Acute Coronary Syndrome and Coronary Artery Disease Acute Coronary Syndrome and Coronary Artery Disease Garrett Preston Clark, D.O

Acute Coronary Syndrome Acute Coronary Syndrome and Coronary Artery and Coronary Artery

DiseaseDisease Garrett Preston Clark, D.O.Garrett Preston Clark, D.O.

http://www.emedicine.com/emerg/topic31.http://www.emedicine.com/emerg/topic31.htmhtm

What is ACS?What is ACS?

Includes clinical presentations that cover the Includes clinical presentations that cover the following range of diagnoses:following range of diagnoses:

1.1. Unstable anginaUnstable angina

2.2. Non–ST-elevation myocardial Non–ST-elevation myocardial infarction (NSTEMI)infarction (NSTEMI)

3.3. ST-elevation myocardial infarction ST-elevation myocardial infarction (STEMI) (STEMI)

http://www.emedicine.com/emerg/topic31.http://www.emedicine.com/emerg/topic31.htmhtm

What is ACS?What is ACS?

1.1. Unstable angina & NSTEMI Unstable angina & NSTEMI unstable plaques w/ nonocclusive unstable plaques w/ nonocclusive thrombosisthrombosis

2.2. STEMI STEMI thrombotic occlusion of thrombotic occlusion of epicardial coronary artery epicardial coronary artery

ACS / CADACS / CAD

Spontaneous and cocaine-related Spontaneous and cocaine-related coronary artery dissection are coronary artery dissection are unusual causes of ACS unusual causes of ACS

Still, should be included in your Still, should be included in your differential especially when a differential especially when a younger female or cocaine user is younger female or cocaine user is being evaluated. being evaluated.

Other considerations for ACS:Other considerations for ACS:

Marfan syndromeMarfan syndromeKawasaki diseaseKawasaki diseaseTakayasu arteritisTakayasu arteritisCystic medial necrosis with aortic Cystic medial necrosis with aortic

root dilatationroot dilatationAneurysm formationAneurysm formationDissection into the coronary arteryDissection into the coronary artery

ACS / CADACS / CAD

Higher incidence in males in all Higher incidence in males in all patients <70 y/opatients <70 y/o

Incidence of angina occurs equally Incidence of angina occurs equally 15 years postmenopause15 years postmenopause

Women more likely to have coronary Women more likely to have coronary events without typical symptomsevents without typical symptoms

ACS Risk Factors:ACS Risk Factors:1.1. Male genderMale gender2.2. Diabetes mellitus (DM)Diabetes mellitus (DM)3.3. Smoking historySmoking history4.4. HypertensionHypertension5.5. Increased ageIncreased age6.6. HypercholesterolemiaHypercholesterolemia7.7. HyperlipidemiaHyperlipidemia8.8. Prior CVAPrior CVA9.9. Inherited metabolic disordersInherited metabolic disorders10.10. Methamphetamine useMethamphetamine use11.11. Occupational stressOccupational stress12.12. Connective tissue diseaseConnective tissue disease

ACS ACS Whats In Your Whats In Your Diff Diff ??

Anxiety Anxiety Aortic Stenosis Aortic Stenosis Asthma Asthma Cardiomyopathy, Dilated Cardiomyopathy, Dilated Esophagitis Esophagitis Gastroenteritis Gastroenteritis Hypertensive Emergencies Hypertensive Emergencies Myocardial Infarction Myocardial Infarction MyocarditisMyocarditis PericarditisPericarditis and Cardiac and Cardiac TamponadeTamponade Pneumothorax, Iatrogenic, Spontaneous and Pneumothorax, Iatrogenic, Spontaneous and PneumomediastinumPneumomediastinum Pulmonary Embolism Pulmonary Embolism

Alternative diagnoses to cardiac ischemia for

patients with chest pain

Non-ischemic cardiovascular

Aortic dissection*

Myocarditis

Pericarditis

Chest wall

Cervical disc disease

Costochondritis

Fibrositis

Herpes zoster (before the rash)

Neuropathic pain

Rib fracture

Sternoclavicular arthritis

Pulmonary

Pleuritis

Pneumonia

Pulmonary embolus*

Tension pneumothorax*

Psychiatric

Affective disorders (eg, depression)

Anxiety disorders

Hyperventilation

Panic disorder

Primary anxiety

Somatiform disorders

Thought disorders (eg, fixed delusions)

Gastrointestinal

Biliary

Cholangitis

Cholecystitis

Choledocholithiasis

Colic

Esophageal

Esophagitis

Spasm

Reflux

Rupture*

Pancreatitis

Peptic ulcer disease

Nonperforating

Perforating*

WHAT’S HAPPENING?WHAT’S HAPPENING?

Disease process includes: Disease process includes: 1.1. A chronic phase of atherosclerosis A chronic phase of atherosclerosis

modification of the blood vessel wall modification of the blood vessel wall 2.2. Development of an atherosclerotic plaqueDevelopment of an atherosclerotic plaque3.3. Thin fibrous cap of extracellular matrix proteins Thin fibrous cap of extracellular matrix proteins

is formed over a lipid core (rich in foam cells & is formed over a lipid core (rich in foam cells & comprised of cholesteryl esters & tissue factor) comprised of cholesteryl esters & tissue factor)

4.4. Thickened intima.Thickened intima.5.5. Rupture of the fibrous cap Rupture of the fibrous cap thrombosis & thrombosis &

partial or total occlusion of the vesselpartial or total occlusion of the vesselhttp://www.uspharmacist.com/index.asp?page=ce/2686/default.htm

Whoop, THERE IT IS:Whoop, THERE IT IS:

OUCH !OUCH !

www.univie.ac.at/.../BE513/EKG/normalEKG.GIF

ACS ACS The Meat & Potatoes Part The Meat & Potatoes Part I:I:

Unstable AnginaUnstable Angina

The ACC/AHA guidelines state that UA The ACC/AHA guidelines state that UA and NSTEMI differ primarily in and NSTEMI differ primarily in

whether the ischemia is severe whether the ischemia is severe enough to cause sufficient enough to cause sufficient

myocardial damage to release myocardial damage to release detectable quantities of a marker of detectable quantities of a marker of

myocardial injury. myocardial injury. http://www.utdol.com/utd/content/topic.do?topicKey=chd/10116&type=A&selectedTitle=1~72


Unstable AnginaUnstable Angina

Unstable angina is considered in Unstable angina is considered in patients with ischemic symptoms patients with ischemic symptoms

suggestive of an ACS and suggestive of an ACS and nono elevation in troponins or CK-MB, elevation in troponins or CK-MB, with with or withoutor without ECG changes indicative ECG changes indicative

of ischemia.of ischemia.

http://www.utdol.com/utd/content/topic.do?topicKey=chd/10116&type=A&selectedTitle=1~72


CLASSIFICATIONS OF UNSTABLE ANGINACLASSIFICATIONS OF UNSTABLE ANGINA

1.1. New onset exertional anginaNew onset exertional angina

2.2. Rest anginaRest angina

3.3. Early post-MI anginaEarly post-MI angina

4.4. Postrevascularization anginaPostrevascularization angina

5.5. PeriproceduralPeriprocedural

6.6. LateLate

New onset anginaNew onset angina::CLASSIFICATIONS OF UNSTABLE ANGINACLASSIFICATIONS OF UNSTABLE ANGINA

If occurring only after heavy physical If occurring only after heavy physical exertion, patients have a prognosis exertion, patients have a prognosis similar to patients with chronic stable similar to patients with chronic stable anginaangina

New angina occurring after minimal New angina occurring after minimal exercise or at rest, has a poorer exercise or at rest, has a poorer prognosis.prognosis.

Rest anginaRest angina::CLASSIFICATIONS OF UNSTABLE ANGINACLASSIFICATIONS OF UNSTABLE ANGINA

Patients at increased risk if:Patients at increased risk if:

1.1. ProlongedProlonged

2.2. Associated with transient ST Associated with transient ST segment changes >0.05 mVsegment changes >0.05 mV

Early post-MI anginaEarly post-MI angina::CLASSIFICATIONS OF UNSTABLE ANGINACLASSIFICATIONS OF UNSTABLE ANGINA

Chest pain occurring within 48 hours Chest pain occurring within 48 hours after an acute MIafter an acute MI

Associated with high risk without Associated with high risk without immediate interventionimmediate intervention

GUSTO GUSTO ((Global Use of Strategies to Open Occluded Global Use of Strategies to Open Occluded

Coronary Arteries) Coronary Arteries) IIb trial IIb trial Refractory ischemia was associated with an Refractory ischemia was associated with an

approximate doubling of mortality among approximate doubling of mortality among patients with ST-segment elevation and a patients with ST-segment elevation and a near tripling risk among those without ST near tripling risk among those without ST elevation.elevation.

Circulation 1998 Nov 3;98(18):1860-8.

GUSTO IIb TRIAL:GUSTO IIb TRIAL:Global Use of Strategies to Open Global Use of Strategies to Open

Occluded Coronary ArteriesOccluded Coronary Arteries

Occurrence of refractory ischemia Occurrence of refractory ischemia was associated with a higher 30 was associated with a higher 30

day mortality compared to day mortality compared to responsive ischemia or no responsive ischemia or no

ischemiaischemia. .

Postrevascularization & Postrevascularization & Periprocedural anginaPeriprocedural angina::

CLASSIFICATIONS OF UNSTABLE ANGINACLASSIFICATIONS OF UNSTABLE ANGINA

PostrevascularizationPostrevascularization Angina Angina occurring after PCI or CABGoccurring after PCI or CABG

PeriproceduralPeriprocedural Ischemic chest pain Ischemic chest pain within 48 hours after stenting.within 48 hours after stenting.

LATE:LATE:CLASSIFICATIONS OF UNSTABLE ANGINACLASSIFICATIONS OF UNSTABLE ANGINA

Delayed onset of anginaDelayed onset of anginaMay reflect restenosis after PCI, graft May reflect restenosis after PCI, graft

stenosis after CABG, or progression stenosis after CABG, or progression of native diseaseof native disease

Patients usually progress to return of Patients usually progress to return of effort anginaeffort angina

ACS ACS The Meat & Potatoes Part II: The Meat & Potatoes Part II:Non–ST-elevation Non–ST-elevation

myocardial infarction myocardial infarction (NSTEMI)(NSTEMI)

UA & NSTEMI often indistinguishable at UA & NSTEMI often indistinguishable at time of initial evaluationtime of initial evaluation

Most patients present with chest pain and Most patients present with chest pain and ST segment depressionST segment depression

ST seg depression is an unfavorable ST seg depression is an unfavorable predictor predictor

Increased incidence of left main or three Increased incidence of left main or three vessel disease compared to those without vessel disease compared to those without ST segment depression ST segment depression

ACS ACS The Meat & Potatoes Part II: The Meat & Potatoes Part II:Non–ST-elevation myocardial Non–ST-elevation myocardial

infarction (NSTEMI)infarction (NSTEMI)

http://www.postgradmed.com/issues/2004/06_04/tak1.gif

ACS ACS The Meat & Potatoes Part The Meat & Potatoes Part II:II:

Non–ST-elevation Non–ST-elevation myocardial infarction myocardial infarction

(NSTEMI)(NSTEMI)Absence of Q waves suggests a high Absence of Q waves suggests a high

rate of spontaneous reperfusionrate of spontaneous reperfusionMay occur after percutaneous May occur after percutaneous

coronary intervention (PCI) or CABGcoronary intervention (PCI) or CABG

Braunwald classificationBraunwald classification

Classification of UA which included patients Classification of UA which included patients with NSTEMI since troponins were not with NSTEMI since troponins were not

measured:measured:

Class I — New onset, severe, or accelerated Class I — New onset, severe, or accelerated Class II — Angina at rest and subacute (no Class II — Angina at rest and subacute (no

anginal episodes within the preceding 48 anginal episodes within the preceding 48 hours) hours)

Class III — Angina at rest and acute (angina Class III — Angina at rest and acute (angina within the preceding 48 hours) within the preceding 48 hours)


Clinical circumstances:Clinical circumstances:

Class A — Secondary UA (in the Class A — Secondary UA (in the setting of anemia, infection, fever, setting of anemia, infection, fever, etc) etc)

Class B — Primary UA Class B — Primary UA Class C — PostClass C — Post


Intensity of treatment:Intensity of treatment:

No or minimal treatment No or minimal treatment Symptoms occurring in the setting of Symptoms occurring in the setting of

standard medical therapy standard medical therapy Symptoms occurring despite Symptoms occurring despite

maximally tolerated doses of beta maximally tolerated doses of beta blockers, blockers, nitratesnitrates, and calcium channel, and calcium channel

Goldman risk score for chest Goldman risk score for chest pain: pain:

ACS Risk Factors ACS Risk Factors Reinforcement:Reinforcement:

1.1. Male genderMale gender2.2. Diabetes mellitus (DM)Diabetes mellitus (DM)3.3. Smoking historySmoking history4.4. HypertensionHypertension5.5. Increased ageIncreased age6.6. HypercholesterolemiaHypercholesterolemia7.7. HyperlipidemiaHyperlipidemia8.8. Prior CVAPrior CVA9.9. Inherited metabolic disordersInherited metabolic disorders10.10. Methamphetamine useMethamphetamine use11.11. Occupational stressOccupational stress12.12. Connective tissue diseaseConnective tissue disease

ACS ACS The Meat & Potatoes Part The Meat & Potatoes Part III:III:

ST-elevation (Q-wave) ST-elevation (Q-wave) myocardial infarction myocardial infarction

(STEMI)(STEMI)

Enough Said?Enough Said?

ACS ACS The Meat & Potatoes Part The Meat & Potatoes Part III:III:

ST-elevation (Q-wave) ST-elevation (Q-wave) myocardial infarction (STEMI)myocardial infarction (STEMI)

In 2000, the European Society of In 2000, the European Society of Cardiology (ESC) with the Cardiology (ESC) with the American College of Cardiology American College of Cardiology (ACC) set out to define an acute, (ACC) set out to define an acute, evolving, or recent MI.evolving, or recent MI.

ESC / ACC Definitions:ESC / ACC Definitions:

Rise and gradual fall in troponin or more rapid Rise and gradual fall in troponin or more rapid rise and fall of biochemical markers of rise and fall of biochemical markers of myocardial necrosis with at least one of the myocardial necrosis with at least one of the following: following:

a. Ischemic symptoms a. Ischemic symptoms b. Development of pathologic Q waves b. Development of pathologic Q waves c. ECG changes indicative of ischemia (ST c. ECG changes indicative of ischemia (ST segment elevation or depression) segment elevation or depression) d. Coronary artery intervention (eg, d. Coronary artery intervention (eg, angioplasty) angioplasty)

Pathologic findings of an acute MIPathologic findings of an acute MI

SO, WHAT’S A Q-WAVE ? ? ?SO, WHAT’S A Q-WAVE ? ? ?

Q = 1Q = 1stst deflection of the QRS which is deflection of the QRS which is negativenegative

When QRS complex consists When QRS complex consists soley of soley of a Q wavea Q wave, it’s called a “QS” complex, it’s called a “QS” complex

Normal Q = less than 0.03 seconds Normal Q = less than 0.03 seconds and can be common in most leads and can be common in most leads (except aVR, V1-V3)(except aVR, V1-V3)

““Is It Is It EvilEvil ???” ???”

Dr_Evil.jpg848 x 440 pixels - 49.0kB diary.ru/~green-filin

THE THE EVIL Q-WAVE ! ! !EVIL Q-WAVE ! ! !

AnyAny Q-Wave in leads V1-V3 is an Q-Wave in leads V1-V3 is an Evil QEvil QQ’s in leads I, II, aVL, aVF, & V4-6 are Q’s in leads I, II, aVL, aVF, & V4-6 are

considered considered evilevil if they are greater than if they are greater than or equal to 0.03 secondsor equal to 0.03 seconds

Evil Q’sEvil Q’s must be greater than or equal must be greater than or equal to 1mm in depth in @ least 2 to 1mm in depth in @ least 2 contiguous leads to be considered for contiguous leads to be considered for Q-wave MI and thereby, making them Q-wave MI and thereby, making them very evil very evil !!

ACS ACS The Meat & Potatoes Part III: The Meat & Potatoes Part III: ST-elevation (Q-wave) ST-elevation (Q-wave) myocardial infarction myocardial infarction

(STEMI)(STEMI)

““Clinically significant ST segment Clinically significant ST segment elevation is considered to be present elevation is considered to be present if it is greater than 1 mm (0.1 mV) in if it is greater than 1 mm (0.1 mV) in at least two anatomically contiguous at least two anatomically contiguous leads, or 2 mm (0.2 mV) in two leads, or 2 mm (0.2 mV) in two contiguous precordial leads”. contiguous precordial leads”.

http://www.utdol.com/utd/content/topic.do?topicKey=ad_emer/2821&view=printhttp://www.utdol.com/utd/content/topic.do?topicKey=ad_emer/2821&view=print

ACS / TREATMENT:ACS / TREATMENT:

In the initial assessment, the following should be In the initial assessment, the following should be implemented if ACS is suspected:implemented if ACS is suspected:

1.1. Airway, breathing, and circulation assessmentAirway, breathing, and circulation assessment2.2. 12-lead ECG obtained 12-lead ECG obtained 3.3. Crash cart nearby Crash cart nearby 4.4. Cardiac monitor attached Cardiac monitor attached 5.5. Oxygen given Oxygen given 6.6. IV access and blood work obtained (series IV access and blood work obtained (series

cardiac) cardiac) 7.7. AspirinAspirin 8.8. NitratesNitrates and and morphinemorphine (unless contraindicated) (unless contraindicated)

http://www.utdol.com/utd/content/topic.do?topicKey=ad_emer/2821&view=print

ACS / TREATMENT:ACS / TREATMENT:Morphine reduces sympathetic Morphine reduces sympathetic stimulation caused by pain and stimulation caused by pain and

anxiety anxiety lowers cardiac workload lowers cardiac workload

Lower cardiac workload = less O2 Lower cardiac workload = less O2 demanddemand

= Patients feel better= Patients feel better


ACS / TREATMENT:ACS / TREATMENT:Due to the lack of data, the ACC/AHA, Due to the lack of data, the ACC/AHA,

& ACCP guidelines did not address & ACCP guidelines did not address the use of clopidogrel in patients the use of clopidogrel in patients managed without reperfusion Tx.managed without reperfusion Tx.

HoweverHowever, , mostmost experts give experts give clopidogrel, 300 mg loading dose clopidogrel, 300 mg loading dose then 75 mg daily based on benefits then 75 mg daily based on benefits demonstrated in non-revascularized demonstrated in non-revascularized patients with non-ST elevation patients with non-ST elevation syndromes. syndromes.


Clopidogrel in Unstable angina Clopidogrel in Unstable angina to prevent Recurrent ischemic to prevent Recurrent ischemic

Events (CURE) TRIAL:Events (CURE) TRIAL:

Clopidogrel Clopidogrel platelet ADP receptor platelet ADP receptor antagonismantagonism

Something to consider if ASA sensitiveSomething to consider if ASA sensitiveCURE Trial suggests more efficacy with CURE Trial suggests more efficacy with

ASA and Plavix combo therapy, but at a ASA and Plavix combo therapy, but at a cost = increased risk of nonintracranial cost = increased risk of nonintracranial bleeding complications.bleeding complications.

Foreign Cars May Save Your Foreign Cars May Save Your Life !Life !

If It’s Good Enough for Bond…If It’s Good Enough for Bond…

http://www.impawards.com/2002/posters/die_another_day_ver1.jpg

www.jamesbondlifestyle.com/.../au010.jpg285 x 218 - 18k

Interventions Shown To Interventions Shown To Decrease Mortality in CADDecrease Mortality in CAD (Die Another Day 007 (Die Another Day 007©©):):

1.1. SStatins tatins

2.2. AASASA

3.3. AACE InhibitorsCE Inhibitors

4.4. BBeta Blockerseta Blockers

““SAAB”SAAB” Nitrates shown to minimize angina Nitrates shown to minimize angina

Sx’s, but NO conclusive evidence Sx’s, but NO conclusive evidence that show decreased mortality.that show decreased mortality.

DON’T FORGET:DON’T FORGET:

Initial EKG is often NOT diagnostic. Initial EKG is often NOT diagnostic. Repeat EKG at 5 to 10 minute intervals Repeat EKG at 5 to 10 minute intervals if patient remains symptomatic & high if patient remains symptomatic & high clinical suspicion for MIclinical suspicion for MI

Ask about phosphodiesterase-5 Ask about phosphodiesterase-5 inhibitors (Viagra, Levitra, Cialis). inhibitors (Viagra, Levitra, Cialis). Nitrates are contraindicated if used Nitrates are contraindicated if used w/in 24 -36 hours due to risk of severe w/in 24 -36 hours due to risk of severe hypotension hypotension

DON’T FORGET:DON’T FORGET:

In the setting of an inferior wall MI, In the setting of an inferior wall MI, remember the possibility of right remember the possibility of right ventricular involvement. Patient ventricular involvement. Patient

dependence on preload to maintain dependence on preload to maintain cardiac output may result in severe cardiac output may result in severe

hypotension w/ nitrate use. hypotension w/ nitrate use.

ST elevation in the right precordial leads - ST elevation in the right precordial leads - V4, V5, and V6 indicates right ventricular V4, V5, and V6 indicates right ventricular

involvementinvolvement

http://www.utdol.com/utd/content/image.do?imageKey=card_pix/right_5.htm&altImageKey=card_pix/normal3.htm

DON”T FORGET:DON”T FORGET:

About ½ the patients with LBBB & About ½ the patients with LBBB & acute MI do acute MI do NOTNOT have Sx’s of chest have Sx’s of chest pain w/ their ischemia pain w/ their ischemia

= Much less likely to receive ASA, = Much less likely to receive ASA, beta blockers, and reperfusion beta blockers, and reperfusion therapytherapy

= Not a good idea= Not a good idea= Beware the LBBB ! ! != Beware the LBBB ! ! !

ACSACSTHERAPY:THERAPY:

Evidence Supports early aggressive Evidence Supports early aggressive strategystrategy

ASAASABeta-BlockerBeta-BlockerACEIsACEIsStatinStatinLMW Heparin or UnfractionatedLMW Heparin or UnfractionatedClopidogrel (PLAVIX)Clopidogrel (PLAVIX)

TEST YOUR SKILL…TEST YOUR SKILL…


A 67 y/o postmenopausal woman w/ CAD, stable A 67 y/o postmenopausal woman w/ CAD, stable angina, CHF, and hyperlipidemia comes for her angina, CHF, and hyperlipidemia comes for her regular 3-month exam. Her vitals: HR: 94, RR: regular 3-month exam. Her vitals: HR: 94, RR: 18, BP: 130/70. Physical exam is WNL. Her LDL 18, BP: 130/70. Physical exam is WNL. Her LDL is 129, HDL is 45. Which of the following is 129, HDL is 45. Which of the following therapeutic options would you prescribe that therapeutic options would you prescribe that have been shown to decrease have been shown to decrease mortalitymortality::

A)A) AtorvastatinAtorvastatinB)B) DigoxinDigoxinC)C) DiltiazemDiltiazemD)D) EstrogenEstrogenE)E) Isosorbide mononitrateIsosorbide mononitrate


A 67 y/o postmenopausal woman w/ CAD, stable A 67 y/o postmenopausal woman w/ CAD, stable angina, CHF, and hyperlipidemia comes for her angina, CHF, and hyperlipidemia comes for her regular 3-month exam. Her vitals: HR: 94, RR: regular 3-month exam. Her vitals: HR: 94, RR: 18, BP: 130/70. Physical exam is WNL. Her LDL 18, BP: 130/70. Physical exam is WNL. Her LDL is 129, HDL is 45. Which of the following is 129, HDL is 45. Which of the following therapeutic options would you prescribe that therapeutic options would you prescribe that have been shown to decrease have been shown to decrease mortalitymortality::

A)A) AtorvastatinAtorvastatinB)B) DigoxinDigoxinC)C) DiltiazemDiltiazemD)D) EstrogenEstrogenE)E) Isosorbide mononitrateIsosorbide mononitrate

THE ENDTHE END

References:References:1.1. http://www.kup.at/kup/images/browser/787.jpghttp://www.kup.at/kup/images/browser/787.jpg

2.2. http://services.epnet.com/GetImage.aspx/getImage.aspx?ImageIID=4708http://services.epnet.com/GetImage.aspx/getImage.aspx?ImageIID=4708

3.3. http://www.chd-taskforce.de/ny2001_schober.htmhttp://www.chd-taskforce.de/ny2001_schober.htm

4.4. sfghed.ucsf.edu/.../ClinicImages/MI%20EKG1.1.jpgsfghed.ucsf.edu/.../ClinicImages/MI%20EKG1.1.jpg

5.5. http://www.utdol.com/utd/content/image.do?imageKey=card_pix/schema_m.htmhttp://www.utdol.com/utd/content/image.do?imageKey=card_pix/schema_m.htm

6.6. http://www.utdol.com/utd/content/topic.do?topicKey=ad_emer/2821&view=printhttp://www.utdol.com/utd/content/topic.do?topicKey=ad_emer/2821&view=print7.7. http://www.utdol.com/utd/content/image.do?imageKey=card_pix/right_5.htm&altImageKey=card_pix/normal3.htmhttp://www.utdol.com/utd/content/image.do?imageKey=card_pix/right_5.htm&altImageKey=card_pix/normal3.htm8. Circulation 1998 Nov 3;98(18):1860-8.9. http://www.postgradmed.com/issues/2004/06_04/tak1.gif

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Acute Coronary Syndrome and Coronary Artery Disease Acute Coronary Syndrome and Coronary Artery Disease Garrett Preston Clark, D.O