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Heart attack and acute coronary syndrome

Highlights

Heart Attack Symptoms

Common signs and symptom of heart attack include:

Immediate Treatment of a Heart Attack

The American Heart Association and the American College of Cardiology recommend:

Secondary Prevention of Heart Attack

Secondary prevention measures are essential to help prevent another heart attack. Do not leave the hospital without discussing these secondary prevention steps with your doctor:

Introduction

The heart is the human body's hardest working organ. Throughout life it continuously pumps blood enriched with oxygen and vital nutrients through a network of arteries to all tissues of the body. To perform this strenuous task, the heart muscle itself needs a plentiful supply of oxygen-rich blood, provided through a network of coronary arteries. These arteries carry oxygen-rich blood to the heart's muscular walls (the myocardium).

A heart attack (myocardial infarction) occurs when blood flow to the heart muscle is blocked, and tissue death occurs from loss of oxygen, severely damaging a portion of the heart.

Anterior heart arteries

Coronary Artery Disease. Coronary artery disease causes nearly all heart attacks. Coronary artery disease is the end result of a complex process called atherosclerosis (commonly called "hardening of the arteries"). This causes blockage of arteries (ischemia) and prevents oxygen-rich blood from reaching the heart.


 Click the icon to see an image of atherosclerosis. 

Heart attack (myocardial infarction) is among the most serious outcome of atherosclerosis. A heart attack can result in several ways from atherosclerosis:


 Click the icon to see an image of myocardial infarction. 

Angina, the primary symptom of coronary artery disease, is typically experienced as chest pain. There are two kinds of angina:

Acute coronary syndrome (ACS) is a severe and sudden heart condition that, although needing aggressive treatment, has not developed into a full blown heart attack. Acute coronary syndrome includes:

Patients diagnosed with acute coronary syndrome (ACS) may be at risk for a major heart attack. Doctors use a patient's medical history, various tests, and the presence of certain factors to help predict which ACS patients are most at risk for developing a more serious condition. The severity of chest pain itself does not necessarily indicate the actual damage in the heart.

Risk Factors

The risk factors for heart attack are the same as those for coronary artery disease (heart disease). They include:

The risks for coronary artery disease increase with age. About 85% of people who die from heart disease are over the age of 65. For men, the average age of a first heart attack is 66 years.

Men have a greater risk for coronary artery disease and are more likely to have heart attacks earlier in life than women. Women’s risk for heart disease increases after menopause, and they are more likely to have angina than men.

Certain genetic factors increase the likelihood of developing important risk factors, such as diabetes, elevated cholesterol and high blood pressure.

African-Americans have the highest risk of heart disease in part due to their high rates of severe high blood pressure as well as diabetes and obesity.

Obesity and Metabolic Syndrome. Excess body fat, especially around the waist, can increase the risk for heart disease. Obesity also increases the risk for other conditions (such as high blood pressure and diabetes) that are associated with heart disease. Obesity is particularly hazardous when it is part of the metabolic syndrome, a pre-diabetic condition that is significantly associated with heart disease. This syndrome is diagnosed when three of the following are present:

There are many ways to control your weight.

Unhealthy Cholesterol Levels. Low-density lipoprotein (LDL) cholesterol is the "bad" cholesterol responsible for many heart problems. Triglycerides are another type of lipid (fat molecule) that can be bad for the heart. High-density lipoprotein (HDL) cholesterol is the "good" cholesterol that helps protect against heart disease. Doctors test for a "total cholesterol" profile that includes measurements for LDL, HDL, and triglycerides. The ratio of these lipids can affect heart disease risk.

High Blood Pressure.High blood pressure (hypertension) is associated with coronary artery disease and heart attack. For an adult, a normal blood pressure reading is below 120/80 mm Hg. High blood pressure is generally considered to be a blood pressure reading greater than or equal to 140 mm Hg (systolic) or greater than or equal to 90 mm Hg (diastolic). Blood pressure readings in the prehypertension category (120 - 139 systolic or 80 - 89 diastolic) indicate an increased risk for developing hypertension.

Diabetes. Diabetes, especially for people whose blood sugar levels are not well controlled, significantly increases the risk of developing heart disease. In fact, heart disease and stroke are the leading causes of death in people with diabetes. People with diabetes, both type 1 and type 2, are also at risk for high blood pressure and unhealthy cholesterol levels, blood clotting problems, kidney disease, and impaired nerve function, all of which can damage the heart.

Physical Inactivity. Exercise has a number of effects that benefit the heart and circulation, including improving cholesterol levels and blood pressure and maintaining weight control. People who are sedentary are almost twice as likely to suffer heart attacks as are people who exercise regularly.

Smoking.Smoking is the most important risk factor for heart disease. Smoking can cause elevated blood pressure, worsen lipids, and make platelets very sticky, raising the risk of clots. Although heavy cigarette smokers are at greatest risk, people who smoke as few as three cigarettes a day are at higher risk for blood vessel abnormalities that endanger the heart. Regular exposure to passive smoke also increases the risk of heart disease in nonsmokers.

Alcohol. Moderate alcohol consumption (one or two glasses a day) can help boost HDL “good” cholesterol levels. Alcohol may also prevent blood clots and inflammation. By contrast, heavy drinking harms the heart. In fact, heart disease is the leading cause of death in alcoholics.

Diet.Diet plays an important role in protecting the heart, especially by reducing dietary sources of trans fats, saturated fats, and cholesterol and restricting salt intake that contributes to high blood pressure.

All nonsteroidal anti-inflammatory drugs (NSAIDs) -- with the exception of aspirin -- carry heart risks. NSAIDs and COX-2 inhibitors may increase the risk for death in patients who have experienced a heart attack. The risk is greatest at higher dosages but some research suggests that even low doses of NSAIDs taken for short periods of time are not safe after a heart attack.

NSAIDs include nonprescription drugs like ibuprofen (Advil, Motrin, generic) and prescription drugs like diclofenac (Cataflam, Voltaren, generic). Celecoxib (Celebrex) is currently the only COX-2 inhibitor that is available in the U.S. It has been linked to cardiovascular risks, such as heart attack and stroke. Patients who have had heart attacks should talk to their doctors before taking any of these drugs.

The American Heart Association recommends that patients who have, or who are at risk for, heart disease first try non-drug methods of pain relief (such as physical therapy, exercise, weight loss to reduce stress on joints, and heat or cold therapy). If these methods don't work, patients should take the lowest effective and safe dose of acetaminophen (Tylenol, generic) or aspirin before using an NSAID. The COX-2 inhibitor celecoxib (Celebrex) should be a last resort.

Prognosis

Heart attacks may be rapidly fatal, evolve into a chronic disabling condition, or lead to full recovery. The long-term prognosis for both length and quality of life after a heart attack depends on its severity, the amount of damage sustained by the heart muscle, and the preventive measures taken afterward.

Patients who have had a heart attack have a higher risk of a second heart attack. Although no tests can absolutely predict whether another heart attack will occur, patients can avoid having another heart attack by healthy lifestyle changes and adherence to medical treatments.

Heart attack also increases the risk for other heart problems, including heart failure, abnormal heart rhythms, heart valve damage, and stroke.

Higher Risk Individuals. A heart attack is always more serious in certain people, including:

Women are more likely to die from a heart attack than men. The gender difference is greatest for younger patients.

Factors Occurring at the Time of a Heart Attack that Increase Severity. The presence of other conditions during a heart attack can contribute to a poorer outlook:

Symptoms

Heart attack symptoms can vary. They may come on suddenly and severely or may progress slowly, beginning with mild pain. Although chest pain is the classic symptom associated with heart attack, a third of patients do not experience this symptom.

Symptoms can vary between men and women. Women are less likely than men to have chest pain, but they are more likely to experience shortness of breath, nausea or vomiting, or jaw and back pain.

Common signs and symptom of heart attack include:

The following symptoms are less likely to be due to heart attack:

However, the presence of these symptoms does not always rule out a serious heart event.

Some people with severe coronary artery disease do not have angina pain. This condition is known as silent ischemia. This is a dangerous condition because patients have no warning signs of heart disease.

If you are having chest pain or other symptoms that may indicate a heart attack, you should:

Diagnosis

When a patient comes to the hospital with chest pain, the following diagnostic steps are usually taken to determine any heart problems and, if present, their severity:

An electrocardiogram (ECG or EKG) measures and records the electrical activity of the heart. The waves measured by the ECG correspond to the contraction and relaxation pattern of the different parts of the heart. Specific waves seen on an ECG are named with letters:

ECG
Normal sinus rhythm

 Click the icon to see an image about ECG waves. 

Doctors use a term called the P-Q or P-R interval, which is the time taken for an electrical impulse to travel from the atria to the ventricle.

The most important wave patterns in diagnosing and determining treatment for a heart attack are called ST elevations and Q waves.

Elevated ST Segments: Heart Attack. Elevated ST segments are strong indicators of a heart attack in patients with symptoms and other indicators. They suggest that an artery to the heart is blocked and that the full thickness of the heart muscle is damaged. The kind of heart attack associated with these findings is referred to as either a Q-wave myocardial infarction or a STEMI (ST-segment elevation myocardial infarction).

However, ST segment elevations do not always mean the patient has a heart attack. For example, an inflammation in the sack around the heart (pericarditis) is another cause of ST-segment elevation.

Non-Elevated ST Segments: Angina and Acute Coronary Syndrome. A depressed or horizontal ST wave suggests some blockage and the presence of heart disease, even if there is no angina present. It occurs in about half of patients with other signs of a heart event. This finding, however, is not very accurate, particularly in women, and can occur without heart problems. In such cases, laboratory tests are needed to determine the extent, if any, of heart damage. In general, one of the following conditions may be present:

An echocardiogram is a noninvasive test that uses ultrasound images of the heart. Your doctor can see whether a part of your heart muscle has been damaged and is not moving. An echocardiogram may also be used as part of an exercise stress test, to detect the location and extent of heart muscle damage at the time of discharge or soon after you leave the hospital after a heart attack.

Radionuclide procedures use imaging techniques and computer analyses to plot and detect the passage of radioactive tracers through the region of the heart. Such tracing elements are typically given intravenously. Radionuclide imaging is useful for diagnosing and determining:

The procedure is noninvasive. It is a reliable measure of severe heart events and can help identify if damage has occurred from a heart attack. A radioactive isotope such as thallium (or technetium) is injected into the patient's vein. The radioactive isotope attaches to red blood cells and passes through the heart in the circulating blood. The isotope can then be traced through the heart using special cameras or scanners. The images may be combined with an electrocardiogram. The patient is tested while resting, then tested again during an exercise stress test. If the scan detects damage, more images are taken 3 or 4 hours later. Damage due to a prior heart attack will persist when the heart scan is repeated. Injury caused by angina, however, will have resolved by that time.

Angiography is an invasive test. It is used when doctors require a detailed “roadmap” of coronary artery blockages. In the procedure:


 Click the icon to see an image about angiography. 

 Click the icon to see another image about angiography. 

When heart cells become damaged, they release different enzymes and other molecules into the bloodstream. Elevated levels of such markers of heart damage in the blood or urine may help predict a heart attack in patients with severe chest pain, and help determine treatment. Tests for these markers are often performed in the emergency room or hospital when a heart attack is suspected. Some markers include:

Treatment

Heart attack is usually treated by:

Early supportive treatments are similar for patients who have acute coronary syndrome (ACS) or those who have had a heart attack.

Oxygen. Oxygen is almost always administered right away, usually through a tube that enters through the nose.

Aspirin. The patient is given aspirin if one was not taken at home.

Medications for Relieving Symptoms.

With a heart attack, clots form in the coronary arteries that supply oxygen to the heart muscle. Opening a clotted artery as quickly as possible is the best approach to improving survival and limiting the amount of heart muscle that is permanently damaged. New guidelines recommend that communities have emergency systems in place to ensure that heart attack patients are directed to appropriate medical centers equipped to treat them as quickly as possible.

The standard medical and surgical solutions for opening arteries are:

Thrombolytic, also called clot-busting or fibrinolytic, drugs are recommended as alternatives to angioplasty. These drugs dissolve the clot, or thrombus, responsible for causing artery blockage and heart-muscle tissue death.

Generally speaking, thrombolysis is considered a good option for patients with full-thickness (STEMI) heart attacks when symptoms have been present for fewer than 12 hours. Ideally, these drugs should be given within 30 minutes of arriving at the hospital if angioplasty is not a viable option. Other situations where a clot-busting drug may be used include when:

Thrombolytics should be avoided or used with great caution in the following patients after heart attack:

Specific Thrombolytics. The standard thrombolytic drugs are recombinant tissue plasminogen activators or rt-PAs. They include alteplase (Activase) and reteplase (Retavase) as well as a newer drug tenecteplase (TNKase). Other types of drugs, such as a combination of an antiplatelet and anticoagulant, may also be given to prevent the clot from growing larger or any new clots from forming.

Thrombolytic Administration. The sooner that thrombolytic drugs are given after a heart attack, the better. The benefits of thrombolytics are highest within the first 3 hours. They can still help if given within 12 hours of a heart attack.

Complications. Hemorrhagic stroke, usually occurring during the first day, is the most serious complication of thrombolytic therapy, but fortunately it is rare.

Percutaneous coronary intervention (PCI), also called angioplasty, and coronary artery bypass graft surgery (CABG) are the standard operations for opening narrowed or blocked arteries. These procedures help restore blood flow (perfusion). They are known as revascularization procedures:

Most patients who meet the criteria for either thrombolytic drugs or angioplasty do better with angioplasty (although only in centers equipped to do this procedure).

Angioplasty/PCI involves procedures such as percutaneous transluminal coronary angioplasty (PTCA) that help open the blocked artery. A typical angioplasty procedure involves the following steps:


 Click the icon to see an image of percutaneous transluminal coronary angioplasty. 

Complications occur in about 10% of patients (most complications occur within the first day). Best results occur in hospital settings with experienced teams and backup. Women who have angioplasty after a heart attack have a higher risk of death than men.

Reclosure and Blockage During or After Angioplasty. Narrowing or reclosure of the artery (restenosis) often occurs during or shortly after angioplasty. It can also occur up to a year after surgery, requiring a repeat angioplasty procedure.

Drug-eluting stents, which are coated with everolimus, sirolimus, or paclitaxel, can help prevent restenosis. They may be better than bare metal stents for patients who have experienced a STEMI heart attack, but they can also increase the risks of blood clots.

It is very important for patients who have drug-eluting stents to take aspirin and clopidogrel (Plavix, generic) for at least 1 year after the stent is inserted, to reduce the risk of blood clots. Clopidogrel, like aspirin, helps to prevent blood platelets from clumping together.

Prasugrel (Effient) is a newer antiplatelet drug that may be used as an alternative to clopidogrel for select patients with acute coronary syndrome who are undergoing angioplasty. It should not be used by patients who have had a previous stroke or transient ischemic attack. Another option for patients is the new antiplatelet drug ticagrelor (Brilinta). Like clopidogrel, prasugrel and ticagrelor are taken in combination with aspirin.

If for some reason patients cannot take a second antiplatelet along with aspirin after angioplasty and stenting, they should receive a bare metal stent instead of a drug-eluting stent.

Coronary artery balloon angioplasty - series

 Click the icon to see a series on coronary artery balloon angioplasty. 

Coronary Artery Bypass Graft Surgery (CABG). Coronary artery bypass graft surgery (CABG) is the alternative procedure to angioplasty for opening blocked arteries, particularly for patients who have two or more blocked arteries. It is a very invasive procedure, however:

Heart bypass surgery - series

 Click the icon to see a series on heart bypass surgery. 

Severely ill patients, particularly those with heart failure or who are in cardiogenic shock, will be monitored closely and stabilized. Oxygen is administered, and fluids are given or replaced when it is appropriate to either increase or reduce blood pressure. Such patients may be given dopamine, dobutamine, or both. Other treatments depend on the specific condition.

Heart failure. Intravenous furosemide may be administered. Patients may also be given nitrates, and ACE inhibitors, unless they have a severe drop in blood pressure or other conditions that preclude them. Clot-busting drugs or angioplasty may be appropriate.

Cardiogenic Shock. Cardiogenic shock is a dangerous condition that includes a drop in blood pressure and other abnormalities. A procedure called intra-aortic balloon counterpulsation (IABP) can help patients with cardiogenic shock when used in combination with thrombolytic therapy. IABP involves inserting a catheter containing a balloon, which is inflated and deflated within the artery to boost blood pressure. Left ventricular assist devices and early angioplasty may also be considered.

An arrhythmia is a deviation from the heart's normal beating pattern caused when the heart muscle is deprived of oxygen. Arrhythmia is a dangerous side effect of a heart attack. A very fast or slow rhythmic heart rate often occurs in patients who have had a heart attack, and is not usually a dangerous sign.

Premature beats or very fast arrhythmias called tachycardia, however, may be predictors of ventricular fibrillation. This is a lethal rhythm abnormality, in which the ventricles of the heart beat so rapidly that they do not actually contract but quiver ineffectually. The pumping action necessary to keep blood circulating is lost.

Preventing Ventricular Fibrillation. People who develop ventricular fibrillation do not always experience warning arrhythmias, and to date, there are no effective drugs for preventing arrhythmias during a heart attack. Preventive strategies include:

Treating Ventricular Fibrillation. Treatment strategies for ventricular fibrillation include:

Managing Other Arrhythmias. People with an arrhythmia called atrial fibrillation have a higher risk for stroke after a heart attack and should be treated with anticoagulants such as warfarin (Coumadin, generic), dabigatran (Pradaxa), rivaroxaban (Xarelto), or apixaban (Eliquis). Other rhythm disturbances called bradyarrhythmias (very slow rhythm disturbances) frequently develop in association with a heart attack and may be treated with atropine or pacemakers.

Medications

Anti-clotting drugs that inhibit or break up blood clots are used at every stage of heart disease. They are generally classified as either anti-platelets or anticoagulants. Both anti-platelets and anticoagulants prevent blood clots from forming but they work in different ways. Anti-platelets prevent blood platelets from sticking together. Anticoagulants are “blood thinners” that stop blood from clotting. Anti-platelets and anticoagulants carry the risk of bleeding, which can lead to dangerous situations, including stroke.

Appropriate anticlotting medications are started immediately in all patients. Such drugs are sometimes used along with thrombolytics, and also as on-going maintenance to prevent a heart attack.

Anti-Platelet Drugs. These drugs inhibit blood platelets from sticking together, and therefore help to prevent clots. Platelets are very small disc-shaped blood cells that are important for blood clotting.

Anticoagulant Drugs. Anticoagulants thin blood. They include:

All of these drugs pose a risk for bleeding. Some research indicates that the newer anticoagulants (dabigatran, rivaroxaban, apixaban) may pose a higher risk for bleeding in patients with acute coronary syndrome than the older anticoagulant warfarin.

Beta blockers reduce the oxygen demand of the heart by slowing the heart rate and lowering pressure in the arteries. They are effective for reducing deaths from heart disease. Beta blockers are often given to patients early in their hospitalization, sometimes intravenously. Patients with heart failure or who are at risk of going into cardiogenic shock should not receive intravenous beta blockers. Long-term oral beta blocker therapy for patients with symptomatic coronary artery disease, particularly after heart attacks, is recommended in most patients.

These drugs include propranolol (Inderal), carvedilol (Coreg), bisoprolol (Zebeta), acebutolol (Sectral), atenolol (Tenormin), labetalol (Normodyne, Trandate), metoprolol (Lopressor, Toprol-XL), and esmolol (Brevibloc). All of these drugs are available in generic form.

Administration During a Heart Attack. The beta blocker metoprolol may be given through an IV within the first few hours of a heart attack to reduce damage to the heart muscle.

Prevention After a Heart Attack. Beta blockers taken by mouth are also used on a long-term basis (as maintenance therapy) after a first heart attack to help prevent future heart attacks.

Side Effects. Beta blocker side effects include fatigue, lethargy, vivid dreams and nightmares, depression, memory loss, and dizziness. They can lower HDL (“good”) cholesterol. Beta blockers are categorized as non-selective or selective. Non-selective beta blockers, such as carvedilol and propranolol, can narrow bronchial airways. Patients with asthma, emphysema, or chronic bronchitis, should not take non-selective beta blockers.

Patients should not abruptly stop taking these drugs. The sudden withdrawal of beta blockers can rapidly increase heart rate and blood pressure. The doctor may want the patient to slowly decrease the dose before stopping completely.

After being admitted to the hospital for acute coronary syndrome or a heart attack, patients should not be discharged without statins or other cholesterol medicine unless their LDL ("bad") cholesterol is below 100 mg/dL. Some doctors recommend that LDL should be below 70 mg/dL.

Angiotensin converting enzyme (ACE) inhibitors are important drugs for treating patients who have had a heart attack, particularly for patients at risk for heart failure. ACE inhibitors should be given on the first day to all patients with a heart attack, unless there are medical reasons for not taking them.

Patients admitted for unstable angina or acute coronary syndrome should receive ACE inhibitors if they have symptoms of heart failure or evidence of reduced left ventricular fraction echocardiogram. These drugs are also commonly used to treat high blood pressure (hypertension) and are recommended as first-line treatment for people with diabetes and kidney damage.

ACE inhibitors include captopril (Capoten), ramipril (Altace), enalapril (Vasotec), quinapril (Accupril), benazepril (Lotensin), perindopril (Aceon), and lisinopril (Prinivil, Zestril). All of these drugs are available in generic form.

Side Effects. Side effects of ACE inhibitors are uncommon but may include an irritating cough, excessive drops in blood pressure, and allergic reactions.

Calcium channel blockers may provide relief in patients with unstable angina whose symptoms do not respond to nitrates and beta blockers, or for patients who are unable to take beta blockers.

Secondary Prevention

You can reduce your risk for a second heart attack by following secondary prevention measures. No one should be discharged from the hospital without these issues being addressed and appropriate medications prescribed. Lifestyle choices, particularly dietary factors, are equally important in preventing heart attacks.

Blood Pressure. Aim for a blood pressure of less than 140/90 mm Hg.

Cholesterol. LDL (“bad”) cholesterol should be substantially less than 100 mg/dL. If triglycerides are greater than or equal to 200 mg/dL, then non-HDL-C should be less than 130 mg/dL. [Non-HDL-C is the difference between total cholesterol and HDL (“good") cholesterol levels.] Nearly everyone who has had a heart attack should receive a prescription for a statin drug before being discharged from the hospital. It is also important to control dietary cholesterol by reducing intake of saturated fats to less than 7% of total calories. Increased omega-3 fatty acid consumption (by eating more fish or taking fish oil supplements) can help reduce triglyceride levels.

Exercise. Exercise for 30 - 60 minutes 7 days a week (or at least a minimum of 5 days a week).

Weight Management. Combine exercise with a healthy diet rich in fresh fruits, vegetables and low-fat dairy products. Your body mass index (BMI) should be 18.5 - 24.8. Waist circumference is also an important measure of heart attack risk. Men’s waist circumferences should be less than 40 inches (102 centimeters), while women’s should be below 35 inches (89 centimeters).

Smoking. It is essential to stop smoking. Also, avoid exposure to second-hand smoke.

Anti-Platelet Drugs. Your doctor may recommend you take low-dose aspirin (75 - 81 mg) on a daily basis. If you have had a drug-coated stent inserted, you must take another anti-platelet drug along with aspirin for at least 1 year following surgery. (Aspirin is also recommended for some patients as primary prevention of heart attack.)

Other Drugs. Your doctor may recommend that you take an ACE inhibitor or beta blocker drug on an ongoing basis. It is also important to have an annual influenza (“flu”) vaccination.

Rehabilitation

Physical rehabilitation is extremely important after a heart attack. Patients with recent episodes of acute coronary syndrome also generally need some sort of supervised exercise training. Cardiac rehabilitation may include:

Patients generally return to work in about 1 - 2 months, although timing can vary depending on the severity of the condition.

Sexual activity after a heart attack has a low risk and is generally considered safe, particularly for people who exercised regularly before the attack. The feelings of intimacy and love that accompany healthy sex can help offset depression.

Major depression occurs in many patients who have ACS or who have had heart attacks. Studies suggest that depression is a major predictor for increased mortality in both women and men. (One reason may be that depressed patients are less likely to comply with their heart medications.)

Guidelines now recommend depression screening for all patients who have had a heart attack. Psychotherapeutic techniques, especially cognitive behavioral therapies, may be very helpful. For some patients, certain types of antidepressant drugs may be appropriate.

Resources

References

2012 Writing Committee Members, Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2012 Aug 14;126(7):875-910. Epub 2012 Jul 16.

Abraham NS, Hlatky MA, Antman EM, Bhatt DL, Bjorkman DJ, Clark CB, et al. ACCF/ACG/AHA 2010 Expert Consensus Document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Circulation. 2010 Dec 14;122(24):2619-33. Epub 2010 Nov 8.

American College of Emergency Physicians; Society for Cardiovascular Angiography and Interventions, O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jan 29;61(4):e78-140. Epub 2012 Dec 17.

Antman EM and Morrow DA. ST-Elevation myocardial infarction: management. In Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Saunders; 2011:chap 55.

Antman EM, Bennett JS, Daugherty A, Furberg C, Roberts H, Taubert KA. Use of nonsteroidal antiinflammatory drugs: an update for clinicians: a scientific statement from the American Heart Association. Circulation. 2007 Mar 27;115(12):1634-42. Epub 2007 Feb 26.

Baber U, Mehran R, Sharma SK, Brar S, Yu J, Suh JW, et al. Impact of the everolimus-eluting stent on stent thrombosis: a meta-analysis of 13 randomized trials. J Am Coll Cardiol. 2011 Oct 4;58(15):1569-77. Epub 2011 Sep 14.

Bradley EH, Nallamothu BK, Herrin J, Ting HH, Stern AF, Nembhard IM, et al. National efforts to improve door-to-balloon time results from the Door-to-Balloon Alliance. J Am Coll Cardiol. 2009 Dec 15;54(25):2423-9.

Cannon CP and Braunwald E. Unstable angina and non-ST elevation myocardial infarction. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Saunders; 2011:chap 56.

Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2011 Dec 6;58(24):e123-210. Epub 2011 Nov 7.

Keller T, Zeller T, Ojeda F, Tzikas S, Lillpopp L, Sinning C, et al. Serial changes in highly sensitive troponin I assay and early diagnosis of myocardial infarction. JAMA. 2011 Dec 28;306(24):2684-93.

Komócsi A, Vorobcsuk A, Kehl D, Aradi D. Use of new-generation oral anticoagulant agents in patients receiving antiplatelet therapy after an acute coronary syndrome: systematic review and meta-analysis of randomized controlled trials. Arch Intern Med. 2012 Nov 12;172(20):1537-45.

Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011 Dec 6;58(24):e44-122. Epub 2011 Nov 7.

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Review Date: 6/28/2013
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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    of the foot, knee, shoulder, hip, hand or other joints. We also treat bone ... gery of the Foot, Ankle, Knee and Shoulder Cartilage and Tendon Repair Inpatient ... e Meniscus Tears Torn ACL and Other Ligament Tears Foot and Ankle Achilles ...

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