o° Acute Coronary Syndr FESERENDD isin ienocrvsnic ssa a hee Deseipion 1 ‘Ns echt tania ests a mma " Nadav bale waleserS oneaniraten " sie ren basi cache Sen arinat: wo pseson Carsopvi sae Pharmacologic treatment for hear failure should be tailored tothe patient’ clinical and hemodynamic state Patients with systolic arterial pressure >100 mm Hg, pulmonary artery ‘occlusion pressure >15 mm Hg, and cardiac Index <2.5 L/min/m should be treated initially with ©"? ‘a vasodilator, ether intravenous nitroglycerin or intravenous nitroprusside in doses of 0.3 to 1 jgkg/min, titrated up in increments of 05 jg/kg/min every 10 minutes. If arterial pressure decreases oF the increase in cardiac ourputis inadequate, inotropic support with dobutamine should be initiated at | to2 jg/kg/min and titrated to <15 ygikg/min, Milrinone isan alternative inotropie agent. Loop diueties, such as furosemide (20-40 mg intravenously or oally every 2-4 hhouts), should be used to reduce pulmonary congestion. Diuretis should be used with eaution in hypotensive patients. Patients with systolic arterial pressure <90 mm Hg, pulmonary arterial occlusion pressure >15 mm ig, and cardiac index <2.5 L/min/m* have cardiogenic shock. These patients should be treated as ‘00n as possible with intra-aortic balloon counterpulsation (IAB). Severely hypotensive patients (eystolic arterial pressure <70 mm Hg) should be treated with norepinephrine to rapidly raise the systolic arterial pressure, I the systolic arterial pressure i 70 co 90 mm Fig with signs of shock, dopamine may be considered initially. Once the systolic blood pressure has stabilized to at east ‘90 mm Hg, dobutamine can be added to further increase cardiac outputand reduce the dosage of ‘vasopressor. Interventional therapy with IABC may be indicated in patents with pump fallure who do not respond promptly to medical therapy, intra-aortic balloon counterpulsation has several potential ‘benefits in these patients, During inflation, the balloon augments coronary blood flow and forward cardiac output, During deflation, it decreases afterload and preload as wel. Intra-aortic balloon ‘counterpulsation and other ventricular assist devices may stabilize the hemodynamic status ‘sufficiently to allow PCT or coronary bypass surgery. Evidence suggests that patients with STEM who develop shock within 36 hours of MI benefit «from early invasive reperfusion performed within 18 hours of onset of shock, In patents with 1- or 2-vessel disease, PCI is preferced, Patients who remain symptomatic and have 3-vessel disease or significant left main coronary artery disease should undergo urgent coronary bypass surgery Percutaneous coronary intervention should also be performed in patients with severe heat fafure and/or pulmonary edema and onset of symptoms within 12 hours. 10-19