positive stress test.Early Invasive Cardiac cath between 4-48 hours and revasc with PCI or CABG as warranted by coronary anatomy.Clopidgrel 300 mg po loading dose and 75 mg daily. For patients being managed medically or those going for cardiac catheterization or PCI, begin clopidogrel at the time of admission. For patients going to CABG, hold clopidogrel for at least 5 days, if possible.Enoxaparin: 1 mg/kg SQ q 12/h; first dose may be preceded by a 30 mg IV bolus. Class IIa recommendation: enoxaparin is preferred over UFH Dalteparin: 120 IU/kg SQ q 12/h (max 10,000 IU 2x daily). IV UFH bolus 60-70 U/kg (max 5,000 U) IV followed by infusion of 12-15 U/kg/h (max 1,000 U/h) titrated to aPTT 1.5 to 2.5 times control.Eptifibatide, Abciximab or Tirofiban Eptifibatide: 180 mcg/kg bolus, followed by second bolus of 180 mcg/kg given 10 minutes after the first, and an infusion of 2.0 mcg/kg/min for 12-18 hours. In patients with Serum Cr between 2-4 mg/dL, the 180 ug/kg bolus and 1.0 mg/kg/min infusion should be administered. Contraindicated in patients with Serum Cr >/=4 mg/dL. Abciximab: 0.25 mg/kg bolus followed by infusion of 0.125 mcg/kg/min (max 10 mcg/min) for 12 h. Tirofiban: 10 mcg/kg bolus followed by 0.15 mcg/kg/min infusion for 12-18 hours.Eptifibatide or Tirofiban Eptifibatide: 180 mcg/kg bolus followed by infusion 2.0 mcg/kg/min for 72-96 h. In patients with Serum Cr between 2-4 mg/dL, the 180 ug/kg bolus and 1.0 mg/kg/min infusion should be administered. Contraindicated in patients with Serum Cr >/=4 mg/dL. Tirofiban: 0.4 mcg/kg/min for 30 min followed by infusion of 0.1 mcg/kg/min for 48-96 h. In patients with severe renal insufficiency (Cr Cl <30 mL/min), the loading dose and maintenance infusion should be decreased by 50%. Abciximab is not recommended for use in unselected patients as "upstream" therapy.Class IIa: enoxaparin preferred over UFH Enoxaparin: 1 mg/kg SQ q 12/h; first dose may be preceded by a 30 mg IV bolus. IV UFH bolus 60-70 U/kg (max 5,000 U) IV followed by infusion of 12-15 U/kg/h (max 1,000 U/h) titrated to aPTT 1.5 to 2.5 times control. Dalteparin: 120 IU/kg SQ q 12 hour, maximum 10,000 IU.Beta-Blockers, nitrates all patientsClopidogrel: 300mg loading dose, then 75 mg daily SQ LMWH Enoxaparin: 1 mg/kg SQ q 12/h; first dose may be preceded by a 30 mg IV bolus. Reduce dose if creat clearance < 30 mg/min or weight < 45 kg. (or use unfractionated heparin).Early Invasive Cardiac cath between 4-48 hours and revasc with PCI or CABG as warranted by coronary anatomy.Early Conservative Initial medical therapy with cath if recurrent ischemia at rest or positive stress test.This program was developed by Christopher P. Cannon, MD, Assistant Professor of Medicine, Harvard Medical School, and Brigham & Women's Hospital, MA and PDA Verticals Corporation. Supported by an unrestricted educational grant from Merck & Co, Inc. Copyright 2001, 2002 Christopher P. Cannon, MD, TIMI Study Group Software copyright 2002, PDA Verticals Corporation. All rights reserved.This program was developed based on analyses and clinical trial information and the ACC/AHA Guidelines for UA/NSTEMI (SEPT 2000, and update MAR 2002) and AMI (Web version 1999). It is designed as a guideline to physicians in treating patients with unstable angina and non-ST elevation MI as well as ST elevation MI. However, in all cases, clinical judgement should be used when utilizing the information found in this program. Note, the link between TIMI Risk Score values and 'high-risk' features in the UA/NSTEMI and AMI Guidelines is made in this program; however, this is not part of the published aforementioned guidelines. Please refer to prescribing information for a complete list of contraindications for selected therapies.Adapted from (1) Antman et al. The TIMI Risk Score for Unstable Angina/Non-ST Elevation MI. JAMA 2000;284(7);835-842 (2) Braunwald et al. ACC/AHA Guidelines for the Management of Patients with Unstable Angina and Non-ST Segment Elevation Myocardial Infarction. J Am Coll Cardiol. 2000;36;970-1062, and 2002 Update, www.acc.org (3) Cannon and O'Gara. Critical Pathways Cardiology. Lippincott Williams & Wilkins 2001. (4) Morrow DA, Antman EM, Snapinn SM, McCabe CH, Theroux P, Braunwald E. An integrated clinical approach to predicting the benefit of tirofiban in non-ST elevation acute coronary syndromes. Application of the TIMI Risk Score for UA/NSTEMI in PRISM-PLUS. Eur Heart J. 2002;23:223-9. (5) Cannon et al. TIMI Risk Score to Predict 6-Month Mortality, Recurrent Cardiac Events, and Relative Benefit of Invasive vs. Conservative Strategy in Patients with Unstable Angina: Results From TACTICS-TIMI 18 (abstract:1150-79). J Am Coll Cardiol;37 (2) Suppl. A:335A. (6) The ESPRIT Investigators. Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy. Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT): a randomised, placebo-controlled trial. Lancet 2000; 356:2037-44. (7) Topol EJ, Moliterno DJ, Herrmann HC, et al. Comparison of two platelet glycoprotein IIb/IIIa inhibitors, tirofiban and abciximab, for the prevention of ischemic events with percutaneous coronary revascularization. N Engl J Med 2001;344:1888-94. (8) Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001;344:1879-87. (9) Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001;345:494-502. (10) Morrow et al., Application of TIMI Risk Score for ST-Elevation MI in NRMI 3. JAMA. 2001;286 (11): 1356-1359. (11) Morrow et al., A simple risk index for rapid initial triage of patientswith ST-elevation myocardial infarction: an InTIME II substudy Lancet 2001;358: 1571-75. (12) Ryan et al., ACC/AHA Guidelines for the Management of Patients with Acute Myocardial Infarction AMI. Web Version 1999. (13) Morrow DA, Antman EM, Charlesworth A, et al. TIMI risk score for ST-elevation myocardial infarction: A convenient, bedside, clinical score for risk assessment at presentation : An intravenous nPA for treatment of infarcting myocardium early II trial substudy. Circulation 2000;102:2031-7.This early TIMI Risk Score can calculate 24 hour and 30 day mortality rates based on 3 factors (heart rate, age, and systolic blood pressure). It can be useful in assessment of risk, even prior to a full medical history. This early TIMI Risk Score can calculate 24 hour and 30 day mortality rates based on 3 factors (HR, Age, SBP). It can be useful in assessment of risk, even prior to a full medical history.Use the popup list at the bottom of the screen (beside the label) to switch between the calculator, outcomes for the calculated score and the guidelines for the calculated score. Other labels with popup lists will appear when appropriate to allow you to access access related/more specific information.As shown, the patient's risk of death at 30 days varies substantially based on TIMI Risk Score, ranging from <1% to 36%. The average risk was 6.7% and thus high risk STEMI patients are TIMI Risk Score >=4.As shown, for both patients treated with reperfusion therapy (primary PCI or thrombolysis) and for patients not treated with reperfusion therapy, the patient's risk of death increases with TIMI Risk Score. As shown, the higher the risk the greater the difference in absolute mortality favoring reperfusion therapy.TIMI Risk Score for STEMI is a simple prognostication scheme that enables a clinician to categorize a patient's risk of death at the time of initial evaluation. TIMI Risk Score applies 8 key variables simultaneously that can be easily ascertained when a patient presents to the medical care system. This program was designed to help clinicians triage patients and to identify the best therapy and strategy.Use the popup list at the bottom of the screen (beside the label) to switch between the calculator, outcomes for the calculated score and the guidelines for the calculated score. Other labels with popup lists will appear when appropriate to allow you to access access related/more specific information.TIMI Risk Score was developed from the TIMI 11B trial, where patients had to have a clear Hx of ischemic pain at rest, documented by clinical findings, ECG changes or + cardiac markers. It has not been tested in patients with CP of unclear etiology. To use the TIMI Risk Score for patients with UA/NSTEMI, look over your patient's Hx for the 7 listed variables on the 'Calc TIMI Risk Score' screen and check the appropriate boxes. The calculator will add up the number of factors, which is the patient's TIMI Risk Score. Then, on the this table, the patient's risk of developing death or new MI over the next 14 days is shown in the first column, & his or her risk of developing death, MI or needing urgent revasc by 14 days is shown in the second column. As illustrated, the higher the number of these risk factors the greater the risk the patient has of having a cardiac event. In addition, as emphasized in the ACC/AHA UA/NSTEMI Guidelines, the higher risk patients will also benefit more from more aggressive antithrombotic-Rx and an Invasive Strategy - see 'Outcomes by Rx.'As shown in this screen, for TRS 0-3, the cardiac event rates will be similar for your patient if you use either Enoxaparin or UFH.For TRS 4-7, if you use Enoxaparin in this patient in place of UFH, the cardiac event rates will be lower.As shown in this screen, for TRS 0-3, if you use Tirofiban + UFH in this patient in place of UFH alone, the cardiac event rates will be lower.For TRS 3-7, if you use Tirofiban + Invasive Strategy, the cardiac event rates will be lower.As shown in this screen, for TRS 0-2, the cardiac event rates will be similar for your patient if you use Tirofiban + Conservative or Tirofiban + Invasive Strategy.As shown in this screen, for TRS 4-7, there is approximately 40-45% reduction in cardiac events with tirofiban plus UFH vs. UFH alone.In each of the TIMI Risk groups, clopidogrel demonstrates a statistically significant 20% relative risk reduction in each group. This is the only intervention that improves outcomes in low risk patients.TIMI Risk Score for UA/NSTEMI is a simple prognostication scheme that enables a clinician to categorize a patient's risk of death and ischemic events at the time of initial evaluation. TIMI Risk Score applies 7 key variables simultaneously that can be easily ascertained when a patient presents to the medical care system. This program was designed to help clinicians triage patients and to identify the best therapy and strategy.Use the popup list at the bottom of the screen (beside the label) to switch between the calculator, outcomes for the calculated score and the guidelines for the calculated score. Other labels with popup lists will appear when appropriate to allow you to access access related/more specific information.3.0.1