text:
Improved Benevolent and Protective Order of Elks of the World
From Wikipedia, the free encyclopedia
Jump to: navigation, search
The Improved Benevolent Protective Order of Elks of the World or IBPOEW is an African-American fraternal order modeled on the Benevolent and Protective Order of Elks. It was established in 1897. In the early 21st century, with 500,000 members and 1500 lodges in the world, the IBPOEW claims to be the largest black fraternal organization.
Contents
[hide]
1 History
2 Organization
3 Membership
4 Ritual
5 Benefits and philanthropy
6 Selected Lodges
7 References
8 Further reading
9 See also
10 External links
History[edit]
The Order claims descent from the Free African Society, the first formal black society in America, founded in 1787 as a mutual aid society by Absalom Jones and Richard Allen in Philadelphia, Pennsylvania. Its formal organization as a separate Order, however, began in February 1897, when it was established in Cincinnati, Ohio, by city residents B. F. Howard and Arthur J. Riggs, a Pullman porter who had been born into slavery. The men had met in another association and wanted to establish a chapter of Elks; the white organization refused them admission.[1] (Note: In 1972 the white-majority BPOE opened admission to African Americans and other minorities.)[2] Riggs had gained a copy of the BPOE ritual and received the first copyright for it, establishing their organization in September 1898.[3] This was a period of a rise in black fraternal associations, with men organizing to work in community and create strong networks.
The BPOE disputed their use of the ritual, but they held the copyright. In 1912 the Improved, Benevolent Protective Order of Elks of the World was sued by the Benevolent and Protective Order of Elks in the State of New York to keep them from using the "Elks" name. The New York Court of Appeals ruled in favor of the BPOE, Judge Barlett stating, "If the members desired the name of an animal there is a long list of beasts, birds, fishes which have not yet been appropriated for such a purpose."[4] The decision was apparently ignored after the IBPOEW made a minor change in the letters on their seal.[5]
The IBPOEW founded a Civil Liberties department in 1926. It was active in opposing the segregation of schools in Gary, Indiana, the next year.[5] The number of blacks in the city had increased markedly during the Great Migration, as men were attracted from the rural South to the city's industrial jobs. At the same time, there were numerous European immigrants settling in the city.
During the 1930s and 1940s, the IBPOEW was active in the effort of blacks to "gain work while resisting union exclusion, workplace segregation, and unemployment."[6] According to historian Venus Green, the Improved Elks labor activism was distinguished from other black fraternal organizations by their "cross-class alliances, male/female solidarity, racial unity, a willingness to join coalitions across ideologies and to engage in multiple forms of struggle, especially militant mass mobilization".[6] In the IBPOEW, ideologies ranged from Christianity to communism, but the members worked together to achieve labor goals.
From 1950 to 1966, the IBPOEW owned and operated as their National Shrine "The John Brown Farm" (also known as "The Kennedy Farm") in southern Washington County, Maryland. That property was the site where John Brown had trained his troops in anticipation of his raid on Harpers Ferry in 1859 that begat the Civil war and the abolition of slavery. The Elks purchased the property as a memorial to Brown and built several buildings on the 235 acre property, including a 50' by 124' auditorium that was used as a meeting place for Elks gatherings of up to three thousand persons on Fourth of July and Labor Day weekends. The auditorium was rented on summer weekends by a local black entrepreneur, John Bishop, who booked into that venue dozens of the biggest stars of rhythm and blues, including Ray Charles, Aretha Franklin, James Brown, Marvin Gaye, Little Richard, Chuck Berry, B. B. King, Eartha Kitt, Otis Redding, Etta James, the Coasters, and the Drifters.[7]
Organization[edit]
The organization and titles of the Improved Elks are reportedly modeled on that of the BPOE. Its Grand Lodge meets annually, and the organization is headquartered in Winton, North Carolina.[5] Like the BPOE, the Improved Elks have an officially recognized female auxiliary, the Daughters of the Improved Benevolent Protective Order of Elks of the World.[8] They were organized by Emma Virginia Kelly on June 13, 1902, in Norfolk, Virginia.[1]
In 1923 the IBPOEW convention in Chicago was attended by 3,000 delegates. At that meeting J. Finley Wilson was re-elected "Grand Exalted Leader'.[9]
Membership[edit]
In 1979 the Improved Elks had approximately 450,000 members.[5] In the early 21st century, they have 500,000 members in 1500 lodges around the world.[1] Like other fraternal associations in the United States, both black and white, the Improved Elks have been dealing with declining membership as older members die. Younger people face a different world, and seem less inclined to join such associations,[2] sometimes preferring explicitly political or professional associations related to work.
Ritual[edit]
Just like the BPOE, the Improved Elks have kept much of their original ritual intact.[5]
Benefits and philanthropy[edit]
The Improved Elks in the United States sponsor scholarship programs, youth summer computer literacy camps, help for children with special needs, and extensive community service activities.[1]
Selected Lodges[edit]
California
Clementine Lodge No. 598 of San Diego
Connecticut
Shining Star Lodge of Stamford
Delaware
Paul Lawrence Dunbar Lodge No. 106 of Wilmington
District of Columbia
Columbia Lodge No. 85 of Washington, D.C.
Massachusetts
Commonwealth Lodge No. 19 of Boston
Quinsigamond Lodge No. 173 of Worcester
New Jersey
Semlight Lodge of Trenton
Monmouth Lodge No. 122 of Trenton
New York
Imperial Lodge No. 127 of New York City
Brooklyn Lodge No. 32
Industry Lodge No. 889 of New York City
Pennsylvania
Philadelphia
Quaker City Elks Lodge No. 720, IBPOEW, Philadelphia, was founded in 1926 and in 1945 was the reportedly the second largest African American Elks Lodge in the country. In 1930, the Lodge erected a home at 1943 Christian Street. [10]
Christopher Perry Lodge No. 965 of Philadelphia
Leonard C. Irvin Lodge No. 994 Philadelphia
Edward W. Henry Lodge No. 1235 of Philadelphia
O.V. Catto Lodge No. 20 of Philadelphia
Rest of state
John A. Watts Lodge No. 224 of Chester
B.F. Howard Lodge No. 580 of Media
John F. Moreland Lodge No. 801 of Monaca
Maple View Lodge No. 780 of Elizabeth
North Side Lodge No. 124 of Pittsburgh
Lawrence Lodge #18 of New Castle
Berks Lodge No. 47 Reading
Unity Lodge No. 71 of Harrisburg
Conestoga Lodge No. 140 of Lancaster
Capt. Levi M. Hood Lodge No. 159 of West Chester
Cyrene Lodge No. 169 of Steelton
Arandale Lodge No. 184 of Altoona
Canon Lodge No. 186 of Canonsburg
Twin City Lodge No. 187 of Farrell
Clinton J. Lewis Lodge No. 201 of Bristol
Edgar A. Still Lodge No. 207 of Williamsport
Booker T. Washington Lodge No. 218 of McKeesport
Brighton Pioneer Lodge No. 219 of Beaver Falls
Valley Lodge No. 294 of New Kensington
Gem City Lodge No. 328 of Erie
Flood City Lodge No. 371 of Johnstown
Elmwood Lodge No. 438 of Norristown
Monroe Lodge No. 513 of Stroudsburg
Okay Lodge No. 697 of Monessen
William E. Burrell Lodge No. 737 of North Hills
Twin County Lodge No. 838 of Vandergrift
Montgomery Lodge No. 1271 of Pottstown
Bethal Lodge No. 1284 Bethlehem
References[edit]
^ Jump up to: a b c d "Our Brief History", IBPOEW official website
^ Jump up to: a b Michelle O'Donnell, "Black Elks Honor Rituals as Membership Dwindles", New York Times, 20 September 2004; accessed 17 May 2017
Jump up ^ Schmidt, Alvin J. Fraternal Organizations, Westport, CT: Greenwood Press, 1980, pp. 107-8
Jump up ^ Preuss, Arthur A Dictionary of Secret and other Societies, St. Louis: B. Herder Book Co., 1924; republished Detroit: Gale Reference Company, 1966; p.206
^ Jump up to: a b c d e Schmidt (1980), p.108
^ Jump up to: a b Venus Green, "Not your average fraternal organization: the IBPOEW and labor activism, 1935–1950", Labor History, Volume 53, 2012 - Issue 4, pp.471-494, Taylor and Francis Online; accessed 17 May 2017
Jump up ^ Maliskas, Ed. John Brown to James Brown - The Little Farm Where Liberty Budded, Blossomed, and Boogied, Hagerstown, MD: Hamilton Run Press, 2016
Jump up ^ Schmidt (1980), p. 107
Jump up ^ Preuss p.179
Jump up ^ "Elks Open New Home Sunday," by W. Rollo Wilson, The Pittsburgh Courier, August 9, 1930, pg. 8 (retrieved September 22, 2017, via newspapers.com at www.newspapers.com/image/40068447/)
Further reading[edit]
Green, Venus, “Not Your Average Fraternal Organization: The IBPOEW and Labor Activism, 1935–1950,” Labor History, 53 (Nov. 2012), 471–94.
See also[edit]
Prince Hall Freemasonry
Grand United Order of Odd Fellows
List of African-American Greek and fraternal organizations
External links[edit]
Official website
This organization-related article is a stub. You can help Wikipedia by expanding it.
v
t
e
Retrieved from "https://en.wikipedia.org/w/index.php?title=Improved_Benevolent_and_Protective_Order_of_Elks_of_the_World&oldid=828619325"
Categories:
African-American organizations
Elks (fraternal order)
Ethnic fraternal orders in the United States
Men's organizations in the United States
Organizations established in 1897
Organization stubs
Hidden categories:
All stub articles
Navigation menu
Personal tools
Not logged in
Talk
Contributions
Create account
Log in
Namespaces
Article
Talk
Variants
Views
Read
Edit
View history
More
Search
Navigation
Main page
Contents
Featured content
Current events
Random article
Donate to Wikipedia
Wikipedia store
Interaction
Help
About Wikipedia
Community portal
Recent changes
Contact page
Tools
What links here
Related changes
Upload file
Special pages
Permanent link
Page information
Wikidata item
Cite this page
Print/export
Create a book
Download as PDF
Printable version
Languages
Add links
This page was last edited on 3 March 2018, at 18:26.
Text is available under the Creative Commons Attribution-ShareAlike License; additional terms may apply. By using this site, you agree to the Terms of Use and Privacy Policy. Wikipedia® is a registered trademark of the Wikimedia Foundation, Inc., a non-profit organization.
Privacy policy
About Wikipedia
Disclaimers
Contact Wikipedia
Developers
Cookie statement
Mobile view
Enable previews

values: mw-page-base noprint

values: mw-head-base noprint

values: firstHeading firstHeading en

values: siteSub noprint

values: jump-to-nav mw-jump

attrs: href class title

attrs: role tabindex class

values: button 0 togglelink

value: span

attrs: class dir

values: toctitle ltr

value: li

values:
/wiki/State_of_New_York
mw-redirect
State of New York

values:
/wiki/Segregated_education
mw-redirect
Segregated education

values:
/wiki/Female_auxiliary
mw-redirect
Female auxiliary

values: Emma Virginia Kelly (page does not exist)

values:
/wiki/San_Diego,_California
mw-redirect
San Diego, California

values: text-indent: -1.6em; margin-left: 1.6em;

values: -moz-column-width: 50em; -webkit-column-width: 50em; column-width: 50em;

values:
/wiki/The_Pittsburgh_Courier
mw-redirect
The Pittsburgh Courier

values:
reflist mw-references-wrap
list-style-type: decimal;

values:
/wiki/Grand_United_Order_of_Odd_Fellows
mw-redirect
Grand United Order of Odd Fellows

values:
nofollow
http://ibpoew.org/
external text

values: position: absolute; right: 15px; display: none;

values:
metadata plainlinks stub
presentation
background:transparent

values: Category:Ethnic fraternal orders in the United States

values: Category:Men's organizations in the United States

values: Category:Organizations established in 1897

values: Discussion about edits from this IP address [ctrl-alt-n]

values: A list of edits made from this IP address [ctrl-alt-y]

values: You are encouraged to create an account and log in; however, it is not mandatory

values: You're encouraged to log in; however, it's not mandatory. [ctrl-alt-o]

values: Discussion about the content page [ctrl-alt-t]

values: p-namespaces navigation vectorTabs p-namespaces-label

values:
p-variants
navigation
vectorMenu emptyPortlet
p-variants-label

values: Past revisions of this page [ctrl-alt-h]

values: p-views navigation vectorTabs p-views-label

values:
p-cactions
navigation
vectorMenu emptyPortlet
p-cactions-label

values:
mw-wiki-logo
/wiki/Main_Page
Visit the main page

values:
/wiki/Main_Page
Visit the main page [ctrl-alt-z]
z

values: Featured content – the best of Wikipedia

values: Find background information on current events

values:
/wiki/Special:Random
Load a random article [ctrl-alt-x]
x

values: portal navigation p-navigation p-navigation-label

values: Guidance on how to use and edit Wikipedia

values: About the project, what you can do, where to find things

values: A list of recent changes in the wiki [ctrl-alt-r]

values: portal navigation p-interaction p-interaction-label

values: List of all English Wikipedia pages containing links to this page [ctrl-alt-j]

values: Recent changes in pages linked from this page [ctrl-alt-k]

values:
/wiki/Wikipedia:File_Upload_Wizard
Upload files [ctrl-alt-u]
u

values: A list of all special pages [ctrl-alt-q]

values: Permanent link to this revision of the page

values: Link to connected data repository item [ctrl-alt-g]

values: Printable version of this page [ctrl-alt-p]

values: /static/images/wikimedia-button-1.5x.png 1.5x, /static/images/wikimedia-button-2x.png 2x

values: /static/images/poweredby_mediawiki_132x47.png 1.5x, /static/images/poweredby_mediawiki_176x62.png 2x

values:
suggestions
display: none; font-size: 13px;

values: mediawiki ltr sitedir-ltr mw-hide-empty-elt ns-0 ns-subject page-Improved_Benevolent_and_Protective_Order_of_Elks_of_the_World rootpage-Improved_Benevolent_and_Protective_Order_of_Elks_of_the_World skin-vector action-view


text:
Cloud storage
From Wikipedia, the free encyclopedia
Jump to: navigation, search
This article is about enterprise-level cloud data storage. For consumer-level file hosting services, see file hosting service.
Cloud storage is a model of data storage in which the digital data is stored in logical pools, the physical storage spans multiple servers (and often locations), and the physical environment is typically owned and managed by a hosting company. These cloud storage providers are responsible for keeping the data available and accessible, and the physical environment protected and running. People and organizations buy or lease storage capacity from the providers to store user, organization, or application data.
Cloud storage services may be accessed through a co-located cloud computer service, a web service application programming interface (API) or by applications that utilize the API, such as cloud desktop storage, a cloud storage gateway or Web-based content management systems.
Contents
[hide]
1 History
2 Architecture
3 Advantages
4 Potential concerns
4.1 Attack surface area
4.2 Supplier stability
4.3 Accessibility
4.4 Other concerns
5 See also
6 References
History[edit]
Cloud computing is believed to have been invented by Joseph Carl Robnett Licklider in the 1960s with his work on ARPANET to connect people and data from anywhere at any time.[1]
In 1983, CompuServe offered its consumer users a small amount of disk space that could be used to store any files they chose to upload.[2]
In 1994, AT&T launched PersonaLink Services, an online platform for personal and business communication and entrepreneurship. The storage was one of the first to be all web-based, and referenced in their commercials as, "you can think of our electronic meeting place as the cloud."[3] Amazon Web Services introduced their cloud storage service AWS S3 in 2006, and has gained widespread recognition and adoption as the storage supplier to popular services such as Smugmug, Dropbox, Synaptop and Pinterest. In 2005, Box announced an online file sharing and personal cloud content management service for businesses.[4]
Architecture[edit]
A high level architecture of cloud storage.
This section may be too technical for most readers to understand. Please help improve it to make it understandable to non-experts, without removing the technical details. The talk page may contain suggestions. (December 2016) (Learn how and when to remove this template message)
Cloud storage is based on highly virtualized infrastructure and is like broader cloud computing in terms of accessible interfaces, near-instant elasticity and scalability, multi-tenancy, and metered resources. Cloud storage services can be utilized from an off-premises service (Amazon S3) or deployed on-premises (ViON Capacity Services).[5]
Cloud storage typically refers to a hosted object storage service, but the term has broadened to include other types of data storage that are now available as a service, like block storage.
Object storage services like Amazon S3 and Microsoft Azure Storage, object storage software like Openstack Swift, object storage systems like EMC Atmos, EMC ECS and Hitachi Content Platform, and distributed storage research projects like OceanStore[6] and VISION Cloud[7] are all examples of storage that can be hosted and deployed with cloud storage characteristics.
Cloud storage is:[6]
Made up of many distributed resources, but still acts as one, either in a federated[8] or a cooperative storage cloud architecture
Highly fault tolerant through redundancy and distribution of data
Highly durable through the creation of versioned copies
Typically eventually consistent with regard to data replicas[9]
Advantages[edit]
Companies need only pay for the storage they actually use, typically an average of consumption during a month.[10] This does not mean that cloud storage is less expensive, only that it incurs operating expenses rather than capital expenses.
Businesses using cloud storage can cut their energy consumption by up to 70% making them a more green business.[11] Also at the vendor level they are dealing with higher levels of energy so they will be more equipped with managing it in order to keep their own costs down as well.
Organizations can choose between off-premises and on-premises cloud storage options, or a mixture of the two options, depending on relevant decision criteria that is complementary to initial direct cost savings potential; for instance, continuity of operations (COOP), disaster recovery (DR), security (PII, HIPAA, SARBOX, IA/CND), and records retention laws, regulations, and policies.[12]
Storage availability and data protection is intrinsic to object storage architecture, so depending on the application, the additional technology, effort and cost to add availability and protection can be eliminated.[13]
Storage maintenance tasks, such as purchasing additional storage capacity, are offloaded to the responsibility of a service provider.[10]
Cloud storage provides users with immediate access to a broad range of resources and applications hosted in the infrastructure of another organization via a web service interface.[14]
Cloud storage can be used for copying virtual machine images from the cloud to on-premises locations or to import a virtual machine image from an on-premises location to the cloud image library. In addition, cloud storage can be used to move virtual machine images between user accounts or between data centers.[15]
Cloud storage can be used as natural disaster proof backup, as normally there are 2 or 3 different backup servers located in different places around the globe.[16]
Cloud storage can be mapped as a local drive with the WebDAV protocol. It can function as a central file server for organizations with multiple office locations.
Potential concerns[edit]
Main article: Cloud computing security
Attack surface area[edit]
Outsourcing data storage increases the attack surface area.[17]
When data has been distributed it is stored at more locations increasing the risk of unauthorized physical access to the data. For example, in cloud based architecture, data is replicated and moved frequently so the risk of unauthorized data recovery increases dramatically. Such as in the case of disposal of old equipment, reuse of drives, reallocation of storage space. The manner that data is replicated depends on the service level a customer chooses and on the service provided. When encryption is in place it can ensure confidentiality. Crypto-shredding can be used when disposing of data (on a disk).
The number of people with access to the data who could be compromised (i.e. bribed, or coerced) increases dramatically. A single company might have a small team of administrators, network engineers and technicians, but a cloud storage company will have many customers and thousands of servers and therefore a much larger team of technical staff with physical and electronic access to almost all of the data at the entire facility or perhaps the entire company.[18] Encryption keys that are kept by the service user, as opposed to the service provider limit the access to data by service provider employees. As for sharing the multiple data with multiple users in cloud, a large number of keys has to be distributed to users via secure channels for decryption, also it has to be securely stored and managed by the users in their devices. And storing these keys requires rather expensive secure storage. To overcome that Key-aggregate cryptosystem[19] can be used.
It increases the number of networks over which the data travels. Instead of just a local area network (LAN) or storage area network (SAN), data stored on a cloud requires a WAN (wide area network) to connect them both.
By sharing storage and networks with many other users/customers it is possible for other customers to access your data. Sometimes because of erroneous actions, faulty equipment, a bug and sometimes because of criminal intent. This risk applies to all types of storage and not only cloud storage. The risk of having data read during transmission can be mitigated through encryption technology. Encryption in transit protects data as it is being transmitted to and from the cloud service.[20] Encryption at rest protects data that is stored at the service provider. Encrypting data in an on-premises cloud service on-ramp system can provide both kinds of encryption protection.
Supplier stability[edit]
See also: Financial Analysis
Companies are not permanent and the services and products they provide can change. Outsourcing data storage to another company needs careful investigation and nothing is ever certain. Contracts set in stone can be worthless when a company ceases to exist or its circumstances change. Companies can:[21][22][23]
Go bankrupt.
Expand and change their focus.
Be purchased by other larger companies.
Be purchased by a company headquartered in or move to a country that negates compliance with export restrictions and thus necessitates a move.
Suffer an irrecoverable disaster.
Accessibility[edit]
Performance for outsourced storage is likely to be lower than local storage, depending on how much a customer is willing to spend for WAN bandwidth[10]
Reliability and availability depends on wide area network availability and on the level of precautions taken by the service provider. Reliability should be based on hardware as well as various algorithms used.
Its a given a multiplicity of data storage.
Other concerns[edit]
Security of stored data and data in transit may be a concern when storing sensitive data at a cloud storage provider[10]
Users with specific records-keeping requirements, such as public agencies that must retain electronic records according to statute, may encounter complications with using cloud computing and storage. For instance, the U.S. Department of Defense designated the Defense Information Systems Agency (DISA) to maintain a list of records management products that meet all of the records retention, personally identifiable information (PII), and security (Information Assurance; IA) requirements[24]
Cloud storage is a rich resource for both hackers and national security agencies.[25][26] Because the cloud holds data from many different users and organizations, hackers see it as a very valuable target.[27]
Piracy and copyright infringement may be enabled by sites that permit filesharing. For example, the CodexCloud ebook storage site has faced litigation from the owners of the intellectual property uploaded and shared there, as have the GrooveShark and YouTube sites it has been compared to.[28][29]
The legal aspect, from a regulatory compliance standpoint, is of concern when storing files domestically and especially internationally.[30]
See also[edit]
Cloud collaboration
Cloud Data Management Interface, better known as CDMI
Cloud database
Comparison of online backup services
File hosting service
Mobile cloud storage
References[edit]
Jump up ^ "A History of Cloud Computing". ComputerWeekly.
Jump up ^ Louden, Bill (September 1983). "Increase Your 100's Storage with 128K from Compuserve". Portable 100. New England Publications Inc. (Volume 1, Number 1): 22. ISSN 0738-7016.
Jump up ^ Daniela Hernandez (May 23, 2014). "Tech Time Warp of the Week". Wired.
Jump up ^ "Box.net lets you store, share, work in the computing cloud". Silicon Valley Business Journal. December 6, 2009. Retrieved October 2, 2016.
Jump up ^ "On-premises private cloud storage description, characteristics, and options".
^ Jump up to: a b S. Rhea, C. Wells, P. Eaton, D. Geels, B. Zhao, H. Weatherspoon, and J. Kubiatowicz, Maintenance-Free Global Data Storage. IEEE Internet Computing , Vol 5, No 5, September/October 2001, pp 40–49. [1] [2]
Jump up ^ A Cloud Environment for Data-intensive Storage Services
Jump up ^ Vernik, Gil, et al. "Data On-boarding in Federated Storage Clouds." Proceedings of the 2013 IEEE Sixth International Conference on Cloud Computing. IEEE Computer Society, 2013.
Jump up ^ Kemme, Bettina, et al. "Consistency in Distributed Systems (Dagstuhl Seminar 13081)." (2013).
^ Jump up to: a b c d ZDNet, Nasuni Cloud Storage Gateway By Dan Kusnetzky, June 1, 2010, [3]
Jump up ^ Gupta, P (20 October 2013). "The usage and adoption of cloud computing by small and medium businesses". International Journal of Information Management (33): 861–874. doi:10.1016/j.ijinfomgt.2013.07.001.
Jump up ^ "Ochs, R. (2012). The New Decision-Makers. CRN (June 22, 2012). Retrieved on December 10, 2012.".
Jump up ^ "4 reasons why cloud and on-premises storage are different, but equally good for people data". 2013-09-09. Retrieved 2013-09-09.
Jump up ^ O’Brien, J. A. & Marakas, G. M. (2011). Computer Software. Management Information Systems 10th ed. 145. McGraw-Hill/Irwin
Jump up ^ Wu C F, Wang Y S, Liu G N, Amies, A, 2012, Create solutions on IBM SmartCloud Enterprise: Transfer image assets between different accounts IBM developerWorks, June 6.
Jump up ^ Kok, Joe. "Best Cloud Storage : Multi Geo-Location Server". GoodCloudStorage. Retrieved 2014-08-11.
Jump up ^ "The Attack Surface Problem". Sans.edu. Retrieved 2013-07-08.
Jump up ^ Cyber%20 Intrusion%20 Mitigation%20 Strategies .pdf "US-CERT ICS-TIP-12-146-01 Targeted Cyber Intrusion and Detection Mitigation Strategies" Check |url= value (help) (PDF).
Jump up ^ Chu, Cheng-Kang; Chow, S.S.M.; Tzeng, Wen-Guey; Zhou, Jianying; Deng, R.H. (2014-02-01). "Key-Aggregate Cryptosystem for Scalable Data Sharing in Cloud Storage". IEEE Transactions on Parallel and Distributed Systems. 25 (2): 468–477. ISSN 1045-9219. doi:10.1109/TPDS.2013.112.
Jump up ^ Transfer files from one onedrive account to another.
Jump up ^ Butler, Brandon (2 June 2014). "Cloud's worst-case scenario: What to do if your provider goes belly up". Network World. Retrieved 20 June 2015.
Jump up ^ Gaudin, Sharon (12 January 2015). "Verizon gets 'black eye' in long cloud shutdown". ComputerWorld. Retrieved 20 June 2015.
Jump up ^ Butler, Brandon (1 November 2013). "Free cloud storage service MegaCloud goes dark". Network World. Retrieved 20 June 2015.
Jump up ^ "DoDD 5015.2 DOD Records Management Program, Section 5.1.3" (PDF).
Jump up ^ Mello, John P. "National Security Agency Pressed to Reveal Details on Google Deal". PCWorld. Retrieved 2013-07-08.
Jump up ^ Spring, Tom. "Google Ditches Microsoft's Windows Over Security Issues, Report Claims". PCWorld. Retrieved 2013-07-08.
Jump up ^ Subashini, S.; Kavitha, V. (2011-01-01). "A survey on security issues in service delivery models of cloud computing". Journal of Network and Computer Applications. 34 (1): 1–11. doi:10.1016/j.jnca.2010.07.006.
Jump up ^ Justin Pot (7 December 2011). "Codex Cloud: Upload Your Books & Read Them Online Along With Other People’s Uploads". MakeUseOf.
Jump up ^ Nancy Messieh (18 October 2011). "Publishers beware: Is CodexCloud the Grooveshark for ebooks?". NextWeb.
Jump up ^ Jones, Hadley. "When Online File Storage Gets Legal: Regulatory Compliance". CloudWedge. Retrieved 2014-01-16.
[hide]
v
t
e
Cloud computing
Applications
Box
Google
G Suite
Docs, Sheets and Slides
HP Cloud (closed)
Microsoft Online
Rackspace
Salesforce
Platforms
Alpha7
Amazon
AppScale
Box
Bluemix
Cloud Foundry
Cocaine (PaaS)
Engine Yard
eXo Platform
Helion
GE Predix
Google App Engine
GreenQloud
Heroku
Inktank
Jelastic
Mendix
Microsoft Azure
OutSystems
openQRM
OpenShift
PythonAnywhere
RightScale
Force.com
SAP Cloud Platform
VMware vCloud Air
WaveMaker
Infrastructure
Amazon
Abiquo Enterprise Edition
CloudStack
CtrlS
Cloud4c
DigitalOcean
EMC Atmos
Eucalyptus
Fujitsu
GoGrid
Google Cloud Platform
GreenButton
GreenQloud
IBM cloud computing
iland
Joyent
Lunacloud
Nimbula
Nimbus
OpenNebula
OpenStack
OrionVM
Rackspace Cloud
SoftLayer
Zadara Storage
libvirt
libguestfs
OVirt
Virtual Machine Manager
Wakame-vdc
Virtual Private Cloud OnDemand
Technologies
Cloud database
Data centers
Distributed file system for cloud
Hardware virtualization
Internet
Networking
Security
Structured storage
Virtual appliance
Web APIs
Virtual private cloud
Category
Commons
Retrieved from "https://en.wikipedia.org/w/index.php?title=Cloud_storage&oldid=808376491"
Categories:
Network file systems
Outsourcing
Cloud storage
Hidden categories:
Pages with URL errors
Wikipedia articles that are too technical from December 2016
All articles that are too technical
Articles needing expert attention from December 2016
All articles needing expert attention
Navigation menu
Personal tools
Not logged in
Talk
Contributions
Create account
Log in
Namespaces
Article
Talk
Variants
Views
Read
Edit
View history
More
Search
Navigation
Main page
Contents
Featured content
Current events
Random article
Donate to Wikipedia
Wikipedia store
Interaction
Help
About Wikipedia
Community portal
Recent changes
Contact page
Tools
What links here
Related changes
Upload file
Special pages
Permanent link
Page information
Wikidata item
Cite this page
Print/export
Create a book
Download as PDF
Printable version
Languages
العربية
বাংলা
Български
Català
Ελληνικά
Español
한국어
Italiano
עברית
नेपाली
Norsk
Polski
Русский
Српски / srpski
Svenska
தமிழ்
Türkçe
Українська
中文
Edit links
This page was last edited on 2 November 2017, at 14:20.
Text is available under the Creative Commons Attribution-ShareAlike License; additional terms may apply. By using this site, you agree to the Terms of Use and Privacy Policy. Wikipedia® is a registered trademark of the Wikimedia Foundation, Inc., a non-profit organization.
Privacy policy
About Wikipedia
Disclaimers
Contact Wikipedia
Developers
Cookie statement
Mobile view
Enable previews

key: html

type: local

value: div

attrs: id class

values: mw-page-base noprint

values: mw-head-base noprint

value: a

attrs: id class lang

values: firstHeading firstHeading en

values: siteSub noprint

values: jump-to-nav mw-jump

attrs: href title

attrs: role class

values:
note
hatnote navigation-not-searchable

value: b

value: p

values:
/wiki/Content_management_systems
mw-redirect
Content management systems

values: button 0 togglelink

values:
/wiki/Joseph_Carl_Robnett_Licklider
mw-redirect
Joseph Carl Robnett Licklider

values:
/wiki/Dropbox_(storage_provider)
mw-redirect
Dropbox (storage provider)

attrs: alt src width height class srcset data-file-width data-file-height

attrs: alt src width height srcset data-file-width data-file-height

values: Wikipedia:Make technical articles understandable

values: plainlinks metadata ambox ambox-style ambox-technical

values:
/wiki/Virtual_machine_image
mw-redirect
Virtual machine image

values:
/wiki/Financial_Analysis
mw-redirect
Financial Analysis

values:
/wiki/Export_restrictions
mw-redirect
Export restrictions

values:
nofollow
external text
//www.worldcat.org/issn/0738-7016

values:
nofollow
http://www.goodcloudstorage.net/
external text

values:
nofollow
external text
//www.worldcat.org/issn/1045-9219

values:
nofollow
external text
//doi.org/10.1109%2FTPDS.2013.112

values:
/wiki/Network_World
mw-redirect
Network World

values:
nofollow
external text
//doi.org/10.1016%2Fj.jnca.2010.07.006

values: -moz-column-width: 30em; -webkit-column-width: 30em; column-width: 30em; list-style-type: decimal;

values:
/wiki/Google_Docs,_Sheets_and_Slides
mw-redirect
Google Docs, Sheets and Slides

values:
/wiki/VMware_vCloud_Air
mw-redirect
VMware vCloud Air

values:
/wiki/Infrastructure_as_a_service
mw-redirect
Infrastructure as a service

values:
/wiki/Virtual_Private_Cloud_OnDemand
mw-redirect
Virtual Private Cloud OnDemand

values: Comparison of structured storage software

attrs: alt src title width height srcset data-file-width data-file-height

values: nowraplinks collapsible autocollapse navbox-inner

values: Category:Wikipedia articles that are too technical from December 2016

values: Category:All articles that are too technical

values: Category:Articles needing expert attention from December 2016

values: Category:All articles needing expert attention

values: Discussion about edits from this IP address [ctrl-alt-n]

values: A list of edits made from this IP address [ctrl-alt-y]

values: You are encouraged to create an account and log in; however, it is not mandatory

values: You're encouraged to log in; however, it's not mandatory. [ctrl-alt-o]

values:
/wiki/Cloud_storage
View the content page [ctrl-alt-c]
c

values: Discussion about the content page [ctrl-alt-t]

values: p-namespaces navigation vectorTabs p-namespaces-label

values:
p-variants
navigation
vectorMenu emptyPortlet
p-variants-label

values: Past revisions of this page [ctrl-alt-h]

values: p-views navigation vectorTabs p-views-label

values:
p-cactions
navigation
vectorMenu emptyPortlet
p-cactions-label

values:
mw-wiki-logo
/wiki/Main_Page
Visit the main page

values:
/wiki/Main_Page
Visit the main page [ctrl-alt-z]
z

values: Featured content – the best of Wikipedia

values: Find background information on current events

values:
/wiki/Special:Random
Load a random article [ctrl-alt-x]
x

values:
uls-settings-trigger
Language settings
0
button
true

values: تخزين سحابي – Arabic

values: ক্লাউড স্টোরেজ – Bangla

values: Облачно съхранение – Bulgarian

values: Αποθηκευτικό νέφος – Greek

values: 클라우드 스토리지 – Korean

values: אחסון ענן – Hebrew

values: क्लाउड स्टोरेज – Nepali

values: Облачное хранилище данных – Russian

values: Складиштење података на облаку – Serbian

values: மேக சேமிப்பகம் – Tamil

values: Хмарні сховища – Ukrainian

values: mediawiki ltr sitedir-ltr mw-hide-empty-elt ns-0 ns-subject page-Cloud_storage rootpage-Cloud_storage vector-experimental-print-styles vector-nav-directionality skin-vector action-view


text:
Management of acute coronary syndrome
From Wikipedia, the free encyclopedia
Jump to: navigation, search
Management of acute coronary syndrome is targeted against the effects of reduced blood flow to the afflicted area of the heart muscle, usually because of a blood clot in one of the coronary arteries, the vessels that supply oxygenated blood to the myocardium. This is achieved with urgent hospitalization and medical therapy, including drugs that relieve chest pain and reduce the size of the infarct, and drugs that inhibit clot formation; for a subset of patients invasive measures are also employed (coronary angiography and percutaneous coronary intervention). Basic principles of management are the same for all types of acute coronary syndrome. However, some important aspects of treatment depend on the presence or absence of elevation of the ST segment on the electrocardiogram, which classifies cases upon presentation to either ST segment elevation myocardial infarction (STEMI) or non-ST elevation acute coronary syndrome (NST-ACS); the latter includes unstable angina and non-ST elevation myocardial infarction (NSTEMI). Treatment is generally more aggressive for STEMI patients, and reperfusion therapy is more often reserved for them. Long term therapy is necessary for prevention of recurrent events and complications.[1]
Contents
[hide]
1 General principles
2 Patient-dependent initial measures
3 Emergency services
4 Initial diagnostic approach
5 Relief of angina
5.1 Nitrates
5.2 Beta blockers
5.3 Oxygen therapy
5.4 Analgesics
6 Antiplatelet drugs
6.1 Aspirin
6.2 P2Y12 inhibitors
6.3 Glycoprotein IIb/IIIa inhibitors
7 Anticoagulants
8 Reperfusion
9 Rehabilitation
10 Special cases
10.1 Cocaine
10.2 Wilderness setting
10.3 Air travel
11 References
11.1 Selected cited works
General principles[edit]
Acute coronary syndromes are commonly caused by a blood clot forming on an atherosclerotic plaque in a coronary artery. Oxygen delivery to a part of heart muscle is blocked, eventually causing cell death.
Acute coronary syndromes are caused by sudden and critical reduction of blood flow in one of the coronary arteries, the vessels that supply oxygenated blood to the myocardium (heart muscle), typically by a blood clot. The principal symptom is typically chest pain, known as angina pectoris; people who present with angina must prompt evaluation for possible acute coronary syndrome.[2]
Acute coronary syndromes are classified to two major categories, according to the patient's electrocardiogram, and specifically the presence or absence of persistent (>20 min) ST segment elevation (or left bundle branch block).[2] Patients with acute coronary syndrome and ST elevation are said to suffer from ST-elevation myocardial infarction (STEMI) and they tend to have one of their coronary arteries totally blocked.[3] Damage is reversible for approximately 20[4]-30[5] minutes after complete obstruction of blood flow; thereafter myocardial cell death ensues and progresses as time passes. Therefore, complete and sustained restoration of blood flow must be as prompt as possible to ensure maximum salvage of functional myocardium, a principle expressed in the maxim "time is muscle".[6] This is achieved with reperfusion therapy, which is based on invasive reopening of the afflicted coronary artery with primary percutaneous coronary intervention, or non-invasive breaking up of the responsible blood clot with a thrombolytic drug.[7]
Patients without ST segment elevation are said to suffer from non-ST-elevation acute coronary syndrome and tend not to have full occlusion of a coronary artery. If there is evidence of myocardial cell death (especially elevated cardiac biomarkers) they are considered to have a non-ST-elevation myocardial infarction (NSTEMI); otherwise they are classified as suffering from unstable angina.[8] Their management is based on the estimation of their risk for adverse events. Patients at low risk can be adequately treated with medical therapy, in many ways similar to the one used for STEMI (but excluding thrombolytics). Those at moderate to high risk benefit from an early invasive strategy, which includes coronary angiography and, if necessary, revascularization with percutaneous coronary intervention or coronary artery bypass surgery.[9]
Medical therapy for acute coronary syndromes is based on drugs that act against ischemia and resultant angina and limit the infarct size (i.e., the area of myocardium that is affected), as well as drugs that inhibit clot formation. The latter include antiplatelet agents, which block the activation and aggregation of platelets (cellular blood components that contribute to clot formation), and anticoagulant agents (which attenuate the coagulation cascade). Long-term therapy in acute coronary syndrome survivors is targeted against recurrence and long term complications (secondary prevention).[1]
Women are taken less seriously than men when they have a heart attack leading to higher mortality among women.[10]
Patient-dependent initial measures[edit]
Information card published by the National Heart, Lung, and Blood Institute urging people with symptoms of angina to call the emergency medical services.
Because of the relationship between the duration of myocardial ischemia and the extent of damage to heart muscle, public health services encourage people experiencing possible acute coronary syndrome symptoms or those around them to immediately call emergency medical services.[11][12][13] Patients with known coronary artery disease who have been prescribed nitroglycerin should promptly take one dose, and call emergency medical services if their symptoms do not improve within 2–5 minutes. Patients should not be transported to hospital by private vehicles instead of an ambulance, unless evacuation by land or air ambulance is impossible (e.g., dangerous weather in a very remote area), and if they must be, it should be done if possible with someone trained in cardiac first aid. Chewing non−enteric-coated aspirin is encouraged (unless there are contraindications).[14]
Health care professionals are responsible for teaching their patients at risk of acute coronary syndrome what the symptoms of this condition are, and that it is imperative to seek urgent medical attention in case they present.[15]
Emergency services[edit]
Emergency Medical Services (EMS) Systems vary considerably in their ability to evaluate and treat patients with suspected acute myocardial infarction. Some provide as little as first aid and early defibrillation. Others employ highly trained paramedics with sophisticated technology and advanced protocols.[16] Paramedic services are capable of providing oxygen, IV access, sublingual nitroglycerine, morphine, and aspirin. Some advanced paramedic systems can also perform 12-lead ECGs.[17] If a STEMI is recognized the paramedic may be able to contact the local PCI hospital and alert the emergency room physician, and staff of the suspected AMI. Some Paramedic services are capable of providing thrombolytic therapy in the prehospital setting, allowing reperfusion of the myocardium.[18][19]
With primary PCI emerging as the preferred therapy for ST-segment elevation myocardial infarction, EMS can play a key role in reducing door-to-balloon intervals (the time from presentation to a hospital ER to the restoration of coronary artery blood flow) by performing a 12-lead ECG in the field and using this information to triage the patient to the most appropriate medical facility.[20][21][22][23] In addition, the 12-lead ECG can be transmitted to the receiving hospital, which enables time saving decisions to be made prior to the arrival of the patient. This may include a "cardiac alert" or "STEMI alert" that calls in off duty personnel in areas where the cardiac cath lab is not staffed 24 hours a day.[24] Even in the absence of a formal alerting program, prehospital 12-lead ECGs are independently associated with reduced door to treatment intervals in the emergency department.[25]
Initial diagnostic approach[edit]
Typical electrocardiogram of an ST segment elevation myocardial infarction. ST elevation in leads I, aVL and V1-V5 indicates an anterior wall myocardial infarction and is shown in orange; reciprocal ST depression in leads II, III and aVF is shown in blue.
In patients with symptoms typical of myocardial ischemia an electrocardiogram must be immediately obtained - e.g., within 10 minutes from first contact with medical or paramedical personnel, including prehospital setting; the electrocardiographic findings will guide the subsequent management. Patients with elevation of the ST segment (or presumed new left bundle branch block) are treated based on guidelines for ST elevation myocardial infarction (STEMI) and must undergo reperfusion therapy as soon as possible. Serum cardiac biomarkers are routinely obtained and their elevation is necessary for confirming diagnosis of myocardial infarction;[26] however, reperfusion must not be delayed by waiting for the results. Patients without the above findings are initially classified as suffering from non ST elevation acute coronary syndrome, and subsequent cardiac biomarker results will differentiate between true non ST elevation myocardial infarction (NSTEMI) and unstable angina.[27][28][29]
Relief of angina[edit]
Relief of the pain of angina is of paramount importance, not only for humane reasons but because the pain is associated with sympathetic activation that causes vasoconstriction and increases the workload of the heart.[27] The pain of myocardial ischemia is likely to respond to any intervention that improves the relationship between oxygen demand and supply, like nitrates, beta blockers and oxygen.[30]
Nitrates[edit]
Nitrates, like nitroglycerin, dilate blood vessels, which is beneficial against myocardial ischemia in two ways: By increasing blood flow in the coronary arteries and the amount of oxygen that arrives to heart muscle; and by relaxing all blood vessels in the body, thereby reducing the workload that heart needs to produce against them and the oxygen it consumes. The preferred mode of administration is sublingually. By relaxing blood vessels nitrates also reduce blood pressure, which must be carefully monitored; they must not be used if hypotension is present. They must also be avoided in patients who have taken sildenafil or other phosphodiesterase type 5 inhibitors (used for erectile dysfunction) within the previous 24–48 hours, as the combination of the two could cause a serious drop in blood pressure. [30][31][32] Intravenous nitrates are useful in patients with hypertension or pulmonary edema.[33]
Beta blockers[edit]
By reducing sympathetic stimulation of the heart, beta blockers decrease heart rate, blood pressure and cardiac output, and hence heart oxygen consumption. Beta-blockers alleviate ischemic pain, and have also been proved to reduce the size of infarcted heart muscle, the risk of arrhythmias, and the proportion of patients with acute coronary syndrome who actually evolve STEMI. However, they have also been shown to increase the risk of acute heart failure. Their early use is contraindicated if there are signs of congestive heart failure (e.g., Killip class II or above) or hypotension, along with other contraindications to beta blockers (slow heart rate, atrioventricular block); in the absence of contraindications beta blocker therapy should begin in the first 24 hours. It may be prudent to prefer oral rather than intravenous forms.[34]
Oxygen therapy[edit]
Initial administration of oxygen to all patients with acute coronary syndrome is common practice; however, there is no evidence to support or refute that supplemental oxygen might be harmful or beneficial for cardiac patients who do not need it.[35] It is currently recommended to give oxygen only to breathless patients or when blood oxygen saturation is low, e.g. <90%.[30][36]
Analgesics[edit]
Analgesic agents that are most commonly used are opioids, and especially morphine, which is considered the analgesic of choice in patients with ST elevation. Along with its pain-controlling properties, morphine also reduces the work of breathing, alleviates breathlessness, reduces anxiety and has favorable action on hemodynamic parameters and cardiac oxygen consumption.[30][37][38] However, in patients presenting without ST elevation, morphine has been shown to have adverse events potential, and its use is considered acceptable only after inadequate pain relief by medication specific against angina.[39] Non-steroidal anti-inflammatory drugs are contraindicated for both categories of patients.[39][40]
Antiplatelet drugs[edit]
All patients with acute coronary syndrome must immediately receive antiplatelet therapy, including aspirin and generally a second oral antiplatelet agent.[41] Bleeding is the most important side-effect of antiplatelets.
Aspirin[edit]
Aspirin inhibits platelet aggregation and formation of blood clots. It is effective across the entire spectrum of acute coronary syndromes, and it actually has been shown to reduce the rate of death in patients with STEMI and in patients presenting without ST elevation. Aspirin is contraindicated in patients with documented allergy or known platelet disorder. Patients who have had gastrointestinal symptoms while on long-term aspirin therapy are usually able to tolerate aspirin in the short term. For patients with true intolerance to aspirin clopidogrel is recommended. Lower doses need days to achieve full antiplatelet effect, therefore a loading dose is necessary for patients who are not already on aspirin.[42]
P2Y12 inhibitors[edit]
Aside of aspirin, three antiplatelet agents taken by mouth have been approved for use in acute coronary syndromes, clopidogrel, ticagrelor and prasugrel; all reduce platelet aggregation by inhibiting the P2Y12 receptor, a type of adenosine phosphate receptor, on the surface of platelets. Not all three of them are equally indicated in all types of acute coronary syndromes. In patients with ST elevation the choice of P2Y12 inhibitor depends on reperfusion strategy; for patients undergoing primary percutaneous coronary intervention ticagrelor and prasugrel are considered superior to clopidogrel, as they are more potent and have more rapid onset of action, at the cost of some increase in bleeding risk; for STEMI patients who are treated with fibrinolysis and those who do not undergo reperfusion treatment only clopidogrel is indicated. Prasugrel must not be given to patients with a history of ischemic stroke or aged 75 years or older. In patients with non-ST elevation acute coronary syndrome current guidelines also recommend immediate administration of dual antiplatelet therapy upon diagnosis; clopidogrel and ticagrelor are indicated in this setting, with ticagrelor considered superior for patients undergoing early invasive strategy (see later). However, emerging evidence questions this strategy.[43] As with aspirin, it is necessary to administer a loading dose.[44][45]
Glycoprotein IIb/IIIa inhibitors[edit]
Glycoprotein IIb/IIIa inhibitors are a class of intravenous antiplatelet agents used in patients undergoing percutaneous coronary intervention, consisting of abciximab, eptifibatide and tirofiban. Patients presenting with ST elevation that will be reperfused with percutaneous coronary intervention may receive one of the above agents at the time of catheterization, or perhaps before. Administering eptifibatide or tirofiban may also be reasonable in patients presenting with NST-ACS who are considered of intermediate or high risk and are treated with early invasive strategy.[46][47]
Anticoagulants[edit]
Anticoagulants in acute coronary syndrome are targeted against the coronary blood clot, as well as towards prevention of thrombotic complications, like formation of blood clots in the ventricles, stroke, pulmonary embolism or deep vein thrombosis.[48] Patients undergoing PCI also need an anticoagulant to prevent catheter thrombosis. Options include unfractionated heparin, enoxaparin (a low molecular weight heparin), fondaparinux (a pentasaccharide antagonist of factor Xa) and bivalirudin (a direct thrombin inhibitor); all the above agents are given parenterally (subcutaneously or intravenously). Unfractionated heparin has the disadvantage of requiring dose adjustment based on a laboratory exam, activated partial thromboplastin time (APTT). In STEMI patients choice depends on the reperfusion strategy used (see below); bivalirudin is used when PCI is employed only, while in the same case fondaparinux is not preferred.[49] Similarly, in Non-STE ACS bivalirudin too is only used when an early invasive strategy is chosen.[50]
Reperfusion[edit]
Main article: Reperfusion therapy
Coronary angiography of a patient with acute myocardial infarction presenting with ST elevation and undergoing primary percutaneous coronary intervention; arrow points at partial occlusion of left circumflex coronary artery; star indicates tip of the guide wire that has been inserted in the artery through the occlusion.
Coronary angiography of the same patient, after dilation of the artery with balloon and placement of stent. The occlusion has been successfully treated.[51]
The concept of reperfusion has become so central to the modern treatment of acute myocardial infarction, that we are said to be in the reperfusion era.[52][53] Patients who present with suspected acute myocardial infarction and ST segment elevation (STEMI) or new bundle branch block on the 12 lead ECG are presumed to have an occlusive thrombosis in an epicardial coronary artery. They are therefore candidates for immediate reperfusion, either with thrombolytic therapy, percutaneous coronary intervention (PCI) or when these therapies are unsuccessful, bypass surgery.
Individuals without ST segment elevation are presumed to be experiencing either unstable angina (UA) or non-ST segment elevation myocardial infarction (NSTEMI). They receive many of the same initial therapies and are often stabilized with antiplatelet drugs and anticoagulated. If their condition remains (hemodynamically) stable, they can be offered either late coronary angiography with subsequent restoration of blood flow (revascularization), or non-invasive stress testing to determine if there is significant ischemia that would benefit from revascularization. If hemodynamic instability develops in individuals with NSTEMIs, they may undergo urgent coronary angiography and subsequent revascularization. The use of thrombolytic agents is contraindicated in this patient subset, however.[54]
The basis for this distinction in treatment regimens is that ST segment elevations on an ECG are typically due to complete occlusion of a coronary artery. On the other hand, in NSTEMIs there is typically a sudden narrowing of a coronary artery with preserved (but diminished) flow to the distal myocardium. Anticoagulation and antiplatelet agents are given to prevent the narrowed artery from occluding.
At least 10% of patients with STEMI do not develop myocardial necrosis (as evidenced by a rise in cardiac markers) and subsequent Q waves on EKG after reperfusion therapy. Such a successful restoration of flow to the infarct-related artery during an acute myocardial infarction is known as "aborting" the myocardial infarction. If treated within the hour, about 25% of STEMIs can be aborted.[55]
Rehabilitation[edit]
Additional objectives are to prevent life-threatening arrhythmias or conduction disturbances. This requires monitoring in a coronary care unit and protocolized administration of antiarrhythmic agents. Antiarrhythmic agents are typically only given to individuals with life-threatening arrhythmias after a myocardial infarction and not to suppress the ventricular ectopy that is often seen after a myocardial infarction.[56][57][58]
Cardiac rehabilitation aims to optimize function and quality of life in those afflicted with a heart disease. This can be with the help of a physician, or in the form of a cardiac rehabilitation program.[59]
Physical exercise is an important part of rehabilitation after a myocardial infarction, with beneficial effects on cholesterol levels, blood pressure, weight, stress and mood.[59] Some patients become afraid of exercising because it might trigger another infarct.[60] Patients are encouraged to exercise, and should only avoid certain exerting activities. Local authorities may place limitations on driving motor vehicles.[61] In most cases, the advice is a gradual increase in physical exercise during about 6–8 weeks following an MI.[62] If it doesn't feel too hard for the patient, the advice about exercise is then the same as applies to anyone else to gain health benefits, that is, at least 20–30 minutes of moderate exercise on most days (at least five days per week) to the extent of getting slightly short of breath.[62]
Some people are afraid to have sex after a heart attack. Most people can resume sexual activities after 3 to 4 weeks. The amount of activity needs to be dosed to the patient's possibilities.[63]
Special cases[edit]
Cocaine[edit]
Cocaine associated myocardial infarction should be managed in a manner similar to other patients with acute coronary syndrome, except that beta blockers should not be used and benzodiazepines should be administered early.[64] The treatment itself may have complications. If attempts to restore the blood flow are initiated after a critical period of only a few hours, the result may be a reperfusion injury instead of amelioration.[65]
Wilderness setting[edit]
In wilderness first aid, a possible heart attack justifies evacuation by the fastest available means, often meaning the initiation of a MEDEVAC. The suspicion or provisional diagnosis of an MI means that it is inappropriate for the patient to walk out of the wilderness setting and will require them to be carried or conveyed in a vehicle. Aspirin, nitroglycerin, and oxygen can all be given with relative ease in a wilderness setting and should be administered as soon as possible in suspected cases of MI. Wilderness management of cardiac arrest differs slightly from that carried out in an urban setting in that it is generally considered acceptable to terminate a resuscitation attempt after 30 minutes if there has been no change in the patient's condition.
Air travel[edit]
Certified personnel traveling by commercial aircraft may be able to assist an MI patient by using the on-board first aid kit, which may contain some cardiac drugs (such as glyceryl trinitrate spray, aspirin, or opioid painkillers), an AED,[66] and oxygen. Pilots may divert the flight to land at a nearby airport. Cardiac monitors are being introduced by some airlines, and they can be used by both on-board and ground-based physicians.[67]
References[edit]
^ Jump up to: a b Current management of acute coronary syndrome is based on guidelines, produced by national and international medical societies according to the principles of evidence-based medicine. Examples are the guidelines of the American Heart Association and American College of Cardiology (O'Gara 2013, Amsterdam 2014) and those of the European Society of Cardiology (Steg 2012, Hamm 2011).
^ Jump up to: a b Hamm 2011, p. 3004.
Jump up ^ Antman EM (2012a). "Chapter 54. ST-segment elevation myocardial infarction: Pathology, pathophysiology, and clinical features". In Bonow RO, Mann DL, Zipes DP, Libby P. Braunwald's heart disease: A textbook of cardiovascular medicine (9th ed.). Saunders. pp. 1087–1110. ISBN 978-0-8089-2436-4. , p. 1092
Jump up ^ Canty J Jr (2012). "Chapter 52. Coronary blood flow and myocardial ischemia". In Bonow RO, Mann DL, Zipes DP, Libby P. Braunwald's heart disease: A textbook of cardiovascular medicine (9th ed.). Saunders. pp. 1049–1055. ISBN 978-0-8089-2436-4.
Jump up ^ Schoen, FJ (2010). "The heart". In Kumar, V.; Abbas, A.K.; Fausto, N.; Aster, J. Robbins and Cotran pathologic basis of disease (8th ed.). Saunders. pp. 529–587. ISBN 978-1-4160-3121-5. . Cited in Antman 2012a, p. 1093
Jump up ^ See:
Antman, Elliott M. (2008). "Time is muscle. Translation into practice". Journal of the American College of Cardiology. 52 (15): 1216–1221. doi:10.1016/j.jacc.2008.07.011. PMID 18926324.
Scott, IA (2010). ""Time is muscle" in reperfusing occluded coronary arteries in acute myocardial infarction". Med J Aust. 193 (9): 495. PMID 21034380.
Jump up ^ Antman 2012b, p. 1118.
Jump up ^ Cannon 2012, p. 1178.
Jump up ^ Cannon 2012, p. 1194.
Jump up ^ Heart attack care dangerously unequal for women, study finds BBC
Jump up ^ Faxon, D; Lenfant, C (2001). "Timing is everything. Motivating patients to call 9-1-1 at onset of acute myocardial infarction". Circulation. 104 (11): 1210–1211. PMID 11551867.
Jump up ^ "What is a heart attack". National Institutes of Health. National Heart, Lung, and Blood Institute. Retrieved 30 September 2014.
Jump up ^ "Heart attack - Symptoms". National Health Service. Retrieved 22 December 2014.
Jump up ^ O'Gara 2013, p. e369.
Jump up ^ Antman 2012b, p. 1111.
Jump up ^ Antman EM, Anbe DT, Armstrong PW, et al. (August 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.
Jump up ^ Alberta Occupational Competency Profile EMT Paramedic Archived 2011-10-05 at the Wayback Machine.. Alberta College Of Paramedics. Updated January 2007, Retrieved June 29, 2011.
Jump up ^ Morrow DA, Antman EM, Sayah A, et al. (July 2002). "Evaluation of the time saved by prehospital initiation of reteplase for ST-elevation myocardial infarction: results of The Early Retavase-Thrombolysis in Myocardial Infarction (ER-TIMI) 19 trial". J. Am. Coll. Cardiol. 40 (1): 71–7. doi:10.1016/S0735-1097(02)01936-8. PMID 12103258.
Jump up ^ Morrison LJ, Verbeek PR, McDonald AC, Sawadsky BV, Cook DJ (2000). "Mortality and prehospital thrombolysis for acute myocardial infarction: A meta-analysis" (PDF). JAMA. 283 (20): 2686–92. doi:10.1001/jama.283.20.2686. PMID 10819952.
Jump up ^ Rokos IC, Larson DM, Henry TD, et al. (2006). "Rationale for establishing regional ST-elevation myocardial infarction receiving center (SRC) networks". Am. Heart J. 152 (4): 661–7. doi:10.1016/j.ahj.2006.06.001. PMID 16996830.
Jump up ^ Moyer P, Feldman J, Levine J, et al. (June 2004). "Implications of the Mechanical (PCI) vs Thrombolytic Controversy for ST Segment Elevation Myocardial Infarction on the Organization of Emergency Medical Services: The Boston EMS Experience". Crit Pathw Cardiol. 3 (2): 53–61. doi:10.1097/01.hpc.0000128714.35330.6d. PMID 18340140.
Jump up ^ Terkelsen CJ, Lassen JF, Nørgaard BL, et al. (April 2005). "Reduction of treatment delay in patients with ST-elevation myocardial infarction: impact of pre-hospital diagnosis and direct referral to primary percutanous coronary intervention". Eur. Heart J. 26 (8): 770–7. doi:10.1093/eurheartj/ehi100. PMID 15684279. T
Jump up ^ Henry TD, Atkins JM, Cunningham MS, et al. (April 2006). "ST-segment elevation myocardial infarction: recommendations on triage of patients to heart attack centers: is it time for a national policy for the treatment of ST-segment elevation myocardial infarction?". J. Am. Coll. Cardiol. 47 (7): 1339–45. doi:10.1016/j.jacc.2005.05.101. PMID 16580518.
Jump up ^ Rokos I. and Bouthillet T., "The emergency medical systems-to-balloon (E2B) challenge: building on the foundations of the D2B Alliance," STEMI Systems, Issue Two, May 2007. Accessed June 16, 2007.
Jump up ^ Cannon, Christopher (1999). Management of acute coronary syndromes. Totowa, NJ: Humana Press. ISBN 0-89603-552-2.
Jump up ^ Thygesen, K; Alpert, JS; Jaffe, AS; Simoons, ML; Chaitman, BR; White, HD (2012). "Third universal definition of myocardial infarction" (PDF). European Heart Journal. 33 (20): 2551–2567. doi:10.1093/eurheartj/ehs184. PMID 22922414. p. 2553
^ Jump up to: a b Steg 2012, p. 2574.
Jump up ^ Amsterdam 2014, p. 14.
Jump up ^ O'Gara 2013, p. e370.
^ Jump up to: a b c d Antman 2012b, p. 1116.
Jump up ^ Cannon 2012, p. 1185.
Jump up ^ Cheitlin, MD; Hutter, AM, Jr, Brindis; RG; et al. (1999). "Use of Sildenafil (Viagra) in Patients With Cardiovascular Disease". Circulation. 99: 168–177. doi:10.1161/01.CIR.99.1.168. PMID 9884398.
Jump up ^ Steg 2012, p. 2598.
Jump up ^ See:
Antman 2012b, pp. 1116–1117
Cannon 2012, p. 1185
O'Gara 2013, p. e398-e390
Stef 2012, p. 2597
Bates, ER (2007). "Role of intravenous β-blockers in the treatment of ST-elevation myocardial infarction. Of mice (dogs, pigs) and men". Circulation. 115: 2904–2906. doi:10.1161/CIRCULATIONAHA.107.707968. PMID 17562966.
Jump up ^ Cabello, Juan B.; Burls, Amanda; Emparanza, José I.; Bayliss, Susan E.; Quinn, Tom (2016). "Oxygen therapy for acute myocardial infarction". The Cochrane Database of Systematic Reviews. 12: CD007160. doi:10.1002/14651858.CD007160.pub4. ISSN 1469-493X. PMID 27991651.
Jump up ^ Amsterdam 2014, p. 30.
Jump up ^ Steg 2012, p. 2576.
Jump up ^ Hilal-Dandan, R; Brunton, L (2013). Goodman and Gilman Manual of Pharmacology and Therapeutics (2nd ed.). McGraw-Hill Professional. p. 291. ISBN 978-0071769174.
^ Jump up to: a b Amsterdam 2014, p. 31.
Jump up ^ O'Gara 2013, p. e391.
Jump up ^ Opie, LH; Garsh BJ (2013). Drugs for the heart (8th ed.). Elsevier Saunders. pp. 471–472. ISBN 9781455733224.
Jump up ^ See:
Antman 2012b, p. 1115
Amsterdam 2014, p. 39
Steg 2012, p. 2589
O'Gara 2013, p. e375, e380
Hamm 2011, p. 3013
Cannon 2012, p. 1186
Jump up ^ Bellemain-Appaix, A; Kerneis, M; O'Connor, SA; et al. (2014). "Reappraisal of thienopyridine pretreatment in patients with non-ST elevation acute coronary syndrome: a systematic review and meta-analysis". BMJ. 349: g6269. doi:10.1136/bmj.g6269. PMC 4208629  . PMID 25954988. Retrieved 2 November 2014.
Jump up ^ Amsterdam 2014, p. 37-40.
Jump up ^ Steg 2012, p. 2583-2584, 2587-2588, 2591.
Jump up ^ O'Gara 2012, p. 377-378.
Jump up ^ Amsterdam 2014, p. 38.
Jump up ^ Antman 2012b, p. 1029.
Jump up ^ Steg 2012, p. 2584-5, 2587-91.
Jump up ^ Amsterdam 2014, p. 41-43.
Jump up ^ Tödt, T; Maret, E; Alfredsson, J; et al. (2012). "Relationship between treatment delay and final infarct size in STEMI patients treated with abciximab and primary PCI". BMC Cardiovasc Disord. 12 (9). doi:10.1186/1471-2261-12-9. PMC 3359186  . PMID 22361039.
Jump up ^ Lee KL, Woodlief LH, Topol EJ, et al. (1995). "Predictors of 30-Day Mortality in the Era of Reperfusion for Acute Myocardial Infarction". Circulation. 91 (6): 1659–1668. doi:10.1161/01.cir.91.6.1659. PMID 7882472.
Jump up ^ Stone GW, Grines CL, Browne KF, et al. (1995). "Predictors of in-hospital and 6-month outcome after acute myocardial infarction in the reperfusion era: the Primary Angioplasty in Myocardial Infarction (PAMI) trail". J Am Coll Cardiol. 25 (2): 370–377. doi:10.1016/0735-1097(94)00367-Y. PMID 7829790.
Jump up ^ "Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group". Lancet. 343 (8893): 311–22. February 1994. doi:10.1016/s0140-6736(94)91161-4. PMID 7905143.
Jump up ^ Verheugt FW, Gersh BJ, Armstrong PW (2006). "Aborted myocardial infarction: a new target for reperfusion therapy". Eur Heart J. 27 (8): 901–4. doi:10.1093/eurheartj/ehi829. PMID 16543251.
Jump up ^ Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL, et al. (1991). "Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial". N Engl J Med. 324 (12): 781–8. doi:10.1056/NEJM199103213241201. PMID 1900101.
Jump up ^ Waldo AL, Camm AJ, deRuyter H, Friedman PL, MacNeil DJ, Pauls JF, Pitt B, Pratt CM, Schwartz PJ, Veltri EP (1996). "Effect of d-sotalol on mortality in patients with left ventricular dysfunction after recent and remote myocardial infarction. The SWORD Investigators. Survival With Oral d-Sotalol". Lancet. 348 (9019): 7–12. doi:10.1016/S0140-6736(96)02149-6. PMID 8691967.
Jump up ^ Julian DG, Camm AJ, Frangin G, Janse MJ, Munoz A, Schwartz PJ, Simon P (1997). "Randomised trial of effect of amiodarone on mortality in patients with left-ventricular dysfunction after recent myocardial infarction: EMIAT. European Myocardial Infarct Amiodarone Trial Investigators". Lancet. 349 (9053): 667–74. doi:10.1016/S0140-6736(96)09145-3. PMID 9078197.
^ Jump up to: a b Life after a Heart Attack. U.S. National Heart, Lung and Blood Institute. Retrieved December 2, 2006.
Jump up ^ Trisha Macnair. Recovering after a heart attack. BBC, December 2005. Retrieved December 2, 2006.
Jump up ^ "Classification of Drivers' Licenses Regulations". Nova Scotia Registry of Regulations. May 24, 2000. Retrieved April 22, 2007.
^ Jump up to: a b Patient UK > After a Myocardial Infarction Reviewed: 19 May 2010
Jump up ^ "Heart Attack: Getting Back Into Your Life After a Heart Attack Archived 2008-07-24 at the Wayback Machine.". American Academy of Family Physicians, updated March 2005. Retrieved December 4, 2006.
Jump up ^ McCord J, Jneid H, Hollander JE, et al. (April 2008). "Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology". Circulation. 117 (14): 1897–907. doi:10.1161/CIRCULATIONAHA.107.188950. PMID 18347214.
Jump up ^ Faxon DP (November 2005). "Coronary interventions and their impact on post myocardial infarction survival". Clinical Cardiology. 28 (11 Suppl 1): I38–44. doi:10.1002/clc.4960281307. PMID 16450811.
Jump up ^ Youngwith, Janice (2008-02-06). "Saving hearts in the air". Dailyherald.com. Retrieved 2008-06-12. [dead link]
Jump up ^ Dowdall N (November 2000). ""Is there a doctor on the aircraft?" Top 10 in-flight medical emergencies". BMJ (Clinical research ed.). 321 (7272): 1336–7. doi:10.1136/bmj.321.7272.1336. PMC 1119071  . PMID 11090520.
Selected cited works[edit]
Steg, PG; James, SK; Atar, D; et al. (2012). "ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation". European Heart Journal. 33 (20): 2569–2619. doi:10.1093/eurheartj/ehs215. PMID 22922416.
Hamm, CW; Bassand, JP; Agewall, S; et al. (2011). "ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation". European Heart Journal. 32 (23): 2999–3054. doi:10.1093/eurheartj/ehr236. PMID 21873419.
O'Gara, PT; Kushner, FG; Ascheim; DD; et al. (2013). "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction". Circulation. 127 (4): e362–e425. doi:10.1161/CIR.0b013e3182742cf6. PMID 23247304. Retrieved 27 September 2014.
Amsterdam, EA; Wengern, NK; Brindis, RG; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. Published online September 23, 2014: 2354–2394. doi:10.1161/cir.0000000000000133. Retrieved 27 September 2014.
Antman, EM, Morrow DA (2012b). "Chapter 55. ST-segment elevation myocardial infarction: Management". In Bonow RO; Mann DL; Zipes DP; Libby P. Braunwald's heart disease: A textbook of cardiovascular medicine (9th ed.). Saunders. pp. 1111–1178. ISBN 978-0-8089-2436-4.
Cannon, CP; Braunwald, E (2012). "Chapter 56. Unstable angina and non-ST elevation myocardial infarction". In Bonow RO; Mann DL; Zipes DP; Libby P. Braunwald's heart disease: A textbook of cardiovascular medicine (9th ed.). Saunders. pp. 1178–1209. ISBN 978-0-8089-2436-4.
Retrieved from "https://en.wikipedia.org/w/index.php?title=Management_of_acute_coronary_syndrome&oldid=832068895"
Categories:
Aging-associated diseases
Cardiovascular diseases
Ischemic heart diseases
Medical emergencies
Cardiac procedures
Hidden categories:
Webarchive template wayback links
All articles with dead external links
Articles with dead external links from October 2010
Use American English from March 2018
All Wikipedia articles written in American English
Navigation menu
Personal tools
Not logged in
Talk
Contributions
Create account
Log in
Namespaces
Article
Talk
Variants
Views
Read
Edit
View history
More
Search
Navigation
Main page
Contents
Featured content
Current events
Random article
Donate to Wikipedia
Wikipedia store
Interaction
Help
About Wikipedia
Community portal
Recent changes
Contact page
Tools
What links here
Related changes
Upload file
Special pages
Permanent link
Page information
Wikidata item
Cite this page
Print/export
Create a book
Download as PDF
Printable version
Languages
Add links
This page was last edited on 23 March 2018, at 17:05.
Text is available under the Creative Commons Attribution-ShareAlike License; additional terms may apply. By using this site, you agree to the Terms of Use and Privacy Policy. Wikipedia® is a registered trademark of the Wikimedia Foundation, Inc., a non-profit organization.
Privacy policy
About Wikipedia
Disclaimers
Contact Wikipedia
Developers
Cookie statement
Mobile view
Enable previews

values: mw-page-base noprint

values: mw-head-base noprint

values: firstHeading firstHeading en

values: siteSub noprint

values: jump-to-nav mw-jump

values: /wiki/Myocardium mw-redirect Myocardium

values:
/wiki/Coronary_angiography
mw-redirect
Coronary angiography

values:
/wiki/ST_segment_elevation
mw-redirect
ST segment elevation

attrs: alt src width height class data-file-width data-file-height

values:
/wiki/Atherosclerotic_plaque
mw-redirect
Atherosclerotic plaque

values:
/wiki/Coronary_artery
mw-redirect
Coronary artery

values: Edit section: Patient-dependent initial measures

values: Information card writing: "Heart Attack: Know the Symptoms. Take Action. Call 911" and depicting people holding their chest in pain

values: National Heart, Lung, and Blood Institute

values:
/wiki/Medical_use_of_nitroglycerin
mw-redirect
Medical use of nitroglycerin

values: Edit section: Initial diagnostic approach

values: Electrocardiography in myocardial infarction

values:
/wiki/Beta_blockers
mw-redirect
Beta blockers

values:
/wiki/Congestive_heart_failure
mw-redirect
Congestive heart failure

values:
/wiki/Adenosine_phosphate
mw-redirect
Adenosine phosphate

values: Edit section: Glycoprotein IIb/IIIa inhibitors

values:
/wiki/Unfractionated_heparin
mw-redirect
Unfractionated heparin

values:
/wiki/Minimally_invasive_procedure
mw-redirect
Minimally invasive procedure

values:
/wiki/Physical_exercise
mw-redirect
Physical exercise

values:
/wiki/Stress_(medicine)
mw-redirect
Stress (medicine)

values:
/wiki/Human_sexual_behavior
mw-redirect
Human sexual behavior

values:
/wiki/Wilderness_first_aid
mw-redirect
Wilderness first aid

values:
/wiki/Patient_evacuation
mw-redirect
Patient evacuation

values:
/wiki/Cardiac_Arrest
mw-redirect
Cardiac Arrest

values:
/wiki/Cardiac_monitors
mw-redirect
Cardiac monitors

values:
nofollow
external text
//doi.org/10.1016%2Fj.jacc.2008.07.011

values:
/wiki/PubMed_Identifier
mw-redirect
PubMed Identifier

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/18926324

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/21034380

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/11551867

values:
nofollow
external text
//doi.org/10.1016%2Fj.jacc.2004.07.002

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/15358045

values: Alberta College Of Paramedics (page does not exist)

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/12103258

values:
nofollow
external text
//doi.org/10.1001%2Fjama.283.20.2686

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/10819952

values:
nofollow
external text
//doi.org/10.1016%2Fj.ahj.2006.06.001

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/16996830

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/18340140

values:
nofollow
external text
//doi.org/10.1093%2Feurheartj%2Fehi100

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/15684279

values:
nofollow
external text
//doi.org/10.1016%2Fj.jacc.2005.05.101

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/16580518

values:
nofollow
external text
//doi.org/10.1093%2Feurheartj%2Fehs184

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/22922414

values:
nofollow
external text
//doi.org/10.1161%2F01.CIR.99.1.168

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/9884398

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/17562966

values:
nofollow
external text
//www.worldcat.org/issn/1469-493X

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/27991651

values:
nofollow
external text
//doi.org/10.1136%2Fbmj.g6269

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/25954988

values:
nofollow
external text
//doi.org/10.1186%2F1471-2261-12-9

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/22361039

values:
nofollow
external text
//doi.org/10.1161%2F01.cir.91.6.1659

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/7882472

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/7829790

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/7905143

values:
nofollow
external text
//doi.org/10.1093%2Feurheartj%2Fehi829

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/16543251

values:
nofollow
external text
//doi.org/10.1056%2FNEJM199103213241201

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/1900101

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/8691967

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/9078197

values: National Heart, Lung and Blood Institute

values:
nofollow
external text
http://familydoctor.org/002.xml

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/18347214

values:
nofollow
external text
//doi.org/10.1002%2Fclc.4960281307

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/16450811

values:
nofollow
external text
//doi.org/10.1136%2Fbmj.321.7272.1336

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/11090520

values: -moz-column-width: 30em; -webkit-column-width: 30em; column-width: 30em; list-style-type: decimal;

values:
nofollow
external text
//doi.org/10.1093%2Feurheartj%2Fehs215

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/22922416

values:
nofollow
external text
//doi.org/10.1093%2Feurheartj%2Fehr236

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/21873419

values:
nofollow
external text
//www.ncbi.nlm.nih.gov/pubmed/23247304

values: Category:Webarchive template wayback links

values: Category:All articles with dead external links

values: Category:Articles with dead external links from October 2010

values: Category:Use American English from March 2018

values: Category:All Wikipedia articles written in American English

values: Discussion about edits from this IP address [ctrl-alt-n]

values: A list of edits made from this IP address [ctrl-alt-y]

values: You are encouraged to create an account and log in; however, it is not mandatory

values: portal navigation p-navigation p-navigation-label

values: Guidance on how to use and edit Wikipedia

values: About the project, what you can do, where to find things

values: A list of recent changes in the wiki [ctrl-alt-r]

values: portal navigation p-interaction p-interaction-label

values: List of all English Wikipedia pages containing links to this page [ctrl-alt-j]

values: Recent changes in pages linked from this page [ctrl-alt-k]

values:
/wiki/Wikipedia:File_Upload_Wizard
Upload files [ctrl-alt-u]
u

values: A list of all special pages [ctrl-alt-q]

values: Permanent link to this revision of the page

values: Link to connected data repository item [ctrl-alt-g]

values: Printable version of this page [ctrl-alt-p]

values: /static/images/wikimedia-button-1.5x.png 1.5x, /static/images/wikimedia-button-2x.png 2x

values: /static/images/poweredby_mediawiki_132x47.png 1.5x, /static/images/poweredby_mediawiki_176x62.png 2x

values:
suggestions
display: none; font-size: 13px;

values: mediawiki ltr sitedir-ltr mw-hide-empty-elt ns-0 ns-subject page-Management_of_acute_coronary_syndrome rootpage-Management_of_acute_coronary_syndrome skin-vector action-view