History

Fact Explanation
Chest pain Chest pain would be the chief symptom. Myocardial ischemic pain describes as acute onset, tightening, squeezing type central chest pain/heaviness radiating to the arms, jaw, or shoulder blade (referred pain), and usually occurs at rest. Chronic stable anginal pain is precipitated by physical activity, lasting no more than a few minutes, and is relieved by rest. Emotional stress can also cause or worsen angina. Sometimes patient may not develop pain as a symptom (silent infarction) particularly patients with diabetes.[1]
Nausea, vomiting Due to activation of the sympathetic nervous system, patient may feel nausea and may vomit.[1]
Sweating Associated sweating also due to activation of the autonomic nervous system, particularly sympathetic nervous system.[1]
Palpitations As a complication of acute coronary syndrome patient may develop arrhythmias causing palpitations.[1]
Dyspnea Patients who developed acute heart failure may present with dyspnea.[1]
Intermittent claudication Peripheral vascular disease is known to be associated with ischemic heart disease and therefore patients may develop symptoms such as intermittent claudication due to muscle ischemia with walking.[1]
History of risk factors Risk factors for the development of ischemic heart disease include cigarette smoking, poorly controlled diabetes, hypertension, hypercholesterolemia, obesity, lack of physical activity, untreated valvular heart disease and cardiomyopathies. Should suspect ischemic heart disease in patients with these predisposing factors.[1]
Past personal or family history of ischemic heart disease Presence of known past or family history of coronary artery disease, including myocardial infarction strongly flavors the diagnosis of acute coronary syndrome due to ischemic heart disease.[1]
References
  1. ACHAR SA, KUNDU S, NORCROSS WA. Diagnosis of acute coronary syndrome. Am Fam Physician [online] 2005 Jul 1, 72(1):119-26 [viewed 12 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16035692

Examination

Fact Explanation
Pallor Patient may be anemic and anemia known to aggravate ischemic heart disease.[1]
Pulse - tachycardia, rhythm abnormalities Due to activation of the sympathetic nervous system, patients may have sinus tachycardia. Some patients may have irregular rhythms due to arrhythmias. Pulses of lower extremities may find absent or weak due to associated peripheral vascular disease.[1]
Hyper/hypotension Known hypertensive patients may have high blood pressure readings and those who have developed acute left ventricular failure as a complication may show low blood pressure readings.[1]
Elevated jugular venous pressure Found in right ventricular infarction causing acute right heart failure.[1]
Displaced cardiac apical impulse In patients with heart failure, due to dilatation of the left ventricle, displaced cardiac apex can be found.[1]
Heart sounds - S3, murmurs New transient mitral regurgitation murmur can be heard. Third heart sound with gallop rhythm can be heard in patients with heart failure.[1]
Basal crepitations In some patients with the development of pulmonary edema as a result of acute left ventricular failure, crepitations can be heard in bases of both lungs.[1]
Diaphoresis Sweating may be able to observe, as a result of autonomic nervous system.[1]
References
  1. ACHAR SA, KUNDU S, NORCROSS WA. Diagnosis of acute coronary syndrome. Am Fam Physician [online] 2005 Jul 1, 72(1):119-26 [viewed 12 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16035692

Differential Diagnoses

Fact Explanation
Acute gastritis/Gastro esophageal reflux disease (GERD) Patient may known to have gastritis/GERD and will describe burning type of pain in the lower sternal, epigastric region with acid regurgitation and a sour or bitter taste in the mouth. ECG will be normal.[1]
Pneumonia with associated pleuritis Patient will have pleuritic type chest pain due to associated pleurisy and other prominent features are fever, productive cough and general ill health. Examination of the lung fields will reveal areas of consolidation. [1]
Acute pericarditis Chest pain found in pericarditis is sudden in onset, pleuritic type and substernal or left precordial in location. It may radiate to the trapezius ridge, neck, arms, or jaw. The pain is relieved by leaning forward and is made worse by lying supine. Examination will reveal pericardial friction rub which is characteristic.[1]
Aortic dissection Chest pain will be associated with a back pain and patient will be hemodynamically unstable.[1]
Acute pneumothorax Patient will be dyspnoeic significantly if it is a tension pneumothorax and the percussion note over the affected area will be hyper-resonant.[1]
Pulmonary embolism Most of the time patient will have a known risk factor such as pregnancy, deep vein thrombosis, thrombophilic condition..etc. D-dimer levels will be high and pulmonary angiogram will show the embolus.[1]
Chest wall pain Chest wall pain is mainly a stinging type, localized pain with no radiation and increased with respiration and chest wall movements. Also pain can be reproduced by palpation.[1]
References
  1. MCCONAGHY JR, OZA RS. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician [online] 2013 Feb 1, 87(3):177-82 [viewed 30 May 2014] Available from: http://www.aafp.org/afp/2013/0201/p177.html

Investigations - for Diagnosis

Fact Explanation
12 lead electrocardiography (ECG) ECG plays a very important role in diagnosing and categorizing acute coronary syndrome in to ST elevation myocardial infarction(STEMI), non ST elevation myocardial infarction(NSTEMI)/unstable angina. ECG changes occur in STEMI over time include, J-point elevation, and tall, peaked, “hyperacute” T waves; ST-segment elevation and reciprocal-lead ST-segment depression also occur(within minutes), abnormal Q waves (within the first day), and T-wave inversion and normalization of ST segments occur within hours to days. To diagnose STEMI where there is transmural myocardial ischemia, there should be ST Segment elevation >= 1 mm in any two limb leads or >= 2 mm in any two contiguous chest leads or new onset left bundle branch block (LBBB). The presence of ST-segment elevation of >1 mm in the lead V4R is highly suggestive of right ventricular myocardial infarction. Subendocardial ischemia classically results in ST-segment depression and T-wave inversion aiding the diagnosis of NSTEMI. However, a normal ECG does not rule out acute coronary syndrome.[1,2]
Cardiac enzymes - troponin T, troponin I, and/or creatine kinase–MB isoenzyme(CKMB), myoglobin Troponin T or I is the most sensitive determinant of acute coronary syndrome, although the CKMB also is used. Early markers of acute ischemia include myoglobin and CKMB when available. Myoglobin can be detected in the serum as early as two hours after myocardial necrosis begins. Useful for ruling out myocardial infarction if the level is normal in the first 4-8 hours after the onset of symptoms.[1,2]
Chest X-ray High-quality portable chest X-ray should be obtained in all patients with STEMI, with the aim of screening for dissection of the ascending aorta and to exclude pneumothorax.[1,2]
Transthoracic and/or transesophageal echocardiography Used to assess left ventricular function, determine the degree of myocardial damage, right ventricular abnormalities and to rule out other disorders such as valvular heart disease or hypertrophic cardiomyopathy as a cause of symptoms. Also can be used to confirm the diagnosis when there is diagnostic uncertainty.[1,2]
Stress test - Exercise ECG Exercise ECGs have an acceptable sensitivity and specificity for detection of myocardial ischemia and are a useful test in the majority of patients. The presence of horizontal or downsloping ST-depressions or elevations > 1 mm define a positive test.[1]
Coronary angiography Coronary Angiography provides reliable anatomical information to identify the presence of stenosis and helps define the potential therapeutic options (i.e. medical management vs. myocardial revascularization).[1,2]
Contrast chest computed tomographic scan or a magnetic resonance imaging scan Should be used to differentiate STEMI from aortic dissection in patients for whom this distinction is initially unclear.[1,2]
Magnetic Resonance Imaging (MRI) Can be used for the accurate measurement of infarct size (both the transmural and circumferential extent of infarction).[2]
Pulmonary artery catheter monitoring Should be performed in patients with progressive hypotension, when unresponsive to fluid administration or when fluid administration may be contraindicated or when suspicion of mechanical complications of STEMI, (papillary muscle rupture, ventricular septal rupture or free wall rupture with pericardial tamponade) if an echocardiogram has not been performed. [2]
Intra-arterial pressure monitoring Should be carried out, in patients with severe hypotension (systolic arterial pressure less than 80 mm Hg, patients receiving vasopressor/inotropic agents or patients with cardiogenic shock.[2]
References
  1. ACHAR SA, KUNDU S, NORCROSS WA. Diagnosis of acute coronary syndrome. Am Fam Physician [online] 2005 Jul 1, 72(1):119-26 [viewed 12 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16035692
  2. O'GARA P. T., KUSHNER F. G., ASCHEIM D. D., CASEY D. E., CHUNG M. K., DE LEMOS J. A., ETTINGER S. M., FANG J. C., FESMIRE F. M., FRANKLIN B. A., GRANGER C. B., KRUMHOLZ H. M., LINDERBAUM J. A., MORROW D. A., NEWBY L. K., ORNATO J. P., OU N., RADFORD M. J., TAMIS-HOLLAND J. E., TOMMASO J. E., TRACY C. M., WOO Y. J., ZHAO D. X.. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation [online] December, 127(4):529-555 [viewed 11 July 2014] Available from: doi:10.1161/​CIR.0b013e3182742c84

Investigations - Fitness for Management

Fact Explanation
Hemoglobin level Should be assessed to identify anemia which can aggravate the disease process in ischemic heart disease.[1]
Platelet count To assess the risk of bleeding.[1]
Serum electrolytes - pottasium To detect electrolyte abnormalities such as hyper/hypokalemia which known to occur with drug therapy, particularly angiotensin converting enzyme inhibitors, angiotensin receptor blockers, spironolactone and diuretics.[1]
Serum creatinine To assess the renal function as some drugs (aldosterone blocking agents) should be prescribed only in patients without significant renal dysfunction.[1]
Random blood sugar/ Fasting blood sugar To detect undiagnosed diabetes.[1]
Lipid profile To identify dyslipidemia.[1]
References
  1. SMITH S. C., BENJAMIN E. J., BONOW R. O., BRAUN L. T., CREAGER M. A., FRANKLIN B. A., GIBBONS R. J., GRUNDY S. M., HIRATZKA L. F., JONES D. W., LLOYD-JONES D. M., MINISSIAN M., MOSCA L., PETERSON E. D., SACCO R. L., SPERTUS J., STEIN J. H., TAUBERT K. A.. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update: A Guideline From the American Heart Association and American College of Cardiology Foundation. Circulation [online] December, 124(22):2458-2473 [viewed 11 July 2014] Available from: doi:10.1161/​CIR.0b013e318235eb4d

Investigations - Followup

Fact Explanation
Full blood count Platelet counts should be monitored daily in patients given unfractionated heparin.[1]
Serum electrolytes - pottasium To detect electrolyte abnormalities such as hyper/hypokalemia which known to occur with drug therapy, particularly angiotensin converting enzyme inhibitors, angiotensin receptor blockers, spironolactone and diuretics.[1]
Serum cratinine To assess the renal function as some drugs (aldosterone blocking agents) should be continued only in patients without significant renal dysfunction. According to the guidelines creatinine should be less than or equal to 2.5 mg/dL in men and less than or equal to 2.0 mg/dL in women.[1]
ECG All patients with STEMI should have follow-up ECGs at 24 hours and at hospital discharge to assess the success of reperfusion and/or the extent of infarction, defined in part by the presence or absence of new Q waves.[1]
Stress echocardiography (or myocardial perfusion imaging) Should be used in patients with STEMI for in-hospital or early post discharge assessment for inducible ischemia when baseline abnormalities are expected to compromise ECG interpretation. Not recommended to use for early routine reevaluation in patients with STEMI in the absence of any change in clinical status or revascularization procedure. Reassessment of left ventricular function 30 to 90 days later may be reasonable.[1]
References
  1. O'GARA P. T., KUSHNER F. G., ASCHEIM D. D., CASEY D. E., CHUNG M. K., DE LEMOS J. A., ETTINGER S. M., FANG J. C., FESMIRE F. M., FRANKLIN B. A., GRANGER C. B., KRUMHOLZ H. M., LINDERBAUM J. A., MORROW D. A., NEWBY L. K., ORNATO J. P., OU N., RADFORD M. J., TAMIS-HOLLAND J. E., TOMMASO J. E., TRACY C. M., WOO Y. J., ZHAO D. X.. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation [online] December, 127(4):529-555 [viewed 11 July 2014] Available from: doi:10.1161/​CIR.0b013e3182742c84

Investigations - Screening/Staging

Fact Explanation
Stress test/ Exercise ECG Exercise ECGs have an acceptable sensitivity and specificity for detection of myocardial ischemia and are a useful test in the majority of patients. The presence of horizontal or downsloping ST-depressions or elevations > 1 mm define a positive test.[1]
Echocardiogram Used to assess left ventricular function, determine the degree of myocardial damage, right ventricular abnormalities and to rule out other disorders such as valvular heart disease or hypertrophic cardiomyopathy as a cause of symptoms. Also can be used to confirm the diagnosis when there is diagnostic uncertainty.[1]
Coronary angiogram Coronary Angiography provides reliable anatomical information to identify the presence of stenosis and helps define the potential therapeutic options (i.e. medical management vs. myocardial revascularization).[1]
References
  1. FIHN S. D., GARDIN J. M., ABRAMS J., BERRA K., BLANKENSHIP J. C., DALLAS A. P., DOUGLAS P. S., FOODY J. M., GERBER T. C., HINDERLITER A. L., KING S. B., KLIGFIELD P. D., KRUMHOLZ H. M., KWONG R. Y. K., LIM M. J., LINDERBAUM J. A., MACK M. J., MUNGER M. A., PRAGER R. L., SABIK J. F., SHAW L. J., SIKKEMA J. D., SMITH C. R., SMITH S. C., SPERTUS J. A., WILLIAMS S. V., ANDERSON J. L.. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation [online] December, 126(25):e354-e471 [viewed 11 July 2014] Available from: doi:10.1161/​CIR.0b013e318277d6a0

Management - General Measures

Fact Explanation
Patient and family education It is important that patients should aware about their disease condition, risk factors, medications, follow up strategies, importance of drug compliance. Also they should be educated regarding monitoring their symptoms by themselves. Should discuss in detail issues of physical activity, return to work, resumption of sexual activity, and travel, including driving and flying. Their family members should educate how to support the patient to cope up with life style modifications. Family members of patients experiencing STEMI should be advised to take cardiopulmonary resuscitation (CPR) training and familiarize themselves with the use of an automated external defibrillator.[1,2]
Life style changes Life style changes include modification of risk factors such as stopping smoking, dietary changes, regular exercise, weight reduction and stress management. Have to assess the use of tobacco and should encourage to stop active or passive smoking. Have to provide counseling, pharmacological therapy (including nicotine replacement and bupropion), and can direct to a formal smoking cessation programs as appropriate.[1,2]
Life style changes - Dietary modifications Patients should advised and encouraged to consume a diet free of sugar, saturated fat and salt and rich in fresh vegetables, fruits, low fat dairy products, foods containing high fiber content, omega 3 fatty acids. Additionally can refer to a nutritionist to further modify their current diet.[1,2]
Life style changes - Physical activity Encourage minimum of 30 to 60 minutes of activity, preferably daily, or at least 3 or 4 times weekly (walking, jogging, cycling, or other aerobic activity). Patients can be referred to a cardiac rehabilitation programme if available.[1]
Treat co-morbid diseases - Diabetes, hypertension, dyslipidemia Life style modifications are very important. When managing diabetes, target HbA1c should be <7%. An insulin infusion to normalize blood glucose is recommended for patients with STEMI and complicated courses. Hypertension should be managed to achieve the goal of <140/90 mmHg or <130/80 mmHg (if chronic kidney disease or diabetes). Antihypertensive drugs such as ACE inhibitors, angiotensin receptor blockers or beta blocker are preferred to control blood pressure. Statins can be used to manage dyslipidemia an omega-3 fatty acids can be given as an adjuvant.[1,2]
References
  1. O'GARA P. T., KUSHNER F. G., ASCHEIM D. D., CASEY D. E., CHUNG M. K., DE LEMOS J. A., ETTINGER S. M., FANG J. C., FESMIRE F. M., FRANKLIN B. A., GRANGER C. B., KRUMHOLZ H. M., LINDERBAUM J. A., MORROW D. A., NEWBY L. K., ORNATO J. P., OU N., RADFORD M. J., TAMIS-HOLLAND J. E., TOMMASO J. E., TRACY C. M., WOO Y. J., ZHAO D. X.. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation [online] December, 127(4):529-555 [viewed 11 July 2014] Available from: doi:10.1161/​CIR.0b013e3182742c84
  2. SMITH S. C., BENJAMIN E. J., BONOW R. O., BRAUN L. T., CREAGER M. A., FRANKLIN B. A., GIBBONS R. J., GRUNDY S. M., HIRATZKA L. F., JONES D. W., LLOYD-JONES D. M., MINISSIAN M., MOSCA L., PETERSON E. D., SACCO R. L., SPERTUS J., STEIN J. H., TAUBERT K. A.. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update: A Guideline From the American Heart Association and American College of Cardiology Foundation. Circulation [online] December, 124(22):2458-2473 [viewed 11 July 2014] Available from: doi:10.1161/​CIR.0b013e318235eb4d

Management - Specific Treatments

Fact Explanation
Acute stage - Resuscitation Acute stage, patient should be resuscitated first according to the advanced cardiac life support. Air way should be maintained, breathing difficulty should be assessed and high flow oxygen should be given via a face mask to maintain arterial oxygen desaturation >90%. Patient should be attached to the cardiac monitor and ECG changes, blood pressure, pulse rate, respiratory rate, oxygen saturation should be monitored continuously. Intravenous access should be gained using wide bore cannula. Senior medical officers should be informed as soon as possible and further management should be decided depending on the situation.[1,2,3]
Hospitalization Patients should be hospitalized to provide continuous ECG monitoring, pulse oximetry and facilities for hemodynamic monitoring and defibrillation.[1,3]
Medical management of acute coronary syndrome - acute stage The immediate therapy should consist of aspirin 162 to 325 mg to be chewed (before or within 30 minutes of arrival) and sublingual nitroglycerin (0.4 mg) every 5 mins for a total of 3 doses and morphine sulfate (2 to 4 mg intravenous (IV) with increments of 2 to 8 mg IV repeated at 5- to 15-minute intervals) for pain relief. Morphine will additionally offload the left ventricle, reducing oxygen demand. Antiemetic such as IV metoclopramide should be given to counteract the adverse effects of morphine.[1,3]
Medical management of acute coronary syndrome - ST elevation myocardial infarction (STEMI) The choice between thrombolysis and percutaneous coronary intervention (PCI) should be decided depending on the individual patient, the place, availability and the timing. Thrombolytic therapy is preferred for patients whose first medical contact occurs less than 3 hours after the onset of symptoms, but for whom PCI is not immediately available; in patients who seek medical attention less than 1 hour after the onset of symptoms (in whom the therapy may abort the infarction); and patients with a history of anaphylaxis due to radiographic contrast material. The drugs commonly used include streptokinase, urokinase, alteplase, reteplase, tenecteplase and tissue plasminogen activator (tPA). Unfractionated heparin should be given intravenously to patients undergoing reperfusion therapy with alteplase, reteplase, or tenecteplase.[1]
Special aspects of managing right ventricular/inferior infarction The aims of treatment are reversal of the decreased filling, restoration of the right-sided stroke volume and improvement of right ventricular function. Patients with reduced cardiac output should be given isotonic saline to maintain adequate right ventricular preload. Inotropic support with dobutamine should be considered, when fluid management fails. These patients are more prone to develop high grade atrioventricular blocks and bradyarrhythmias. So careful monitoring is needed to detect and treat early as possible. Drugs which reduce the cardiac preload such as nitrates, diuretics and vasodilators should be avoided.[1]
Medical management of acute coronary syndrome - Unstable angina/Non ST elevation myocardial infarction (NSTEMI) Anti-thrombotic therapy includes antiplatelet therapy with aspirin and clopidogrel (or prasugrel); as well as anticoagulation with unfractionated heparin, low molecular weight heparins (such as enoxaparin) or fondaparinux sodium. Glycoprotein IIb/IIIa inhibitors may also be considered in selected patients. Oral beta-blocker therapy should also be initiated (unless contraindicated), while angiotensin converting enzyme (ACE) inhibitors should also be commenced in patients with pulmonary congestion or left ventricular impairment.[3]
Reperfusion therapy - Percutaneous coronary intervention (Angioplasty and stent implantation) Percutaneous coronary intervention (PCI) is indicated when the patient presents within the first 3 hours after the onset of pain, in a setting where there is a skilled interventional cardiologist and catheterization laboratory with surgical backup. It should be performed within 90 minutes after initial medical contact (door to balloon time = 90 minutes). Primary PCI consists of urgent balloon angioplasty (with or without stenting), without the previous administration of thrombolytic therapy. It is preferred even after 90 minutes in patients with a contraindication to thrombolysis or a high risk of bleeding following thrombolysis; patients with clinical findings suggesting a high likelihood of a complicated medical course or death (i.e. hypotension, pulmonary congestion); and patients with cardiogenic shock. Sometimes have to perform due to failed fibrinolytic therapy, where it is called "rescue PCI".[1]
Surgical interventions - Coronary artery bypass graft surgery (CABG), heart transplantation CABG has been shown to improve the prognosis in medium to high risk patients. It is effective in relieving symptoms and reduces the risk of death over the long term. Emergency or urgent CABG indicated in patients with STEMI and who are eligible for a surgery, when the PCI failed and persistent or recurrent ischemia refractory to medical therapy. Rarely heart transplantation also has been performed to cure the disease.[1,2,3]
Medical management of chronic stable angina Pharmacological measures can be broadly categorized into anti-anginal drugs, and vasculoprotective drugs. Anti-anginals include nitrates, beta-blockers and calcium channel blockers. Nitrates act by dilating both systemic and coronary arteries (including some stenoses) and the systemic veins. The resulting venous pooling of blood decreases cardiac work and chamber size. Beta-blockers work by decreasing myocardial oxygen consumption by reducing the heart rate, blood pressure, and myocardial contractility. Calcium channel blockers dilate coronary and systemic arteries, increase coronary blood flow and decrease myocardial oxygen consumption. Verapamil and Diltiazem also reduce cardiac rate and contractility. Vasculoprotective drugs include aspirin and clopidogrel, lipid lowering drugs like statins, and ACE inhibitors. Aspirin and Clopidogrel exert an anti-platelet activity, preventing thrombus formation and propagation. Statins slow the progression of coronary atherosclerosis and stabilize existing plaques. ACE inhibitors have been reported to reduce morbidity and mortality.[2]
Management of complications Continuous monitoring, anticipation, early identification and management of complications plays a crucial role in the management. Rhythm disturbances or conduction abnormalities should be detected early and corrected. Pharmacological treatment with electric shock therapy can be used for tachyarrhythmias and temporary or permanent pacing can be used for bradyarrhythmias. Inotropic support should be given for hypotension that does not resolve after volume loading. A diuretic should be given to patients with pulmonary congestion if there is associated volume overload. Patients with acute papillary muscle and ventricular septal, free wall rupture should be considered for urgent cardiac surgical repair.[1,3]
Intra-aortic balloon counterpulsation Intra-aortic balloon counterpulsation should be used in STEMI patients with low out put state/in cardiogenic shock/hypotension (systolic blood pressure<90 mm Hg or 30 mm Hg below baseline mean arterial pressure), who do not respond to other interventions.[1]
Anticoagulation - Warfarin therapy Warfarin should be given to post-STEMI patients with indications for anticoagulation such as either persistent or paroxysmal atrial fibrillation, patients with left ventricular thrombus noted on an imaging study and patients with left ventricular dysfunction and extensive regional wall-motion abnormalities. Also recommended for the patients allergic to aspirin.[1]
References
  1. O'GARA P. T., KUSHNER F. G., ASCHEIM D. D., CASEY D. E., CHUNG M. K., DE LEMOS J. A., ETTINGER S. M., FANG J. C., FESMIRE F. M., FRANKLIN B. A., GRANGER C. B., KRUMHOLZ H. M., LINDERBAUM J. A., MORROW D. A., NEWBY L. K., ORNATO J. P., OU N., RADFORD M. J., TAMIS-HOLLAND J. E., TOMMASO J. E., TRACY C. M., WOO Y. J., ZHAO D. X.. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation [online] December, 127(4):529-555 [viewed 11 July 2014] Available from: doi:10.1161/​CIR.0b013e3182742c84
  2. FIHN S. D., GARDIN J. M., ABRAMS J., BERRA K., BLANKENSHIP J. C., DALLAS A. P., DOUGLAS P. S., FOODY J. M., GERBER T. C., HINDERLITER A. L., KING S. B., KLIGFIELD P. D., KRUMHOLZ H. M., KWONG R. Y. K., LIM M. J., LINDERBAUM J. A., MACK M. J., MUNGER M. A., PRAGER R. L., SABIK J. F., SHAW L. J., SIKKEMA J. D., SMITH C. R., SMITH S. C., SPERTUS J. A., WILLIAMS S. V., ANDERSON J. L.. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation [online] December, 126(25):e354-e471 [viewed 11 July 2014] Available from: doi:10.1161/​CIR.0b013e318277d6a0
  3. WRIGHT R. S., ANDERSON J. L., ADAMS C. D., BRIDGES C. R., CASEY D. E., ETTINGER S. M., FESMIRE F. M., GANIATS T. G., JNEID H., LINCOFF A. M., PETERSON E. D., PHILIPPIDES G. J., THEROUX P., WENGER N. K., ZIDAR J. P., JACOBS A. K.. 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/ Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation [online] December, 123(18):2022-2060 [viewed 11 July 2014] Available from: doi:10.1161/CIR.0b013e31820f2f3e