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The Evolving Face of Myocardial Reperfusion in Acute Coronary Syndromes: A Primer for the Internist R. Jay Widmer, MD, PhD, Peter M. Pollak, MD, Malcolm R. Bell, MD, Bernard J. Gersh, MBChB, DPhil, Nandan S. Anavekar, MBBCh Mayo Clinic Proceedings Volume 93, Issue 2, Pages 199-216 (February 2018) DOI: 10.1016/j.mayocp.2017.11.016 Copyright © 2017 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 1 Commonalities in risk stratification. GRACE = Global Registry of Acute Coronary Events; HEART = History, ECG, Age, Risk factors, and Troponin; MI = myocardial infarction; PURSUIT = Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy; TIMI = Thrombosis in Myocardial Infarction. Mayo Clinic Proceedings 2018 93, 199-216DOI: (10.1016/j.mayocp.2017.11.016) Copyright © 2017 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 2 Initial management of acute coronary syndrome (ACS). ECG = electrocardiography; GP = glycoprotein; LMWH = low-molecular-weight heparin; UFH = unfractionated heparin. Mayo Clinic Proceedings 2018 93, 199-216DOI: (10.1016/j.mayocp.2017.11.016) Copyright © 2017 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 3 Initial invasive (A), ischemia-guided (B), and medical management (C) strategies for non–ST-elevation acute coronary syndrome (NSTE-ACS). ACEI/ARB = angiotensin-converting enzyme inhibitor/angiotensin receptor blocker; β-B = Beta blocker; CABG = coronary artery bypass graft surgery; CCB = calcium channel blocker; ECG = electrocardiography; GP = glycoprotein; LMWH = low-molecular-weight heparin; LV = left ventricular; LVEF = left ventricular ejection fraction; PCI = percutaneous coronary intervention; UA = unstable angina; UFH = unfractionated heparin. Mayo Clinic Proceedings 2018 93, 199-216DOI: (10.1016/j.mayocp.2017.11.016) Copyright © 2017 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 4 Management strategies in ST-elevation myocardial infarction (STEMI). A, General treatment strategy of patient with STEMI with the primary determinant being presentation at a PCI-capable hospital followed by the time of first medical contact to device/reperfusion. B, In a PCI-capable hospital, the patient should be adequately loaded prior to PCI with antiplatelet agents (aspirin and P2Y12 inhibitor) as well as an anticoagulant (usually unfractionated heparin). C, At a non-PCI-capable hospital, if fibrinolysis is decided upon, the patient should also be treated with antiplatelet agents and an anticoagulant. GP = glycoprotein; PCI = percutaneous coronary intervention; UFH = unfractionated heparin. Mayo Clinic Proceedings 2018 93, 199-216DOI: (10.1016/j.mayocp.2017.11.016) Copyright © 2017 Mayo Foundation for Medical Education and Research Terms and Conditions