"1. Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours' duration (Level of Evidence: A)"
"2. Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours' duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from FMC(Level of Evidence: B)"
"3. Primary PCI should be performed in patients with STEMI and cardiogenic shock or acute severe HF, irrespective of time delay from myocardial infarction (MI) onset(Level of Evidence: B)"
"1. PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable (Level of Evidence: B)"
"1. Primary PCI is reasonable in patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia between 12 and 24 hours after symptom onset (Level of Evidence: B)"
"1. Placement of a stent (bare-metal stent or drug-eluting stent) is useful in primary PCI for patients with STEMI (Level of Evidence: A)"
"2. Bare-metal stents†should be used in patients with high bleeding risk, inability to comply with 1 year of dual antiplatelet therapy (DAPT), or anticipated invasive or surgical procedures in the next year(Level of Evidence: C)"
"1. Drug-eluting stents should not be used in primary PCI for patients with STEMI who are unable to tolerate or comply with a prolonged course of DAPT because of the increased risk of stent thrombosis with premature discontinuation of one or both agents (Level of Evidence: B)"
Antiplatelet Therapy to Support Primary PCI for STEMI (DO NOT EDIT)
"3. A loading dose of a P2Y12receptor inhibitor should be given as early as possible or at time of primary PCI to patients with STEMI. Options include(Level of Evidence: B)"
"4. P2Y12inhibitor therapy should be given for 1 year to patients with STEMI who receive a stent (bare-metal or drug-eluting) during primary PCI using the following maintenance doses:(Level of Evidence: B)"
"1. It is reasonable to use 81 mg of aspirin per day in preference to higher maintenance doses after primary PCI (Level of Evidence: B)"
"2. It is reasonable to start treatment with an intravenous glycoprotein (GP) IIb/IIIa receptor antagonist such as abciximab (Level of Evidence: A), high-bolus-dose tirofiban (Level of Evidence: B), or double-bolus eptifibatide (Level of Evidence: B) at the time of primary PCI (with or without stenting or clopidogrel pretreatment) in selected patients with STEMI who are receiving unfractionated heparin (UFH)"
"1. It may be reasonable to administer intravenous GP IIb/IIIa receptor antagonist in the precatheterization laboratory setting (e.g., ambulance, emergency department) to patients with STEMI for whom primary PCI is intended (Level of Evidence: B)"
"2. It may be reasonable to administer intracoronary abciximab to patients with STEMI undergoing primary PCI (Level of Evidence: B)"
"3.Continuation of a P2Y12inhibitor beyond 1 year may be considered in patients undergoing drug-eluting stent placement (Level of Evidence: C)"
Anticoagulant Therapy to Support Primary PCI (DO NOT EDIT)
"1.For patients with STEMI undergoing primary PCI, the following supportive anticoagulant regimens are recommended "
"a.UFH, with additional boluses administered as needed to maintain therapeutic activated clotting time levels, taking into account whether a GP IIb/IIIa receptor antagonist has been administered (Level of Evidence: C)"
"1. Fondaparinux should not be used as the sole anticoagulant to support primary PCI because of the risk of catheter thrombosis (Level of Evidence: B)"
"1. In patients with STEMI undergoing PCI who are at high risk of bleeding, it is reasonable to use bivalirudin monotherapy in preference to the combination of UFH and a GP IIb/IIIa receptor antagonist(Level of Evidence: B)"
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary(DO NOT EDIT)[1]
Renin-Angiotensin-Aldosterone System Inhibitors (DO NOT EDIT)
"1. An angiotensin-converting enzyme inhibitor should be administered within the first 24 hours to all patients with STEMI with anterior location, HF, or ejection fraction less than or equal to 0.40, unless contraindicated(Level of Evidence: A)"
"2. An angiotensin receptor blocker should be given to patients with STEMI who have indications for but are intolerant of angiotensin-converting enzyme inhibitors(Level of Evidence: B)"
"3. An aldosterone antagonist should be given to patients with STEMI and no contraindications who are already receiving an angiotensin-converting enzyme inhibitor and beta blocker and who have an ejection fraction less than or equal to 0.40 and either symptomatic HF or diabetes mellitus(Level of Evidence: B)"
"1. Urgent CABG is indicated in patients with STEMI and coronary anatomy not amenable to PCI who have ongoing or recurrent ischemia, cardiogenic shock, severe HF, or other high-risk features(Level of Evidence: B)"
"2. CABG is recommended in patients with STEMI at time of operative repair of mechanical defects (Level of Evidence: B)"
"1. The use of mechanical circulatory support is reasonable in patients with STEMI who are hemodynamically unstable and require urgent CABG (Level of Evidence: C)"
"1. Emergency CABG within 6 hours of symptom onset may be considered in patients with STEMI who do not have cardiogenic shock and are not candidates for PCI or fibrinolytic therapy (Level of Evidence: C)"
Timing of Urgent CABG in Patients With STEMI in Relation to Use of Antiplatelet Agents
"2. Clopidogrel or ticagrelor should be discontinued at least 24 hours before urgent on-pump CABG, if possible(Level of Evidence: B)"
"3. Short-acting intravenous GP IIb/IIIa receptor antagonists (eptifibatide, tirofiban) should be discontinued at least 2 to 4 hours before urgent CABG (Level of Evidence: B)"
"4. Abciximab should be discontinued at least 12 hours before urgent CABG (Level of Evidence: B)"
"1. Urgent off-pump CABG within 24 hours of clopidogrel or ticagrelor administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding (Level of Evidence: B)"
"2. Urgent CABG within 5 days of clopidogrel or ticagrelor administration or within 7 days of prasugrel administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding (Level of Evidence: C)"
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary[1]
Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals
"1. All communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of emergency medical services and hospital-based activities. Performance can be facilitated by participating in programs such as Mission: Lifeline and the Door-to-Balloon Alliance(Level of Evidence: B)"
"2. Performance of a 12-lead electrocardiogram (ECG) by emergency medical services personnel at the site of first medical contact (FMC) is recommended in patients with symptoms consistent with STEMI(Level of Evidence: B)"
"3. Reperfusion therapy should be administered to all eligible patients with STEMI with symptom onset within the prior 12 hours(Level of Evidence: A)"
"4. Primary PCI is the recommended method of reperfusion when it can be performed in a timely fashion by experienced operators(Level of Evidence: A)"
"5. Emergency medical services transport directly to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI, with an ideal FMC-to-device time system goal of 90 minutes or less(Level of Evidence: B)"
"6. Immediate transfer to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI who initially arrive at or are transported to a non–PCI-capable hospital, with an FMC-to-device time system goal of 120 minutes or less(Level of Evidence: B)"
"7. In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI at non–PCI-capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes because of unavoidable delays (Level of Evidence: B)"
"8. When fibrinolytic therapy is indicated or chosen as the primary reperfusion strategy, it should be administered within 30 minutes of hospital arrival(Level of Evidence: B)"
"1. Reperfusion therapy is reasonable for patients with STEMI and symptom onset within the prior 12 to 24 hours who have clinical and/or ECG evidence of ongoing ischemia. Primary PCI is the preferred strategy in this population (Level of Evidence: B)"
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[2]
"1.Control of resting heart rate using either a beta blocker or nondihydropyridine calcium channel antagonist is recommended for patients with persistent or permanent AF and compensated HF with preserved ejection fraction (Level of Evidence: B)"
"2. In the absence of pre-excitation, intravenous beta-blocker administration (or a nondihydropyridine calcium channel antagonist in patients with HFpEF) is recommended to slow the ventricular response to AF in the acute setting, with caution needed in patients with overt congestion, hypotension, or HF with reduced left ventricular ejection fraction(Level of Evidence: B)"
"3. In the absence of pre-excitation, intravenous digoxin or amiodarone is recommended to control heart rate acutely in patients with HF(Level of Evidence: B)"
"4.Assessment of heart rate control during exercise and adjustment of pharmacological treatment to keep the rate in the physiological range is useful in symptomatic patients during activity.(Level of Evidence: C)"
"5. Digoxin is effective to control resting heart rate in patients with HF with reduced ejection fraction(Level of Evidence: B)"
"1. AV node ablation should not be performed without a pharmacological trial to achieve ventricular rate control (Level of Evidence: C)"
"2. For rate control, intravenous nondihydropyridine calcium channel antagonists, intravenous beta blockers, and dronedarone should not be administered to patients with decompensated HF (Level of Evidence: C)"
"1. A combination of digoxin and a beta blocker (or a nondihydropyridine calcium channel antagonist for patients with HFpEF) is reasonable to control resting and exercise heart rate in patients with AF (Level of Evidence: B)"
"2. It is reasonable to perform AV node ablation with ventricular pacing to control heart rate when pharmacological therapy is insufficient or not tolerated (Level of Evidence: B)"
"3. Intravenous amiodarone can be useful to control heart rate in patients with AF when other measures are unsuccessful or contraindicated. (Level of Evidence: C)"
"4. For patients with AF and rapid ventricular response causing or suspected of causing tachycardia-induced cardiomyopathy, it is reasonable to achieve rate control by either AV nodal blockade or a rhythm-control strategy (Level of Evidence: B)"
"5. For patients with chronic HF who remain symptomatic from AF despite a rate-control strategy, it is reasonable to use a rhythm-control strategy(Level of Evidence: C)"
"1. Oral amiodarone may be considered when resting and exercise heart rate cannot be adequately controlled using a beta blocker (or a nondihydropyridine calcium channel antagonist in patients with HFpEF) or digoxin, alone or in combination (Level of Evidence: C)"
"2. AV node ablation may be considered when the rate cannot be controlled and tachycardia-mediated cardiomyopathy is suspected (Level of Evidence: C)"
Fournier's gangrene
Physiologic Variables
High Abnormal Values
Normal
Low Abnormal Values
+4
+3
+2
+1
0
+1
+2
+3
+ 4
Temperature
>41
39-40.0
38.5-39
36-38.4
34-35.9
32-33.9
30-31.9
<29.9
Heart Rate
>180
140-179
110-139
70-109
55-69
40-54
<39
Respiratory Rate
>50
35-49
25-34
12-24
10-11
6-9
<5
Serum Sodium (mmol/L)
Serum Potassium (mmol/L)
Serum Creatinine (mg/100/ml*2 for acute renal failure)
Hematocrit
WBC (Total/mm*1000)
Serum Bicarbonate (Venous,mmol/l)
Region
Gender
Incidence/100,000
Prevalence/100,000
Region 1
M
Incidence
Prevalence
F
Incidence
Prevalence
Region 2
M
Incidence
Prevalence
F
Incidence
Prevalence
Region 3
M
Incidence
Prevalence
F
Incidence
Prevalence
Region 4
M
Incidence
Prevalence
F
Incidence
Prevalence
Region 5
M
Incidence
Prevalence
F
Incidence
Prevalence
Zika Prevention
How Long to Wait Before Attempting to Have a Baby in Zika Endemic areas
Presence of Symptoms
Women
Men
Zika symptoms
At least 8 weeks after symptoms start
At least 6 months after symptoms start
No Zika symptoms
Talk with doctor or healthcare provider
Talk with doctor or healthcare provider
Zika sexual transmission
For People Who Have Traveled to an Area with Zika
If you are pregnant
Pregnant women should not travel to areas with Zika. If you must travel to an area with Zika, talk to your healthcare provider.
If your partner is pregnant
Use condoms correctly, every time you have vaginal, anal, or oral sex or do not have sex for the entire pregnancy.
If you and your partner are planning a pregnancy
Discuss your plans for pregnancy with a healthcare provider to determine your risk and the options available.
If you or your partner are not pregnant and are not planning a pregnancy
Men - consider using condoms or not having sex for at least 6 months after travel (if you don’t have symptoms) or for at least 6 months from the start of symptoms (or Zika diagnosis) if you develop Zika. Women- consider using condoms or not having sex for at least 8 weeks after travel (if you don’t have symptoms) or for at least 8 weeks from the start of symptoms (or Zika diagnosis) if you develop Zika.
For People Living in an Area with Zika
If you or your partner are pregnant
Use condoms from start to finish, every time you have vaginal, anal, or oral sex or do not have sex for the entire pregnancy. It is also very important to see a healthcare provider to discuss your options during pregnancy
If you and your partner are planning a pregnancy
Discuss your plans for pregnancy with a healthcare provider to determine your risk and the options available.
If you or your partner are not pregnant and are not planning a pregnancy
Consider using condoms or not having sex as long as there is Zika in the area. If either you or your partner develop symptoms of Zika or have concerns, talk to a healthcare provider and follow the guidelines on the left.
• Associated with high grade fever, acute gingivitis and oral ulcerations • The vesicles are small, grouped together and on an erythematous base • Absence of rash on palms and soles • A Tzanck test shows multinucleated giant cells and direct fluorescent antigens test can also help to differentiate hand-foot-and-mouth disease from herpes simplex virus infection
↑January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN0009-7322.