Nursing Practice Keywords: Acute coronary syndrome/ /Unstable Review This article has been Cardiology double-blind peer reviewed In this article... ● Pathophysiology and risk factors for acute coronary syndrome ● Signs, symptoms, diagnosis and treatment of ACS ● Priorities in care for with ACS

Diagnosis, management and nursing care in acute coronary syndrome

Key points Authors Selina Jarvis is research nurse and former Mary Seacole development scholar, Acute coronary King’s College Hospital Foundation Trust; Selva Saman is consultant, Port Shepstone 1syndrome is Regional Hospital, Port Shepstone, South Africa. a common and potentially Abstract Acute coronary syndrome refers to a range of potentially life-threatening life-threatening conditions that affect the coronary artery blood supply to the heart, and is a common condition associated presentation in patients with coronary heart disease. Understanding the diagnostic with coronary approaches, as well as pharmacological and coronary interventions is crucial, given heart disease the prevalence of ACS. This article discusses current evidence-based guidance in the Primary management of ACS and the critical role of nurses. 2 percutaneous coronary intervention Citation Jarvis S, Saman S (2017) Diagnosis, management and nursing care in acute within 12 hours of coronary syndrome. Nursing Times; 113: 3, 31-35. symptom onset is the first-line treatment Pharmacological very three minutes one person is Treatment aims to ease symptoms, 3 management in admitted to a UK hospital with improve coronary artery blood flow and the acute phase acute coronary syndrome (British prevent complications. Immediate man- focuses on pain EHeart Foundation, 2017), a agement, combined with cardiac rehabili- relief and prevention common and life-threatening condition tation and secondary prevention, can of further clot associated with coronary heart disease. ACS improve patients’ outcomes and quality of formation while (Box 1) refers to a range of conditions life. Nurses have a key role in: minimising the risk affecting the blood supply to the heart mus- l Facilitating and administering prompt of bleeding cles (myocardium); these include unstable treatment to patients; After discharge angina, non-ST segment elevation myocar- l Promoting the swift recognition of 4 from hospital, dial infarction (NSTEMI) and ST segment deterioration; patients need elevation myocardial infarction (STEMI). l Providing holistic care and secondary ACS can result from a sudden drop in psychosocial support; prevention involving blood flow through the coronary arteries l Encouraging patients to engage in medications, cardiac supplying the different regions of the myo- healthy secondary-prevention rehabilitation and cardium. This can compromise the myo- behaviours. lifestyle changes cardium, leading to reversible ischaemia or Nurses play a a complete loss of blood supply, which in Pathophysiology 5 crucial role in turn leads to myocardial infarction and Most ACS cases are caused by atheroscle- delivering care and ultimately myocardial cell death (necrosis). rosis, which takes place in the coronary psychological In-hospital mortality from ACS has arteries, often decades before a cardiac support at all fallen from 20% to around 5% over the past event. The formation of an atherosclerotic stages of the 30 years, which may be due to better drug plaque begins with low-grade inflamma- journey therapies, prompt recognition and treat- tion in the inner layer of blood vessels. The ment protocols (National Institute for endothelial cells lining blood vessels sus- Health and Care Excellence, 2013a). Timely tain injury, change shape and become management is crucial to reduce the risk increasingly permeable to fluid, lipids and of mortality and further cardiac events. white blood cells. Circulating cholesterol

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carriers, especially low-density lipopro- Box 1. Universal definition of ACS tein (LDL), can enter the arterial wall and undergo oxidation. White blood cells are A rise in blood troponin level above the 99th percentile of the normal range and/or a involved and transform into macrophages, fall in troponin alongside one or more of the following criteria: which engulf LDL; when they become lipid l Symptoms suggestive of cardiac ischaemia laden they are referred to as foam cells. l New electrocardiogram changes indicating new ischaemia (change to the ST These lipid-rich plaques contain inflam- segment or T wave or new left bundle branch block) matory cells, cellular debris, smooth l Development of a pathological Q wave in the ECG muscle cells with cholesterol, and a fibrous l Imaging evidence of new loss of viable myocardium or new regional wall motion capsule. Over time they can progress and abnormality (abnormal movement of heart muscle) cause luminal narrowing of the blood Sources: Adapted from NICE (2014) and Thygesen et al (2012) vessel, thereby limiting blood flow. ACS is usually triggered by the rupture of an atherosclerotic plaque in the wall of a cor- Fig 1. STEMI changes in ACS coronary intervention (PCI). Often they will onary artery; this causes activation, adhe- communicate with the cardiology team sion and aggregation of platelets and the Blocked before arrival, which will facilitate urgent clotting systems, leading to the formation blood flow coronary reperfusion strategies (coronary of a thrombus. If the thrombus completely angioplasty with/without stents placed in occludes the coronary artery, the section of the affected coronary artery) once the the myocardium supplied by that artery is patient has arrived in hospital. starved of oxygen, leading to myocardial cell Primary PCI has become the first-line necrosis, and typical ST elevation changes treatment in patients with STEMI pre- are seen on an electrocardiogram (Fig 1). In senting within 12 hours of onset of symp- addition, cardiac enzymes are released from toms, provided it can be given within damaged myocardial cells (troponin I and T, 120 minutes of the time in which throm- Atheroma creatinine kinase MB isoenzyme), which can bolysis could be given (NICE, 2013a). If pri- be measured in the blood. mary PCI is not available or there is a delay, thrombolysis may be performed (using Atheroma lining Risk factors for ACS coronary artery drugs such as alteplase and reteplase) after ACS is more common in men, older people discussion with the on-call cardiologist – and those with a family history of if there are no major contraindications. Ischaemia Infarction ischaemic heart disease. Modifiable risk If the ECG does not reveal an MI but car- factors include smoking, obesity, hyper- ACS = acute coronary syndrome. STEMI = ST diac ischaemia is suspected, patients tension, dyslipidaemia and poor diet. Life- segment elevation myocardial infarction should be admitted and have serial 12-lead style changes such as smoking cessation, ECGs to assess any dynamic changes. If weight loss, exercise, adherence to blood- there is myocardial damage, cardiac pressure drugs, tight glucose control in syncope or autonomic symptoms such as enzymes (typically troponins T and I) are patients with diabetes, and management of sweating, nausea, tachycardia or vomiting raised, which can help confirm the diag- dyslipidaemias can be useful in both pri- may also occur (with or without chest nosis. NICE (2013b) advises that troponin mary and secondary prevention. pain). Close attention to vital signs is crit- be included in the initial assessment on ical as patients can deteriorate and become admission and a second sample be taken Signs and symptoms haemodynamically unstable or develop 10-12 hours after symptoms began. Patients typically present with central and . Increases or decreases of troponin above chest pain or tightness described as dull or or below the normal limit on the repeat test crushing; it can radiate to the jaw or down Diagnosis and first investigations can confirm NSTEMI. A negative troponin the left arm and normally lasts for >15 min- A thorough clinical history and physical and no ECG changes can support a decision utes. Some patients, however, such as examination should be undertaken and to discharge patients who may have those with diabetes, older people or supported by an ECG. This helps delineate unstable angina. These patients should women, may not have chest pain. the treatment pathway and, in cases of receive follow-up in a rapid chest pain clinic Mnemonics, such as SOCRATES, can be STEMI, decide whether the patient needs or in cardiology; their risk of adverse cardiac used to assess patients’ chest pain: urgent reperfusion. If ACS is suspected, events is 0.2% (Weinstock et al, 2015). l S – site of pain; the emergency services should be called Fig 2 outlines the principles of ACS diag- l O – onset of pain; and, on arrival, paramedics should per- nosis and management. l C – character of the pain; form an immediate ECG. Many paramedics l R – any radiation; are trained to recognise ECG changes seen Risk prediction l A – associated factors; in STEMI, which include ST elevation of Adults with NSTEMI or unstable angina l T – timing of the pain; ≥1mm height in two adjacent chest leads, should be assessed for their risk of future l E – exacerbating/alleviating factors; for ST elevation of ≥2mm in two adjacent limb adverse cardiovascular events using an example, position or inspiration; leads, and new left bundle branch block. established risk scoring system that predicts l S – severity of the pain using a rating If STEMI is suspected, paramedics will six-month mortality (NICE, 2013b). This scale of 1-10 (10 being the worst pain). aim to take patients directly to a ‘heart attack helps to plan clinical management and peter lamb peter Shortness of breath, palpitations, centre’ that offers primary percutaneous decide on the best place of care (for example,

Nursing Times March 2017 / Vol 113 Issue 3 32 www.nursingtimes.net Fig 2. Overview of ACS diagnosis and management antiplatelet drugs is used. This drug class includes clopidogrel and the faster-acting prasugrel and ticagrelor. Antiplatelet ACS suspected agents are associated with potentially life- Symptom variation in women, older threatening bleeding. NICE recommends people and people with diabetes using ticagrelor, as risk of bleeding is lower than with the others (NICE, 2013a). 12-lead ECG The European Society of Cardiology rec- Clinical assessment ommends ticagrelor with aspirin in No ST elevation seen on ST elevation or LBBB patients with moderate-risk NSTEMI ECG seen on ECG (Roffi et al, 2015). Many patients will have to continue dual antiplatelet treatment for Confirm these +ve Troponin test -ve 12 months after an MI regardless of how it are new ECG was managed. changes NSTEMI Unstable angina Anticoagulation agents STEMI Anticoagulation is used to prevent clot for- Medical mation. Fondaparinux, an antithrombin management: aim Discharge and agent, reduces ischaemic events and for PCI within 72 Primary PCI or arrange follow-up improves long-term morbidity and mor- hours in patients fibrinolysis if delay investigations tality; 2.5mg should be given subcutane- with a six-month ously once daily (Fifth Organization to mortality rate ≥3% Assess Strategies in Acute Ischemic Syn- dromes Investigators et al, 2006). It is asso- ACS = acute coronary syndrome. ECG = electrocardiogram. LBBB = left bundle branch block. ciated with a reduced risk of major NSTEMI = non-ST segment elevation myocardial infarction. PCI = percutaneous coronary bleeding compared with other anticoagu- intervention. STEMI = ST segment elevation myocardial infarction. lants – bleeding risk being a concern with most of them (NICE, 2013b). coronary care or a medical assessment unit). There is some evidence that giving supple- In patients with renal dysfunction Several tools are available to stratify mor- mental oxygen to patients with uncompli- (serum creatinine >256μmol/L), unfrac- tality risk in ACS, including: cated MI can be harmful (Stub et al, 2015). tionated heparin is used. The decision to l Global Registry of Acute Coronary give an anticoagulant, and which one, Events score (GRACE; Bit.ly/ Antiplatelet agents revolves around whether and when the GRACERiskScore) (Granger et al, 2003); Platelets play a pivotal role in clot formation patient is due to have PCI, as well as their l Thrombolysis in Myocardial Infarction after an atherosclerotic plaque ruptures, so bleeding risk and cardiovascular risk score. (TIMI) score (Antman et al, 2000). dual antiplatelet therapy is crucial in ACS Table 1 compares GRACE and TIMI for management – both in NSTEMI and STEMI. Glycoprotein IIb/IIIa inhibitors (GPIs) risk scoring in ACS. Aspirin is linked to reduced mortality GPIIb/IIIa receptor activation is the last in ACS, with sustained effects at 10 years step in platelet aggregation when a clot is Pharmacological management (Baigent et al, 1998), so it is standard prac- forming, so GPIs can be effective but, Pain relief tice to give patients 300mg of non-enteric again, are linked to bleeding. NICE (2013b) Patients presenting with chest pain may coated aspirin on presentation. Alongside recommends a GPI (for example, eptifiba- need sublingual or buccal glyceryl trini- aspirin, the P2Y12 antagonist group of tide or tirofiban) be considered in patients: trate (GTN) to relieve pain; those with intractable pain may need a GTN infusion (NICE, 2013a). GTN promotes venodilation Table 1. Risk scoring in ACS: GRACE versus TIMI and dilatation of the coronary arteries. It TIMI GRACE can be given to patients with ischaemic History l Age l Hypertension l Age chest pain provided their systolic blood l Diabetes l Smoking pressure is >90mmHg. It is contraindicated l Dyslipidaemia l Family in patients with an inferior MI or suspected history l History of right ventricular involvement, as it can ischaemic heart disease cause haemodynamic deterioration. Some patients with nitrate-refractory Presentation l Severe angina l Heart rate l Systolic blood pain receive opioids, such as intravenous l Prior aspirin use (<7 days) pressure l Elevated creatinine morphine, at small doses every few min- l Elevated cardiac markers l Heart failure l Cardiac arrest utes until they are pain free. l ST-segment deviation l Elevated cardiac markers l ST-segment deviation Oxygen ACS = acute coronary syndrome. GRACE = Global Registry of Acute Coronary Events. Patients with acute chest pain and pre- TIMI = Thrombolysis in Myocardial Infarction. sumed ACS do not need oxygen unless Sources: Adapted from Granger et al (2003) and Antman et al (2000) they present with hypoxia or heart failure.

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Box 2. Discharge and carvedilol) should be started as early as pos- NSTEMI secondary prevention post MI sible provided there is no hypotension, All patients with NSTEMI should receive signs of heart failure, bradycardia or heart antiplatelet and anticoagulation therapy. Diagnosis and arrangements for block. They reduce the workload on the Definitive coronary reperfusion strategies follow-up heart, decrease ischaemia and limit the are also required – NICE strongly recom- Include in every discharge summary: development and/or size of an infarct. mends that GRACE or TIMI are used to l Confirmation of acute MI diagnosis The NICE pathway on MI secondary pre- determine the level of risk. Patients at l Investigation results vention (NICE, 2017) recommends that ACE intermediate or high risk should be offered l Future management plans inhibitors (such as ramipril, lisinopril and coronary angiography, followed by PCI if l Secondary prevention advice enalapril) are also started as early as pos- needed, within 72 hours of admission. Patients should be given a copy of their sible – normally within 24 hours. Evidence Patients with NSTEMI or unstable angina discharge summary suggests they are associated with a reduced who are clinically unstable should have incidence of major adverse cardiovascular angiography (followed by PCI if indicated) Cardiac rehabilitation (CR) events when given within the first days of within 24 hours of becoming clinically Advise patients about CR and encourage ACS onset, and can lead to improvement in unstable (NICE, 2014). them to attend. CR consists of: left ventricular ejection fraction, thereby l Physical activity reducing the risk of heart failure (Køber et Nursing care priorities l Travel and health advice al, 1995). Patients who have had symptoms Acute hospital admission l Psychological and social support or signs of heart failure with ACS can be Keeping clear and comprehensive notes is l Advice on sexual activity started on an aldosterone antagonist such crucial to ensure all nurses caring for l Support with lifestyle changes as eplerenone; this is initiated a few days patients with ACS know the patients’ clin- after ACE inhibitors and has been shown to ical status, areas of concerns and manage- Cardiac risk factors and lifestyle changes reduce morbidity and mortality after acute ment plan. Nurses caring for patients who l Control blood pressure MI (Pitt et al, 2003). recently had coronary angiography should l Reduce LDL cholesterol Statins, aimed at lowering cholesterol, monitor radial or femoral access sites and l Maintain glycaemic control are crucial to secondary prevention; the be able to recognise complications. Close l Stop smoking Scandinavian Simvastatin Survival Study communication with cardiac catheterisa- l Maintain a healthy diet and follow-up studies confirmed their tion laboratory staff and the coronary care l Take up appropriate physical activity beneficial effects on morbidity and mor- unit is crucial. Nurses receiving these l Restrict alcohol use to safe levels tality by lowering LDL cholesterol levels patients need clear information about the l Maintain a healthy weight (Pederson et al, 2000). However, their type of procedure they had, any complica- action may go beyond lowering LDL and tions, medications and IV fluids, and Drug therapy for secondary prevention raising high-density lipoprotein choles- whether they have received anticoagulants Offer all of the following drugs: terol: Cannon et al (2004) confirmed bene- or GPIs, which will put them at greater risk l ACE inhibitor fits of high-dose atorvastatin and NICE of bleeding (Macdonald et al, 2016). l Dual platelet therapy (2013b) recommends that patients with General priorities for patients with ACS l Beta-blocker confirmed ACS receive atorvastatin 80mg are haemodynamic monitoring and close l Statin for secondary prevention, provided there observation of vital signs. A review of fluid Ensure the GP is aware of the timing of are no contraindications. status can provide information about renal drug titration and the need to monitor perfusion, as some patients may present renal function and blood pressure Coronary reperfusion strategies with, or develop, heart failure. In patients ACE = angiotensin-converting enzyme. LDL = STEMI with diabetes, capillary blood glucose low-density lipoprotein. MI = myocardial Patients who present with STEMI within levels should be regularly checked; some infarction. 12 hours of symptom onset should receive may be put on IV insulin if their blood glu- Source: Adapted from National Institute for emergency reperfusion within two hours to cose is >11mmol/L. Patients recently diag- Health and Care Excellence (2015) restore the coronary arterial flow and sal- nosed with diabetes should be referred to vage the myocardium (NICE, 2013a). PCI is the diabetes specialist nurse. usually performed through the radial artery, Symptom monitoring is important to l With intermediate or high although the femoral artery is used in 10-15% achieve pain relief with GTN or morphine. cardiovascular mortality risk who are of cases (Macdonald et al, 2016). In the Myo- Swift recognition of any cardiac changes due to undergo PCI within 72-96 hours; cardial Ischaemia National Audit Project on the serial ECGs is also a key aspect of l Who have had PCI with difficult lesions (2014), 92% of eligible patients in England, nursing care. Patients considered at high in the coronary arteries. 87% in Wales and 95% in Belfast received PCI risk should be managed where continuous within 90 minutes of arrival in hospital. cardiac monitoring is available as they are Antihypertensives and statins Lagerqvist et al (2006) showed a signifi- at risk of arrhythmias, which can precede a Hypertension is a major cardiac risk factor cant reduction in death and MI at five years cardiac arrest. Patients at intermediate that contributes to ACS risk, and antihyper- in patients who received combined anti- risk may be managed in a medical assess- tensive drugs such as beta-blockers, angio- coagulation and primary PCI. PCI is superior ment unit, where they are likely to receive tensin-converting enzyme (ACE) inhibitors to thrombolytics, which are reserved for serial ECGs. Nurses caring for patients and aldosterone antagonists are associated when PCI is not possible. The overarching with ACS should have ECG interpretation with improved outcomes. Beta-blockers aim is for patients to have follow-up with skills, as ECG changes or arrhythmias are (for example, metoprolol, bisoprolol, coronary stenting within 6-24 hours. signs of potential deterioration.

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Other elements of nursing care include should also be advised to seek urgent med- of Medicine; 354: 1464-1476. ongoing management of IV cannulas, cen- ical assessment if any chest pain recurs. Granger CB et al (2003) Predictors of hospital mortality in the global registry of acute coronary tral venous pressure lines, urinary cathe- Advice can be reinforced with written events. Archives of Internal Medicine; 163: 19, ters and wounds and dressings. information, such as booklets from the 2345-2353. Patients are likely to be anxious and British Heart Foundation (bhf.org.uk), and Køber L et al (1995) A clinical trial of the angiotensin-converting-enzyme inhibitor frightened. Nurses should be calm and patients can be signposted to support trandolapril in patients with left ventricular reassuring, and ensure pain and other groups and websites such as NHS Choices dysfunction after myocardial infarction. New symptoms are well controlled. They play a (nhs.uk) as appropriate (Scottish Intercol- England Journal of Medicine; 333: 1670-1676. central role in providing psychosocial sup- legiate Guidelines Network, 2016). Lagerqvist B et al (2006) 5-year outcomes in the FRISC-II randomised trial of an invasive versus a port; when possible, they should give Nurses should address patients’ concerns non-invasive strategy in non-ST-elevation acute patients a chance to speak about their and refer them to cardiac nurses or dietitians coronary syndrome: a follow-up study. Lancet; 368: experiences, address their concerns and for specialist advice, as well as the primary 9540, 998-1004. Macdonald N et al (2016) Acute coronary relay these to the multidisciplinary team. care team for ongoing secondary prevention. syndromes- the role of the CCU nurse. Part II: a They should also encourage them to attend a look at inpatient recovery and discharge. British Discharge and secondary prevention cardiac rehabilitation programme; this is Journal of Cardiac Nursing; 11: 11, 544-547. Myocardial Ischaemia National Audit Project in MI patients particularly so for hard-to-reach groups – (2014) How the NHS Cares for Patients with Heart There are several things to consider when older people, women, some ethnic groups, Attack. Annual Public Report April 2013-March patients with a confirmed MI (either people in rural areas, those of lower socioec- 2014. Bit.ly/MINAPReport2014 NSTEMI or STEMI) are ready to be dis- onomic status – in which attendance is lower National Institute for Health and Care Excellence (2017) Myocardial Infarction: Secondary Prevention charged home (Box 2). Secondary preven- than average (NICE, 2015; Dalal et al, 2015). Overview. Bit.ly/NICEMI2Pathway tion should be at the heart of nurses’ strate- National Institute for Health and Care Excellence gies. Patients need to understand their Specialist nurses (2015) Secondary Prevention after a Myocardial Infarction. nice.org.uk/qs99 condition and be encouraged to make any The development of chest pain specialist National Institute for Health and Care Excellence lifestyle changes needed, which will be cru- and ACS specialist nurse roles has (2014) Acute Coronary Syndromes in Adults. nice. cial to prevent recurrence. They will be dis- improved care for ACS patients, particu- org.uk/qs68 National Institute for Health and Care Excellence charged with much information, but the larly those with NSTEMI. These nurses can (2013a) Myocardial Infarction with ST-segment priority is for them to understand: perform acute triage assessments and facil- Elevation: Acute Management. nice.org.uk/cg167 l They have had an acute MI; itate early access to specialist services and National Institute for Health and Care Excellence (2013b) Unstable Angina and NSTEMI: Early l Results of any investigations; cardiologists. Studies are starting to show Management. nice.org.uk/cg94 l How their condition will be managed. that nurse-led early triage can help identify O’Neill L et al (2014) Nurse-led Early Triage (NET) Patients are likely to go home with sev- patients early, facilitating rapid interven- study of chest pain patients: a long term evaluation eral drugs and many will need to take them tion (O’Neill et al, 2014; Alfakih et al, 2009). study of a service development aimed at improving the management of patients with non-ST-elevation for the rest of their lives. These drugs usu- acute coronary syndromes. European Journal of ally comprise dual antiplatelet therapy, Conclusion Cardiovascular Nursing; 13: 3, 253-260. beta-blockers, statins and ACE inhibitors. ACS is a common, life-threatening condi- Pedersen TR et al (2000) Follow-up study of patients randomized in the Scandinavian Simvastatin Some patients will also need aldosterone tion and, in our ageing population, its Survival Study (4S) of cholesterol lowering. American antagonists. Nurses must ensure patients: incidence is likely to rise. Nurses have a Journal of Cardiology; 86: 3, 257-262. l Understand the dosages and crucial role in the clinical management of Pitt B et al (2003) Eplerenone, a selective aldosterone blocker, in patients with left ventricular administration routes; patients with ACS, by helping them under- dysfunction after myocardial infarction. New l Know not to discontinue treatment stand their condition and care, and pro- England Journal of Medicine; 348: 1309-1321. without medical advice. moting secondary prevention. NT Roffi M et al (2015) 2015 ESC Guidelines for the Where possible relatives should be management of acute coronary syndromes in patients presenting without persistent ST-segment involved in discussions, as they can often References Alfakih K et al (2009) Nurse specialist-led elevation: Task Force for the Management of Acute help with lifestyle changes. Patients should management of acute coronary syndromes. British Coronary Syndromes in Patients Presenting receive advice on travel and be made aware Journal of Cardiology; 16: 132-134. without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). European of the rules about driving after an MI. 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British Heart Foundation (2017) CVD Statistics: 2020-2035. you have completed the multiple- BHF UK Factsheet. Bit.ly/BHFCVDstatsUK Weinstock MB et al (2015) Risk for clinically choice assessment, you can download Cannon CP et al (2004) Intensive versus moderate relevant adverse cardiac events in patients with chest pain at hospital admission. JAMA Internal a certificate to store in your Nursing lipid lowering with statins after acute coronary syndromes. New England Journal of Medicine; 350: Medicine; 175: 7, 1207-1212. Times Learning Passport or professional 1495-1504. portfolio as CPD or revalidation evidence. Dalal HM et al (2015) Cardiac rehabilitation. British For more on this topic go online... Visit nursingtimes.net/ Medical Journal; 351: h5000. l Barriers to attending cardiac NTSACardiacSyndrome to take the Fifth Organization to Assess Strategies in acute Ischemic Syndromes Investigators (2006) rehabilitation assessment. Comparison of fondaparinux and enoxaparin in Bit.ly/NTCardiacRehab acute coronary syndromes. New England Journal

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