急性冠脉综合征指南课件

ACC/AHAPocketGuidelinesNovember,2002TheManagementofPatientswithUnstableAnginaand

Non-ST-SegmentElevation

MyocardialInfarctionACC/AHAClassifications

ExpertOpinionandRecommendationsClassIConditionsforwhichthereisevidenceand/orgeneralagreementthatagivenprocedureortreatmentisbeneficial,useful,andeffectiveClassIIConditionsforwhichthereisconflictingevidenceand/oradivergenceofopinionabouttheusefulness/efficacyofaprocedureortreatmentClassIIaweightofevidence/opinionisinfavorofusefulness/efficacyClassIIbusefulness/efficacyislesswellestablishedbyevidence/opinionClassIIIConditionsforwhichthereisevidenceand/orgeneralagreementthattheprocedure/treatmentisnotuseful/effectiveandinsomecasesmaybeharmfulAII.InitialEvaluationBandManagementCClinicalAssessmentDEarlyRiskStratificationEImmediateManagementA.ClinicalAssessment

RecommendationforInitialTriagePatientwithpossibleACSshouldnotbeevaluatedsolelyoverthetelephonebutshouldbereferredtoafacilitythatallowsevaluationbyaphysicianandtherecordingofa12-leadelectrocardiogram(ECG)01PatientswithasuspectedACSwithchestdiscomfortatrestfor>20minutes,hemodynamicinstability,orrecentsyncopeorpresyncopeshouldbestronglyconsideredforimmediatereferraltoanemergencydepartmentoraspecializedchestpainunit02ClassIB.EarlyRiskStratification

RecommendationClassIPatientswhopresentwithchestdiscomfortshouldundergoearlyriskstratificationthatfocusesonanginalsymptoms,physicalfindings,ECGfindings,andbiomarkersofcardiacinjuryA12-leadECGshouldbeobtainedimmediatelyinpatientswithongoingchestdiscomfortB.EarlyRiskStratification

RecommendationClassIBiomarkersofcardiacinjuryshouldbemeasuredinallpatientswhopresentwithchestdiscomfortconsistentwithACS.Acardiac-specifictroponinisthepreferredmarker,andifavailable,itshouldbemeasuredinallpatients.Creatinephosphokinase-MBisoenzyme(CK-MB)bymassassayisalsoacceptable.Inpatientswithnegativecardiacmarkerswithin6hoursoftheonsetofpain,anothersampleshouldbedrawnbetween6and12hoursB.EarlyRiskStratification

RecommendationTotalCK(withoutMB),aspartateaminotransferase(AST),serumglutamicoxaloacetictransaminase(SGOT),-hydroxybutyricdehydrogenaseand/orlactatedehydrogenaseforthedetectionofmyocardialinjuryClassIIIClassIIbC-reactiveprotein(CRP)andothermarkersofinflammationshouldbemeasuredShort-TermRiskofDeathorNonfatalMI

inPatientswithUnstableAngina

High-Risk(

1oftheFollowingFeaturesMustbePresent)History Acceleratingtempoofischemicsymptomsinpreceding48hCharacterofpain Prolongedongoing(>20min)restpainClinicalfindings Pulmonaryedema,mostlikelyrelatedtoischemia

NewofworseningMRmurmur

S3ornew/worseningrales

Hypotension,bradycardia,tachycardia

Age>75yrsECGfindings Anginaatrest,withtransientST-segmentchanges0.05mV

Bundle-branchblock,neworpresumednew

SustainedventriculartachycardiaCardiacmarkers Elevated(eg.TnTorTnI>0.1ng/ml)

Short-TermRiskofDeathorNonfatalMI

inPatientswithUnstableAngina

Intermediate-Risk(Musthave1oftheFollowingFeatures)History PriorMI,peripheralorcerebrovasculardisease,orCABG;

prioraspirinuseCharacterofpain Prolonged(>20min)restangina,nowresolved,with

moderateorhighlikelihoodofCAD

Restanigna(<20minorrelievedwithrestofsublingualNTG)Clinicalfindings Age>70yrsECGfindings T-waveinversion>0.2mV

PathologicalQwavesCardiacmarkers Slightlyelevated(eg.TnT>0.01but<0.1ng/ml)

Short-TermRiskofDeathorNonfatalMI

inPatientswithUnstableAngina

Low-Risk(MayhaveanyoftheFollowingFeatures)History

Characterofpain New-onsetorprogressiveCCSClassIIIorIVanginainthe

past2weekswithmoderateorhighlikelihoodofCADClinicalfindings

ECGfindings NormalorunchangedECGduringanepisodeof

chestdiscomfortCardiacmarkers Normal

RecommendationfortheDiagnosisofNoncardiacCauseofSymptomsClassI 1.theinitialevaluationofthepatientwithsuspectedACSshouldincludeasearchfornoncoronarycausesthatcouldexplainthedevelopmentofsymptomsThemajorobjectivesofthephysicalexaminationsaretoidentifypotentialprecipitatingcausesofmyocardialischemia(e.g.,uncontrolledhypertensionorthyrotoxicosis),evidenceofotherchronicdisease(e.g.,aorticstenosisorhypertrophiccardiomyopathy),andcomorbidconditions(e.g.,pulmonarydisease)andtoassessthehemodynamicimpactoftheischemiceventToolsforRiskStratification11/0212The12-leadECGliesatthecenterofthedecisionpathwayfortheevaluationandmanagementofpatientswithischemicdiscomfort.Arecordingmadeduringanepisodeofpresentingsymptomsisparticularlyvaluable.Importantly,transientST-segmentchanges(>0.05mV)thatdevelopduringasymptomaticepisodeatrestandthatresolvewhenthepatientbecomesasymptomaticstronglysuggestacuteischemiaandaveryhighlikelihoodofunderlyingsevereCADToolsforRiskStratification11/0213BiomarkersareofcriticalimportanceintheevaluationofpatientswithUA/NSTEMI.Thetroponinsoffergreatdiagnosticsensitivitybecauseofyourabilitytoidentifypatientswithlesseramountsofmyocardialdamage.

Nevertheless,theselesseramountsofdamageareassociatedwithhigh-riskpatientswithACSsbecausetheyarethoughttorepresentmicroinfarctionsthatresultfrommicroembolifromanunstableplaque.Point-of-CareTests

Cardiactroponins

CK-MB

MyoglobinBiochemicalCardiacMarkersforEvaluationandManagementofPatientsSuspectedofHavinganACSbutWithout

ST-SegmentElevationon12-LeadECGPeakA,earlyreleaseofmyoglobinorCK-MBisoformsafterAMI01PeakB,cardiactroponinafterAMI02PeakC,CK-MBafterAMI03PeakD,cardiactroponinafterunstableangina.04CardiacTroponins11/0216AdvantagespowerfultoolforriskstratificationgreatersensitivityandspecificitythanCK-MBdetectionofrecentMIupto2weeksafteronsetDisadvantageslowsensitivityinveryearlyphaseofMI(<6haftersymptomonset)limitedabilitytodetectlateminorreinfarctionClinicalrecommendationsusefulasasingletesttoefficientlydiagnoseNSTEMI(includingminormyocardialdamage),withserialmeasurementsCK-MB11/0217Advantagesrapid,cost-efficient,accurateassaysabilitytodetectearlyreinfarctionDisadvantageslossofspecificityinsettingofskeletalmusclediseaseorinjury,includingsurgerylowsensitivityduringveryearlyMI(<6haftersymptomonset)orlateraftersymptomonset(>36h)andforminormyocardialdamage(detectablebytroponins)ClinicalrecommendationspriorstandardandstillacceptablediagnostictestinmostclinicalcircumstancesMyoglobin11/0218AdvantageshighsensitivityusefulinearlydetectionofMIdetectionofreperfusionmostusefulinrulingoutMIDisadvantagesverylowspecificityinsettingofskeletalmuscleinjuryordiseaserapidreturntonormalrangelimitssensitivityforlaterpresentationsClinicalrecommendationsshouldnotbeusedasonlydiagnosticmarkerbecauseoflackofcardiacspecificityC.ImmediateManagement

ClassI-Recommendations

1.Thehistory,physicalexamination,12-leadECG,andinitialcardiacmarkertestsshouldbeintegratedtoassignpatientswithchestpaintooneoffourcategories:annoncardiacdiagnosis,chronicstableangina,possibleACS,anddefiniteACS.

2.PatientswithdefiniteorpossibleACSwhoseinitial12-leadECGandcardiacmarkerlevelsarenormalshouldbeobservedinfacilitywithcardiacmonitoring,andrepeatECGandcardiacmarkermeasurementshouldbeobtained6to12hoursaftertheonsetofsymptomsC.ImmediateManagement

ClassIRecommendations

3.Inpatientsinwhomischemicheartdiseaseispresentorsuspected,ifthefollow-up12-leadECGandcardiacmarkermeasurementsarenormal,astresstest(exerciseorpharmacological)toprovokeischemiamaybeperformed.Low-riskpatientswithanegativestresstestcanbemanagedasoutpatients

4.PatientswithdefiniteACSandongoingpain,positivecardiacmarkers,newST-segmentdeviations,newdeepT-waveinversions,hemodynamicabnormalities,orapositivestresstestshouldbeadmittedtothehospital

5.PatientswithpossibleACSandnegativecardiacmarkerswhoareunabletoexerciseorwhohaveanabnormalrestingECGshouldhaveapharmacologicalstresstestSymptomsSuggestiveofACSDefiniteACSNoSTelevationAlgorithmfortheEvaluationandManagement

ofPatientsSuspectedofHavinganACS.STelevationPossibleACSChronicStableAnginaNoncardiacDiagnosisTreatmentas

indicatedby

alternativediagnosisSeeACC/AHA/ACP

GuidelinesforChronic

StableAnginaNondiagnosticECG

NormalInitialserum

cardiacmarkersSTand/orTwavechanges

Ongoingpain

Positivecardiacmarkers

HemodynamicabnormalitiesObserve

Follow-upat4-8hours;

ECG,cardiacmarkersEvaluationfor

reperfusiontherapySeeACC/AHA

Guidelinesfor

AcuteMINorecurrentpain;Negativefollow-upstudiesRecurrentischemicpain

orpositivefollow-upstudiesDiagnosisofACSconfirmedAdmittohospital

ManageviaacuteischemiapathwayStressstudytoprovokeischemia

ConsiderevaluationofLVfunctionifischemiapresent

(Testmaybeperformedpriortodischargeorasoutpatient)Negative:

Potentialdiagnoses:

nonischemicdiscomfort

low-riskACSPositive:

DiagnosisofACS

confirmedArrangementfor

outpatientfollow-upAnti-ischemicTherapyAntiplateletandAnticoagulationTherapyRiskStratificationEarlyConservativevs.InvasiveStrategiesIII.HospitalCareAcuteIschemicPathway11/0223RecurrentIschemiaand/or

STsegmentshift,orDeepT-waveInversion,orPositivecardiacmarkersEarlyInvasivestrategyAspirin

Beta-blockers

NitratesAntithrombinregimenGPIIb/IIIainhibitor

Monitoring(rhythmandischemia)Immediate

angiography12-24hour

angiographyPatient

stabilizesRecurrent

symptoms/ischemiaHeartfailureSeriousarrhythmiaFollowon

MedicalRxEF<.40EarlyConservativestrategyEvaluateLVfunctionEF.40StressTestNotlowriskLowriskA.Anti-IschemicTherapy

ClassI-Recommendations

1.BedrestwithcontinuousECGmonitoringforischemiaandarrhythmiadetectioninpatientswithongoingrestpain

2.Sublingualfollowbyintravenousnitroglycerin(NTG)forimmediatereliefofischemiaandassociatedsymptoms

3.MorphinesulfateintravenouslywhensymptomsarenotimmediatelyrelievedwithNTGorwhenacutepulmonarycongestionispresent

4.Abeta-blocker,withthefirstdoseadministeredintravenouslyifthereisongoingchestpain,followedbyoraladministration,intheabsenceofcontraindicationsA.Anti-IschemicTherapy

ClassI-RecommendationsAnondihydropyridinecalciumantagonists(e.g.,verapamilordiltiazem)intheabsenceofsevereleftventricular(LV)dysfunctionorothercontraindicationsinpatientswithcontinuingorfrequentrecurringischemiawhenbeta-blockersarecontraindicatedAndangiotensin-convertingenzymeinhibitor(ACEI)whenhypertensionpersistsdespitetreatmentwithNTGandabeta-blockersinpatientswithLVsystolicdysfunctionorcongestiveheartfailure(CHF)andinACSpatientswithdiabetesA.Anti-IschemicTherapy

Recommendationsorallong-actingcalciumantagonistsforrecurrentischemiaintheabsenceofcontraindicationsandwhenbeta-blockersandnitratesarefullyused

AnACEIforallpost-ACSpatientsClassIIa extended-releaseformofnondihydropyridinecalciumantagonistsinsteadofabeta-blocker

immediate-releasedihydropyridinecalciumantagonistsinthepresenceofa-blockerClassIIbA.Anti-IschemicTherapy

RecommendationsNTGorothernitrateswithin24hoursofsildenafil(Viagra)use

Immediate-releaseddihydropyridinecalciumantagonistsintheabsenceofabeta-blockerClassIII B.AntiplateletandAnticoagulationTherapyAntithrombotictherapyisessentialtomodifythediseaseprocessesanditsprogressiontodeath,myocardialinfarction(MI),orrecurrentMI.Acombinationofaspirin(ASA),clopidogrel,andunfractionated(UFH)orlowmolecularweight(LMWH)heparin,representsthemosteffectivetherapy.AplateletglycoproteinGPIIb/IIIareceptorantagonistsshouldbeusedinpatientswithcontinuingischemiaorwithotherhigh-riskfeaturesinwhomanearlyinvasivestrategyisplanned.B.AntiplateletandAnticoagulationTherapyForpatientsinwhomtherearecontraindicationsforASAuse,clopidogrelshouldbeadministered.Intheabsenceofahighriskforbleeding,aspirinandclopidogrelshouldbeadministeredpriortoPCIandclopidogrelshouldbecontinuedforatleastonemonthafterstenting.Aspirinshouldbecontinuedforanindefiniteperiod.B.AntiplateletandAnticoagulationTherapyHeparin(eitherUFHorlowmolecularweightheparin(LMWH])isakeycomponentintheantithromboticmanagementofUA/NSTEMI.ThedoseofUFHshouldbetitratedtoanactivatedpartialthromboplastintimethatis1.5to2.5timescontrol.AdvantageofLMWHpreparationsaretheeaseofsubcutaneousadministrationandtheabsenceofaneedformonitoring.Furthermore,theLMWHsstimulateplateletslessthanUFHdoesandarelessfrequentlyassociatedwithheparin-inducedthrombocytopenia.However,theyappeartobeassociatedwithsignificantlymorefrequentminor(butnotmajor)bleedingB.AntiplateletandAnticoagulationTherapyWhenplateletsareactivated,theGPIIb-IIIareceptorundergoesachangeinconfigurationthatresultsinbindingoffibrinogentoplateletreceptors,resultinginplateletaggregation.TheefficacyofGPIIb-IIIaantagonistsinpreventionofthecomplicationsassociatedwithpercutaneouscoronaryintervention(PCI)hasbeendocumentedinnumeroustrials,manyofwhichwerecomposedentirelyorinlargepartofpatientswithUA.TrialswithtirofIbanandonetrialwitheptifibatidehavealsoshownefficacyinUA/NSEMIpatients,onlysomeofwhomunderwentinterventions.InPCItrials,theadministrationofabciximabconsistentlyshowedasignificantreductionintherateofMIandtheneedforurgentrevascularizationAntiplateletandAnticoagulationTherapyAntiplateletandAnticoagulationTherapyTreatmentwithtoGPIIb-IIIablockersincreasetheriskofbleeding,whichistypicallymucocutaneousorinvolvestheaccesssiteofvascularintervention.Bloodhemoglobinandplateletcountsshouldbemonitored,andpatientsurveillanceforbleedingshouldbeperformeddailyduringtheadministrationofGPIIb/IIIablockersB.AntiplateletandAnticoagulationTherapy

ClassI-Recommendations

1.Antiplatelettherapyshouldbeinitiatedpromptly.ASAshouldbeadministeredassoonaspossibleafterpresentationandcontinuedindefinitely

2.ClopidogrelshouldbeadministeredtohospitalizedpatientswhoareunabletotakeASAbecauseofhypersensitivityormajorgastrointestinalintolerance

3.Inhospitalizedpatientsinwhomanearlynon-interventionalapproachisplanned,clopidogrelshouldbeaddedtoASAassoonaspossibleonadmissionandadministeredforatleast1monthandforupto9months.AntiplateletandAnticoagulationTherapy1ClassIRecommendations2InpatientsforwhomaPCIisplanned,clopidogrelshouldbestartedandcontinuedforatleast1monthandupto9monthsinpatientswhoarenotathighriskforbleeding3InpatientstakingclopidogrelinwhomCABGisplanned,ifpossiblethedrugshouldbewithheldforatleast5days,andpreferablyfor7days.4AntiplateletandAnticoagulationTherapy1ClassIRecommendations2AnticoagulationwithsubcutaneousLMWHorintravenousunfractionated(UFH)shouldbeaddedtoantiplatelettherapywithASAand/orclopidogrel3AplateletGPIIb/IIIaantagonistshouldbeadministered,inadditiontoASAandheparin,topatientsinwhomcatheterizationandPCIareplanned.TheGPIIb/IIIaantagonistmayalsobeadministeredjustpriortoPCI4AntiplateletandAnticoagulationTherapy

RecommendationsEnoxaparinispreferabletoUFHasananticoagulantintheabsenceofrenalfailureandunlessCABGisplannedwithin24h.ClassIIaIntravenousfibrinolytictherapyinpatientswithoutacuteST-segmentelevation,atrueposteriorMI,orapresumednewleft-bundle-branchclock(LBBB)AbciximabadministrationinpatientsinwhomPCIisnotplannedClassIIIIntravenousThrombolyticTherapy

inNon-STElevationMIAntiplateletandAnticoagulationTherapy

ClassIIIRecommendationsC.RiskStratification11/0239ThemanagementofpatientswithanACSrequirescontinuousriskstratification.ThegoalofnoninvasivetestingaretodeterminethepresenceorabsenceofischemiainpatientswithalowlikelihoodofCADandtoestimateprognosis.C.RiskStratification11/0240 Becauseofsimplicity,lowercost,andwidespreadfamiliaritywithperformanceandinterpretation,thestandardlow-levelexerciseECGstresstestremainsthemostreasonabletestinpatientsabletoexercisewhohavearestingECGthatisinterpretableforST-segmentshifts.

PatientswithanECGpatternthatwouldinterferewithinterpretationoftheSTsegmentshouldhaveanexercisetestwithimaging.

Patientswhoareunabletoexerciseshouldhaveapharmacologicalstresstestwithimaging.C.RiskStratification

ClassI-Recommendations

1.Noninvasivestresstestinginlow-riskpatientswhohavebeenfreeofischemiaatrestorwithlow-levelactivityandfreeofCHFforaminimumof12to24hours

2.Non-invasivestresstestinginpatientsatintermediateriskwhohavebeenfreeofischemiaatrestorwithlow-levelactivityandofCHFforaminimumof2or3days

3.ChoiceofstresstestisbasedontherestingECG,abilitytoperformexercise,localexpertise,andtechnologiesavailable

4.PromptangiographywithoutnoninvasiveriskstratificationforfailureofstabilizationwithintensivemedicaltreatmentC.RiskStratification

RecommendationsClassIIa 1.Anoninvasivetest(echocardiogramorradionuclideangiogram)toevaluateLVfunctioninpatientswithdefiniteACSwhoarenotscheduledforcoronaryarteriographyandleftventriculographyD.EarlyConservativeVersusInvasiveStrategiesTwodifferenttreatmentstrategies,termed“earlyconservative”and“earlyinvasive”haveevolvedforpatientswithUA/NSTEMI.Intheearlyconservativestrategy,coronaryangiogrpahyisreservedforpatientswithevidenceofrecurrentischemia(anginaorST-segmentchangesatrestorwithminimalactivity)orastronglypositivestresstestdespitevigorousmedicaltherapy.Intheearlyinvsivestrategy,patientswithoutclinicallyobviouscontraindicationstocoroanryrevascularizationareroutinelyrecommendedforearlycoronaryangiographyandangiographicallydirectedrevascularizationifpossible.D.EarlyConservativeVersusInvasiveStrategiesInpatientswithUA/NSTEMIwithoutrecurrentischemiainthefirst24hours,theuseofearlyangiographyprovidesaconvenientapproachtoriskstratification.Itcanidentifythepatientswithnosignificantcoronarystenosesandthosewith3-vesseldiseasewithLVdysfunctionorleftmaindisease.Theformergrouphasanexcellentprognosis,whereasthelatergourpmayderiveasurvivalbenefitfromcoronaryarterybypassgraftsurgery(CABG).D.EarlyConservativeVersusInvasiveStrategiesInaddition,earlyPCIoftheculpritlesionhasthepotentialtoreducetheriskforsubsequenthospitalizationandtheneedformultipleantianginaldrugscomparedwiththeearlyconservativestrategy,Inpatientswithouthigh-riskfeatures,coronaryarteriographyisoptionalandcanbesafelydeferred.D.EarlyConservativeVersusInvasiveStrategies

ClassI-Recommendations1. AnearlyinvasivestrategyisrecommendedinpatientswithUA/NSTEMIandanyofthefollowinghigh-riskindicators:Recurrentangina/ischemiaatrestorwithlow-levelactivitiesdespiteintensiveanti-ischemiatherapyElevatedTnTorTnINeworpresumednewST-segmentdepressionatpresentationRecurrentangian/ischemiawithCHFsymptoms,anS3gallop,pulmonaryedema,worseningrales,orneworworseningmitralregurgitation.D.EarlyConservativeVersusInvasiveStrategies

ClassI-RecommendationsHigh-riskfindingsonnoninvasivestresstestingDepressedLVsystolicfunction(eg.ejectionfraction[EF]<0.40onnoninvasivestudy).Hemodynamicinstabilityoranginaatrestaccompaniedbyhypotension.Sustainedventriculartachycardia.PCIwithin6months.PriorCABGIntheabsenceofthesefindings,witheranearlyconservativeoranearlyinvasivestrategyinhospitalizedpatientswithoutcontrainciationsforrevascualrizaitonEarlyConservativeVersusInvasiveStrategies

ClassI-RecommendationsEarlyConservativeVersusInvasiveStrategies

RecommendationsAnearlyinvasivestrategyinpatientswithrepeatedpresentationsforACSdespitetherapyandwithoutevidenceofongoingischemiaorhighriskClassIIa01Coronaryangiographyinpatietnswithextensivecomorbidities(eg,liverorpulmonaryfailure,cancer),inwhomrisksofrevascularizationarenotlikelytooutweighthebenefitsCoronaryangiographyinpatientswithacutechestpainandalowlikelihoodofACS.ClassIII02IV.CoronaryRevascularizationRecommendationsforRevascularizationwithPCIandCABGinPatientswithUA/NSTEMIRecommendationsforRevascularization1ClassI-Recommendations2CABGforpatientswithsignificantleftmainCAD3CABGforpatientswith3-vesselCAD;thesurvivalbenefitisgreatestinpatientswithabnormalLVfunction(EF<0.50)4CABGforpatientswith2-vesselCADwithsignificantproximalleftanteriordescendingCADandwitherabnormalLVfunction(EF<0.50)ordemonstrableischemiaonnoninvasivetesting5RecommendationsforRevascularization1ClassI-Recommendations2PCIorCABGforpatientswith1-or2-vesselCADwithoutsignificantproximalleftanteriordescendingCADbutwithalargeareaofviablemyocaridumandhigh-riskcriteriaonnoninvasivetesting3PCIforpatientswithmultivesselCADwithsuitablecoronaryanatomy,withnormalLVfunction,andwithoutdiabetes4CABGwiththeinternalmammaryarteryforpatientswithmultivesselCADandtreateddiabetesmellitusIntravenousplateletGPIIb/IIIainhibitorinUA/NSTEMIpatientsundergoingPCIRecommendationsforRevascularization

ClassI-RecommendationsRecommendationsforRevascularization1Recommendations2ClassIIa3PCIorCABGforpatientswith1-vesselCADwithsignificantproximalleftanteriordescendingCAD4ClassIIb5PCIforpatientswith2-or3-vesselCADwithsignificantproximaleftanteriordescendingCAD,withtreateddiabetesorabnormalLVfunction,andwithanatomysuitableforcatheter-basedtherapy 6ClassIIIPCIorCABGforpatientswithinsignificantcoronarystenosis(<50%diameter)PCIinpatientswithsignificantleftmaincoronaryarterydiseasewhoarecandidatesforCABGRecommendationsforRevascularization

RecommendationsV.HospitalDischargeandPost-HospitalDischargeCarePostdischargeTherapy1ClassI-Recommendations2Beforehospitaldischarge,thepatientsand/oradesignatedresponsiblecaregivershouldbeprovidedwithwell-understoodinstructionswithrespecttomedicationtype,purpose,dose,frequency,andpertinentsideeffects.3Drugsrequiredinthehospitaltocontrolischemiashouldbecontinuedaft