Updated flowchart Acute coronary syndromes (2012)

Report
Acute coronary syndrome without ST elevation
ASA - Nitrate - Beta-blocker –
P2Y12 inhibitor # - Anticoagulation*
HIGH RISK
LOW RISK
Recurrent severe ischemia
Elevated troponin
No recurrent ischemia
Hemodynamic instability
Early post infarct angina
No troponin rise
Major arrhythmias (VF, VT)
Diabetes mellitus #
No diabetes
Coronarography
Urgent (< 2h)
Early (< 72h)
(< 24h if Grace > 140)
Non-invasive testing
Consider IIB-IIIA antagonist + heparin
OR bivalirudin
*Anticoagulation:
Fondaparinux (+UHF in case of PCI) / Enoxaparin / UFH
# P2Y12 inhibitor: Ticagrelor / Prasugrel (reimbursement only in diabetic patients with PCI )
clopidogrel (high bleeding risk or low risk ACS)
ST elevation MI (<12 h after onset of pain)
ASA- Morphine - Heparin* - P2Y12 inhibitor *
Admission in non-PCI-center
OR
1st medical contact outside hospital
Admission in
PCI-center
•
Transfer time to PCI center < 90 min
(transfer time<60 if ischemic time<2h)
YES
•
Hemodynamic instability
(shock / cardiac failure/ malignant arrhythmias)
•
Contra-indication thrombolysis
NO
Thrombolysis
Primary PCI
• Thrombus aspiration
Failed
Succes
Rescue PCI
Coronaro/
PCI 3-24h
• Bivalirudin
( IIB-IIIa antagonists for bail-out)
* • PPCI: UFH and Prasugrel 60 mg/ Ticagrelor 180mg
•Trombolysis: Enoxaparin and clopidogrel 300mg (adjusted dose if >75y)

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