Thach Nguyen，MD， FACC， FSCAI，St Mary Medical Center Hobart IN When a patient with acute myocardial infarction (AMI) arrives to the emergency room (ER)， with just a phone call to the ER physician， we can know whether the patient will die in the next 24 hours.

    If the heart rate is less than 100 and the blood pressure is above 100， then the mortality is very low in the next 24 hours. If a patient comes with an AMI and bleeding in the leg because of fracture， then the first thing to do (after stabilizing the patient) is to do an abdominal and femoral angiogram. If there is no extravasation of contrast， then the arterial system is intact. At that time， coronary angiogram can be done. If angioplasty and stenting (PCI) is needed， then the patient can undergo PCI with 5000 units of heparin and clopidogrel (300-600 mg). A few hours or days after PCI， the patient can undergo surgery of the leg. The reason why the patient could undergo surgery is because the effects of heparin wear off after 2 and 4 hours while clopidogrel does not achieve its therapeutic effect until 24 hours later. In this 18 hours window without therapeutic anticoagulant or antiplatelet level， the patient could undergo any surgery if needed. If the patient vomits blood， an emergency gastroscopy could be done and if there is arterial bleeding， then the bleeding could be stopped by clamping the bleeding artery with one or many hemoclips (Boston Scientific， Boston MA).Once the bleeding is controlled， the patient could undergo PCI without problem. If the patient has AMI while on coumadin for atrial fibrillation or previous mitral valve replacement， if the INR is between 2 and 3.5， then the patient could undergo PCI with clopidogrel. There is no need of heparin because the anticoagulant level is therapeutic. In general， bleeding which can be controlled by mechanical mean is not a contra-indication for PCI.