Chronic kidney disease

■ Refractory chest discomfort despite maximal pharmacotherapy for ACS

■ Recent Ml within the past 2 weeks

AC5s, acute coronary Syndromes; CAD, coronary a? le*y disease; CHD, coronary heart disease; DM, diabeles rnellilus; HTN, hypertension; iViL myocardial infarction; NSTE, non-5T-seg merit elevation; TIIV1,1, thrombolysis in myocardial infarction,

PA positive biochemical marker for infarction is a value of troponin I, troponin T, or creatine kinase myocardial band of greater than the iVil detection limit

From Spinier 5A, de Denus Acute Coronary Syndromes, In DlPlrp J I, Talbert RL Yee GC et al; (edsj Pharmacotherapy; A Pathophysiologic Approach, 7th ed. New York: McGraw-Hill; 2003; 254r with permission.

Additional Testing and Risk Stratification

At some point during hospitalization but prior to discharge, patients with MI should

have their left ventricular function (LVF) evaluated for risk stratification. ' The most common way LVF is measured is using an echocardiogram to calculate the patient's left ventricular ejection fraction (LVEF). Left ventricular function is the single best predictor of mortality following MI. Patients with LVEFs less than 40% are at highest risk of death. Patients with ventricular fibrillation or sustained ventricular tachycardia occurring more than 2 days following MI and those with LVEF less than 30% (measured at least 1 month after STE MI and 3 months after coronary artery revascularization with either PCI or CABG) benefit from placement of an implantable cardioverter defibrillator (ICD).316

Predischarge from the hospital, stress testing (Fig. 8-3) may be indicated in: (a) moderate-or low-risk patients in order to determine who would benefit from coronary angiography to establish the diagnosis of CAD, and (b) patients following MI to predict intermediate-and long-term risk of recurrent MI and death. In most cases, patients with a positive stress test indicating coronary ischemia will then undergo coronary angiography and subsequent revascularization of significantly occluded coronary arteries. If a patient has a negative exercise stress test for ischemia, the patient is at lower risk for subsequent CHD events.

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