Post cardiac injury syndrome: Difference between revisions
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{{CMG}} '''Associate Editor-In-Chief:''' {{Ibtisam}} | |||
'''''Synonyms and keywords:''''' PCIS | '''''Synonyms and keywords:''''' PCIS | ||
==Overview== | ==Overview== | ||
Post cardiac injury syndrome (PCIS) encompasses three causes of [[pericarditis]]: | Post cardiac injury syndrome (PCIS) encompasses three causes of [[pericarditis]]: [[Post myocardial infarction syndrome]] ([[PMIS]]) or [[Dressler's syndrome]], [[Postpericardiotomy syndrome]] ([[PCS]]) and Posttraumatic pericarditis. | ||
==Historical Perspective== | ==Historical Perspective== | ||
*Dressler's syndrome was first discovered by William Dressler, a Jewish-American Cardiologist at Maimonides Medical Centre, in 1956. | *Dressler's syndrome was first discovered by William Dressler, a Jewish-American Cardiologist at Maimonides Medical Centre, in 1956. | ||
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{{familytree | | | | | | | | | A01 |A01='''Post cardiac injury syndrome(PCIS)'''}} | {{familytree | | | | | | | | | A01 |A01='''Post cardiac injury syndrome(PCIS)'''}} | ||
{{familytree | | | | |,|-|-|-|-|+|-|-|-|-|.| | | }} | {{familytree | | | | |,|-|-|-|-|+|-|-|-|-|.| | | }} | ||
{{familytree | | | |B01 | | | B02 | | | B03 | | |B01= | {{familytree | | | |B01 | | | B02 | | | B03 | | |B01=Post-myocardial <br> infarction pericarditis|B02=Post-pericardiotomy <br> syndrome (PPS)|B03=Post-traumatic <br> pericarditis}} | ||
{{familytree | | | | |!| | | | | | | | | |!| }} | {{familytree | | | | |!| | | | | | | | | |!| }} | ||
{{familytree | | |,|-|^|.| | | | | | |,|-|^|.|}} | {{familytree | | |,|-|^|.| | | | | | |,|-|^|.|}} | ||
{{familytree | | D01 | | D02 | | | | E01 | | E02 |D01=Early infarct-associated pericarditis|D02=Dressler's Syndrome|E01=Thoracic trauma|E02=Iatrogenic trauma}} | {{familytree | | D01 | | D02 | | | | E01 | | E02 |D01=Early infarct-associated <br> pericarditis|D02=Late post-myocardial <br> infarction pericarditis <br> (Dressler's Syndrome)|E01=Thoracic <br> trauma|E02=Iatrogenic <br> trauma}} | ||
{{familytree/end}} | {{familytree/end}} | ||
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Both syndromes represent the delayed occurrence of [[pericarditis]]. [[Post-myocardial infarction syndrome]] is obviously due to [[myocardial infarction]] and [[postpericardiotomy syndrome]] is due to the myocardial injury that occurs during cardiac surgery. The initial trigger seems to be the combination of damage occurring to the pericardial or pleural mesothelial cells and blood entering the pericardial space which causes the release of cardiac antigens into the circulation. It leads to the formation of immune complexes which get deposited into the pericardium, pleura, lungs, joints etc eliciting an inflammatory response. <ref name="pmid1737407">{{cite journal| author=Khan AH| title=The postcardiac injury syndromes. | journal=Clin Cardiol | year= 1992 | volume= 15 | issue= 2 | pages= 67-72 | pmid=1737407 | doi=10.1002/clc.4960150203 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1737407 }} </ref> | Both syndromes represent the delayed occurrence of [[pericarditis]]. [[Post-myocardial infarction syndrome]] is obviously due to [[myocardial infarction]] and [[postpericardiotomy syndrome]] is due to the myocardial injury that occurs during cardiac surgery. The initial trigger seems to be the combination of damage occurring to the pericardial or pleural mesothelial cells and blood entering the pericardial space which causes the release of cardiac antigens into the circulation. It leads to the formation of immune complexes which get deposited into the pericardium, pleura, lungs, joints etc eliciting an inflammatory response. <ref name="pmid1737407">{{cite journal| author=Khan AH| title=The postcardiac injury syndromes. | journal=Clin Cardiol | year= 1992 | volume= 15 | issue= 2 | pages= 67-72 | pmid=1737407 | doi=10.1002/clc.4960150203 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1737407 }} </ref> | ||
==Clinical Features<ref name="pmid30322760">{{cite journal| author=Li W, Sun J, Yu Y, Wang ZQ, Zhang PP, Guo K | display-authors=etal| title=Clinical Features of Post Cardiac Injury Syndrome Following Catheter Ablation of Arrhythmias: Systematic Review and Additional Cases. | journal=Heart Lung Circ | year= 2019 | volume= 28 | issue= 11 | pages= 1689-1696 | pmid=30322760 | doi=10.1016/j.hlc.2018.09.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30322760 }} </ref> | ==Clinical Features== | ||
[[Specific activity|Specific]] [[symptoms]] of post-cardiac injury syndrome include:<ref name="pmid30322760">{{cite journal| author=Li W, Sun J, Yu Y, Wang ZQ, Zhang PP, Guo K | display-authors=etal| title=Clinical Features of Post Cardiac Injury Syndrome Following Catheter Ablation of Arrhythmias: Systematic Review and Additional Cases. | journal=Heart Lung Circ | year= 2019 | volume= 28 | issue= 11 | pages= 1689-1696 | pmid=30322760 | doi=10.1016/j.hlc.2018.09.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30322760 }} </ref> | |||
*Pleuritic chest pain | *[[Pleuritic chest pain]] | ||
*Fever | *[[Fever]] | ||
*Elevated markers of inflammation | *Elevated [[Marker|markers]] of [[inflammation]] | ||
*Pericardial effusion | *[[Pericardial effusion]] | ||
*Pleural effusion | *[[Pleural effusion]] | ||
*Pulmonary infiltrates | *[[Pulmonary]] [[Infiltration (medical)|infiltrates]] | ||
==Differentiating Post cardiac injury syndrome from other Diseases== | ==Differentiating Post cardiac injury syndrome from other Diseases== | ||
*PCIS must be differentiated from other diseases that cause | *[[Post cardiac injury syndrome|PCIS]] must be [[Differentiate|differentiated]] from other [[diseases]] that [[Causes|cause]] [[fever]], [[chest pain]] and pleuropericardial effusion, such as: | ||
:*Pleuritis or Pleuropericarditis | |||
:*Pulmonary | :*[[Pleuritis]] or Pleuropericarditis | ||
:*Boerhaave Syndrome | :*[[Pulmonary embolism]] | ||
:*Blunt | :*[[Boerhaave syndrome|Boerhaave Syndrome]] | ||
:*Pneumothorax | :*[[Blunt trauma|Blunt]] [[chest]] wall [[trauma]] | ||
:*Connective tissue disorders (e.g SLE) | :*[[Pneumothorax]] | ||
:*[[Connective tissue disorders]] (e.g [[SLE]]) | |||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
| Line 59: | Line 57: | ||
==Risk Factors== | ==Risk Factors== | ||
These are the factors which increase the risk of post cardiac injury syndrome: | These are the factors which increase the [[RiskMetrics|risk]] of [[post cardiac injury syndrome]]: <ref name="pmid20511488">{{cite journal| author=Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM | display-authors=etal| title=Pericardial disease: diagnosis and management. | journal=Mayo Clin Proc | year= 2010 | volume= 85 | issue= 6 | pages= 572-93 | pmid=20511488 | doi=10.4065/mcp.2010.0046 | pmc=2878263 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20511488 }}</ref> | ||
*Cardiac Surgery (including [[AVR]], [[MVR]] and aortic surgery) | *[[Cardiac surgery|Cardiac Surgery]] (including [[AVR]], [[MVR]] and aortic surgery) | ||
*Young age | *Young age | ||
*Previous pericarditis | *Previous [[pericarditis]] | ||
*Viral Infection | *Viral Infection | ||
*Prior treatment with prednisone | *Prior treatment with prednisone | ||
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==Treatment== | ==Treatment== | ||
Dressler's syndrome is typically treated with high dose (up to 650 mg PO q 4 to 6 hours) enteric-coated [[aspirin]]. Acetominophen can be added for pain management as this does not affect the coagulation system. Anticoagulants should be discontinued if the patient develops a pericardial effusion. | Dressler's syndrome is typically treated with high dose (up to 650 mg PO q 4 to 6 hours) enteric-coated [[aspirin]]. <ref name="pmid15358045">{{cite journal| author=Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M | display-authors=etal| title=ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). | journal=J Am Coll Cardiol | year= 2004 | volume= 44 | issue= 3 | pages= 671-719 | pmid=15358045 | doi=10.1016/j.jacc.2004.07.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15358045 }}</ref> Acetominophen can be added for pain management as this does not affect the coagulation system. Anticoagulants should be discontinued if the patient develops a pericardial effusion. | ||
[[Non-steroidal_anti-inflammatory_drug|NSAIDs]] such as [[ibuprofen]] should be avoided in the peri-infarct period as they: | [[Non-steroidal_anti-inflammatory_drug|NSAIDs]] such as [[ibuprofen]] should be avoided in the peri-infarct period as they: | ||
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== Treatment == | == Treatment == | ||
=== Medical Therapy === | === Medical Therapy === | ||
*The mainstay of therapy for postcardiac injury syndrome is Anti-inflammatory NSAIDs in combination with colchicine. | *The mainstay of therapy for postcardiac injury syndrome is Anti-inflammatory NSAIDs in combination with colchicine. <ref name="pmid27406462">{{cite journal| author=Shah SR, Alweis R, Shah SA, Arshad MH, Manji AA, Arfeen AA | display-authors=etal| title=Effects of colchicine on pericardial diseases: a review of the literature and current evidence. | journal=J Community Hosp Intern Med Perspect | year= 2016 | volume= 6 | issue= 3 | pages= 31957 | pmid=27406462 | doi=10.3402/jchimp.v6.31957 | pmc=4942520 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27406462 }}</ref> | ||
*Aspirin is preferred in postmyocardial infarction pericarditis. | *Aspirin is preferred in postmyocardial infarction pericarditis. | ||
*Recurrent cases can be treated with glucocorticoids in combination with aspirin and colchicine. | *Recurrent cases can be treated with glucocorticoids in combination with aspirin and colchicine. | ||
Latest revision as of 03:30, 29 August 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Ibtisam Ashraf, M.B.B.S.[2]
Synonyms and keywords: PCIS
Overview
Post cardiac injury syndrome (PCIS) encompasses three causes of pericarditis: Post myocardial infarction syndrome (PMIS) or Dressler's syndrome, Postpericardiotomy syndrome (PCS) and Posttraumatic pericarditis.
Historical Perspective
- Dressler's syndrome was first discovered by William Dressler, a Jewish-American Cardiologist at Maimonides Medical Centre, in 1956.
- Postcommissurotomy syndrome, initially described in 1952 in patients undergoing mitral valve surgery. [1] It was later renamed to Postpericardiotomy syndrome in 1958. [2]
Classification
| Post cardiac injury syndrome(PCIS) | |||||||||||||||||||||||||||||||||||
| Post-myocardial infarction pericarditis | Post-pericardiotomy syndrome (PPS) | Post-traumatic pericarditis | |||||||||||||||||||||||||||||||||
| Early infarct-associated pericarditis | Late post-myocardial infarction pericarditis (Dressler's Syndrome) | Thoracic trauma | Iatrogenic trauma | ||||||||||||||||||||||||||||||||
Pathophysiology
Both syndromes represent the delayed occurrence of pericarditis. Post-myocardial infarction syndrome is obviously due to myocardial infarction and postpericardiotomy syndrome is due to the myocardial injury that occurs during cardiac surgery. The initial trigger seems to be the combination of damage occurring to the pericardial or pleural mesothelial cells and blood entering the pericardial space which causes the release of cardiac antigens into the circulation. It leads to the formation of immune complexes which get deposited into the pericardium, pleura, lungs, joints etc eliciting an inflammatory response. [3]
Clinical Features
Specific symptoms of post-cardiac injury syndrome include:[4]
- Pleuritic chest pain
- Fever
- Elevated markers of inflammation
- Pericardial effusion
- Pleural effusion
- Pulmonary infiltrates
Differentiating Post cardiac injury syndrome from other Diseases
- PCIS must be differentiated from other diseases that cause fever, chest pain and pleuropericardial effusion, such as:
- Pleuritis or Pleuropericarditis
- Pulmonary embolism
- Boerhaave Syndrome
- Blunt chest wall trauma
- Pneumothorax
- Connective tissue disorders (e.g SLE)
Epidemiology and Demographics
- Incidence: Dressler's syndrome was reported to occur in about 3 to 4% of MI cases. Now it has been markedly decreased due to improvements in the management of Myocardial infarction which result in the small infarct size whereas postpericardiotomy syndrome has been reported in 10 to 40% of patients after cardiac surgery.[5]
Age
- Dressler's syndrome occurs more often in younger age groups.
- The risk of postpericardiotomy syndrome (PPS) increases with age.
Gender
- Female gender is an independent risk factor for postpericardiotomy syndrome.[6]
Race
- There is no racial predilection for post cardiac injury syndrome.
Risk Factors
These are the factors which increase the risk of post cardiac injury syndrome: [7]
- Cardiac Surgery (including AVR, MVR and aortic surgery)
- Young age
- Previous pericarditis
- Viral Infection
- Prior treatment with prednisone
- Blood type B negative
- Halothane anesthesia
Natural History, Complications and Prognosis
Natural History
- Post cardiac injury syndrome usually occurs in 1 to 6 weeks after initial pericardial injury.
- Most patients presents with fever which subsides within 2-3 weeks.
Complications
Rare complications include the development of:
Prognosis
- Post cardiac injury syndrome has relatively a good prognosis.
- The recurrence rate is reported to be 10-15% but has a small risk of developing constrictive pericarditis which requires a long term follow-up.[5]
Diagnosis
Diagnostic Criteria
- Dressler syndrome typically occurs 1–2 weeks after STEMI. Its diagnostic criteria do not differ from those for acute pericarditis including two of the following criteria: (i) Pleuritic chest pain; (ii) Pericardial friction rub; (iii) ECG changes (new widespread ST-segment elevation and PR depressions in multiple leads (except for aVR and V1); and (iv) Pericardial effusion.[8]
- Diagnostic criteria for Postpericardiotomy Syndrome include the presence of at least two of the following five symptoms: (i) new or worsening pleural effusion, (ii) new or worsening pericardial effusion, (iii) fever without alternative causes, (iv) pleuritic chest pain, and (v) pleural or pericardial rubbing[9]
Symptoms
Both syndromes share common symptoms which include fever and pleuritic pain.
Physical Examination
The following findings may be present:
Cardiovascular
Lungs
Laboratory Studies
The following lab abnormalities may be present:
- An elevated erythrocyte sedimentation rate.
- A leukocytosis.
Chest x-ray
A pleural effusion with or without pulmonary infiltrates may be present.
Electrocardiogram
The change of ECG from the baseline and showing the following findings can be suggestive of pericarditis:
- Diffuse ST-segment elevation with PR depression
Echocardiography
It can be used to
- Determine the presence or absence of pericardial effusion and
- Rule out the possibility of cardiac tamponade.
Cardiac MRI
To assess the posterior pericardium, which is difficult to visualize with the echocardiogram.
Treatment
Dressler's syndrome is typically treated with high dose (up to 650 mg PO q 4 to 6 hours) enteric-coated aspirin. [10] Acetominophen can be added for pain management as this does not affect the coagulation system. Anticoagulants should be discontinued if the patient develops a pericardial effusion.
NSAIDs such as ibuprofen should be avoided in the peri-infarct period as they:
- Increase the risk of reinfarction
- Adversely impact left ventricular remodeling.
- Block the effectiveness of aspirin
Treatment
Medical Therapy
- The mainstay of therapy for postcardiac injury syndrome is Anti-inflammatory NSAIDs in combination with colchicine. [11]
- Aspirin is preferred in postmyocardial infarction pericarditis.
- Recurrent cases can be treated with glucocorticoids in combination with aspirin and colchicine.
Surgery
- Surgical intervention is not recommended for the treatment of post cardiac injury syndrome.
- Pericardiocentesis with catheter drainage is considered the standard of care for patients with a significant pericardial effusion due to complications of PCIS (i.e cardiac tamponade or constrictive pericarditis).[12]
Prevention
- Colchicine significantly reduces the incidence of post cardiac injury syndrome.
ACC/AHA Treatment Guidelines (DO NOT EDIT)[13]
| “ |
Class I1. Aspirin is recommended for treatment of pericarditis after STEMI. Doses as high as 650 mg orally (entericcoated) every 4 to 6 hours may be needed. (Level of Evidence: B) 2. Anticoagulation should be immediately discontinued if pericardial effusion develops or increases. (Level of Evidence: C) Class IIa1. For episodes of pericarditis after STEMI that are not adequately controlled with aspirin, it is reasonable to administer 1 or more of the following:
Class IIb1. Corticosteroids might be considered only as a last resort in patients with pericarditis refractory to aspirin or NSAIDs. Although corticosteroids are effective for pain relief, their use is associated with an increased risk of scar thinning and myocardial rupture. (Level of Evidence: C) 2. Nonsteroidal anti-inflammatory drugs may be considered for pain relief; however, they should not be used for extended periods because of their effect on platelet function, an increased risk of myocardial scar thinning, and infarct expansion. (Level of Evidence: B) Class III1. Ibuprofen should not be used for pain relief because it blocks the antiplatelet effect of aspirin and it can cause myocardial scar thinning and infarct expansion. (Level of Evidence: B) |
” |
Sources
- The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [13]
- The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [14]
References
- ↑ JANTON OH, GLOVER RP, O'NEILL TJ, GREGORY JE, FROIO GF (1952). "Results of the surgical treatment for mitral stenosis; analysis of one hundred consecutive cases". Circulation. 6 (3): 321–33. doi:10.1161/01.cir.6.3.321. PMID 14954527.
- ↑ ITO T, ENGLE MA, GOLDBERG HP (1958). "Postpericardiotomy syndrome following surgery for nonrheumatic heart disease". Circulation. 17 (4, Part 1): 549–56. doi:10.1161/01.cir.17.4.549. PMID 13523766.
- ↑ Khan AH (1992). "The postcardiac injury syndromes". Clin Cardiol. 15 (2): 67–72. doi:10.1002/clc.4960150203. PMID 1737407.
- ↑ Li W, Sun J, Yu Y, Wang ZQ, Zhang PP, Guo K; et al. (2019). "Clinical Features of Post Cardiac Injury Syndrome Following Catheter Ablation of Arrhythmias: Systematic Review and Additional Cases". Heart Lung Circ. 28 (11): 1689–1696. doi:10.1016/j.hlc.2018.09.001. PMID 30322760.
- ↑ 5.0 5.1 Imazio M, Hoit BD (2013). "Post-cardiac injury syndromes. An emerging cause of pericardial diseases". Int J Cardiol. 168 (2): 648–52. doi:10.1016/j.ijcard.2012.09.052. PMID 23040075.
- ↑ Imazio M, Brucato A, Rovere ME, Gandino A, Cemin R, Ferrua S; et al. (2011). "Contemporary features, risk factors, and prognosis of the post-pericardiotomy syndrome". Am J Cardiol. 108 (8): 1183–7. doi:10.1016/j.amjcard.2011.06.025. PMID 21798503.
- ↑ Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM; et al. (2010). "Pericardial disease: diagnosis and management". Mayo Clin Proc. 85 (6): 572–93. doi:10.4065/mcp.2010.0046. PMC 2878263. PMID 20511488.
- ↑ Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H; et al. (2018). "2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC)". Eur Heart J. 39 (2): 119–177. doi:10.1093/eurheartj/ehx393. PMID 28886621.
- ↑ van Osch D, Nathoe HM, Jacob KA, Doevendans PA, van Dijk D, Suyker WJ; et al. (2017). "Determinants of the postpericardiotomy syndrome: a systematic review". Eur J Clin Invest. 47 (6): 456–467. doi:10.1111/eci.12764. PMID 28425090.
- ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M; et al. (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction)". J Am Coll Cardiol. 44 (3): 671–719. doi:10.1016/j.jacc.2004.07.002. PMID 15358045.
- ↑ Shah SR, Alweis R, Shah SA, Arshad MH, Manji AA, Arfeen AA; et al. (2016). "Effects of colchicine on pericardial diseases: a review of the literature and current evidence". J Community Hosp Intern Med Perspect. 6 (3): 31957. doi:10.3402/jchimp.v6.31957. PMC 4942520. PMID 27406462.
- ↑ "StatPearls". 2020. PMID 28723017.
- ↑ 13.0 13.1 Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation. 110 (9): e82–292. PMID 15339869. Unknown parameter
|month=ignored (help) - ↑ Antman EM, Hand M, Armstrong PW; et al. (2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation. 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078. Unknown parameter
|month=ignored (help)