Revascularization is to restore blood flow to the ischemic myocardium with the objective of limiting a continuous damage to reduce ventricular irritability and improve short-term and long-term course. Modes of revascularization include thrombolysis with fibrinolytic drugs The percutaneous coronary intervention (PCI) with or without stent placement Coronary artery bypass surgery (CABG) use, time and modality of revascularization depend on which (ACS) is present acute coronary syndrome, the time of presentation, scope and location of anatomical lesions and the availability of personnel and means (procedure for acute coronary syndromes.). Procedure for acute coronary syndromes. Unstable angina and non-ST-segment elevation myocardial infarction An immediate reperfusion in patients with uncomplicated non-ST-segment elevation myocardial infarction (NSTEMI), in which a completely closed infarct-related artery during the presentation is unusual or in patients with unstable angina pectoris who respond to medical treatment, not so much. Such patients are usually within the first 24-48 hours of hospitalization angiography subjected to identify coronary lesions that require PCI or CABG. A non-interventional approach and the attempt of medical treatment for patients in whom angiography following shows only a small area of ??myocardium at risk lesion morphology inaccessible PCI Anatomically insignificant disease (<50% coronary stenosis) Significant disorder of the left hand in patients candidates for CABG is furthermore should be postponed angiography or PCI in favor of medical care in patients with a high risk of procedure-related morbidity or mortality. Clinical calculator: TIMI (thrombolysis in myocardial infarction) scores for unstable angina or non-ST-segment elevation myocardial infarction patients with persistent chest pain despite maximum medical treatment or complications (for example, markedly elevated cardiac markers, presence of circulatory shock, acute mitral regurgitation, ventricular septal defect. unstable arrhythmias), however, should be referred directly to the cardiac catheterization laboratory to identify coronary lesions that PCI or CABG require. CABG is recommended in patients with main stem involvement or main stem equivalent (prox. RIVA + RCX) and those brought forward with left ventricular dysfunction, or diabetes mellitus PCI usually seen in patients with stable angina pectoris. The CABG must also be considered when the PCI is not successful, can not be performed (eg. As in lesions that are long or near bifurcation points lie) or acute Koronararteriendissektion caused. Fibrinolytic agents are in an unstable angina or NSTEMI not indicated one, the risks outweigh the potential benefits. ST-segment elevation myocardial infarction Acute PCI is the preferred treatment of ST-segment elevation myocardial infarction (STEMI), if it is available on time (door-to-balloon time <90 min) can be carried out and by an experienced interventionists. Indications for urgent PCI in the later stages of STEMI are hemodynamic instability, malignant arrhythmias that require a transvenous stimulation or repeated cardioversion, and an age of> 75 years. (Editor’s note: There is medically no reason to proclaim a delay here These patients are also included immediately in the HK lab.). If the lesions CABG require the mortality rate is about 4-12% and the morbidity rate is 20 -43%. If it is likely that there will be a significant delay in the availability of PCI, thrombolysis should in STEMI patients who meet the criteria (see table: fibrinolysis for STEMI), are performed. Reperfusion using a fibrinolytic agent is most effective during the first minutes to hours after the onset of myocardial infarction. The earlier a Fibriolytikum is given, the better. The goal is a thrombolysis within 30-60 minutes (door-to-needle time). The biggest success is within the first 3 hours, but the drugs are effective up to 12 hours. Fibrinolytic agents in combination with aspirin to reduce the mortality rate in the hospital by 30-50% and improve ventricular function. The use of fibrinolytic by trained paramedics before hospitalization can significantly reduce the time to treatment and should be considered in situations where PCI is not min within 90 possible, especially in patients within 3 h are presented after symptom onset , (Editor’s note:.! This contradicts massive German treatment reality it may be applied in the American Paramedic system, but is in the German rescue service system with emergency physicians as not allowed) Regardless require most patients who undergo thrombolysis, ultimately, a referral to a PCI-capable facility for elective angiography and PCI if required prior to discharge. (Editor’s note: this guideline recommendations: 1. preclinical lysis: the patient is primarily in an intervention clinic, the second hospital-lysis without catheterization laboratory, transfer to lysis in a center, third PCI immediately Lyseversagen in Lyseerfolg within 4-24 hours ) a PCI should be considered for fibrinolytic therapy when chest pain or ST segment elevation stop ?60 minutes after the lysis or if pain and ST-segment elevation recur. A PCI should be paid, however, only be carried out if they min at <90 can be started by cons onset of symptoms. Is a PCI impossible fibrinolytic therapy can be repeated. Properties and selection of fibrinolytic drugs have been discussed elsewhere. Fibrinolysis for STEMI criteria peculiarities ECG criteria * ST-segment elevation in ?2 contiguous leads Typical symptoms and left bundle branch block is not known as old pure posterior MI (large R wave in V1 and ST depression in V1-V4) Absolute contraindications aortic dissection Previous hämorrha gic stroke (at any time) Previous ischemic stroke within 1 yr active internal bleeding (not menstruation) Intracranial tumor pericarditis Relative contraindications blood pressure> 180/110 mmHg after initial antihypertensive therapy to trauma or major surgery within 4 weeks Active stomach ulcers pregnancy bleeding incompressible vascular puncture Current anticoagulation (INR> 2) * patients are presented in a hyper acute phase of MI with giant T waves, do not meet the current criteria for conducting a fibrinolysis. The ECG is repeated after 20-30 minutes to see if an ST-segment elevation has developed.


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