![]() RESIDENTS CAN ALWAYS START WITH ASPIRIN AND ANTI-THROMBIN AND DISCUSS PGY12 TIMING with CARDS.Įarly trials such as the VA Cooperative Study (1983) and ISIS-2 (1988) demonstrated that aspirin, which inhibits platelets through irreversible cyclooxygenase blockade, decreases mortality in UA/NSTEMI. PLACE ALL PATIENTS WITH NSTEMI ON APPROPRIATE MEDICAL THERAPY. May have benefit, but may also delay CABG if needed. Unclear if patients should be pre-treated prior to invasive strategies in first 24 hours. Prasugrel and ticagrelor more rapid onset. Ticagrelor (see PLATO Trial) has reduction in death from vascular causes or MI in 1 year compared to clopidogrel, may see bradycardia. Prasugrel has increased bleeding risk but better ichemic outcomes. Newer agents likely better based on recent studies. Certain newer trials so benefit to Ticagrelor and prasugrel, still not clear about which is best but all patients need to be on one of the 3. P2Y12 inhibitor AHA/ACC Class 1 (clopidogrel, prasugrel, ticagrelor). Aspirin Class I therapy in all ACS patients 162-325 mg (rapidly inhibits platelet activation by halting thromboxane A2 production). ACC/AHA Class 1 recommendation: anti-coagulation recommended for all patients with NSTE-ACS: Unfractionated heparin or LMWH. Medical therapy will usually include both anti-thrombin strategies and anti-platelet strategies seen below. Those without immediate need but still intermediate risk will undergo invasive strategy within 48 hours while receiving medical therapy. In addition, TACTICS-TIMI 18 was also a trial of the IIb/IIIa inhibitor tirofiban, which continues to have a limited role in NSTE-ACS, primarily as bailout therapy in patients undergoing PCI of high-risk lesions.Īngiography is preformed immediately for refractory angina, hemodynamic instability, ventricular arrythmia, or acute heart failure. It is important to note that although both the biomarker and TIMI risk stratification findings (i.e., patients with negative troponins or patients with TIMI risk score 0-2 do not benefit from an early invasive strategy) are often incorporated into routine clinical practice, the interaction between the primary outcome and these individual subgroups did not reach statistical significance however, given stark numerical differences and apparent risk-response pattern within the TIMI score group (i.e., as TIMI risk increased, benefit with early angiography increased), lack of statistical interaction likely reflects underpowered subgroups in this case rather than a spurious finding. Overall the results of TACTICS-TIMI 18 provide practical guidance for the selection of patients who are most likely to benefit from early coronary angiography and intervention in non-STEMI ACS. Importantly, patients with TIMI score 0-2 and patients with undetectable troponins (25% of the study population) did not appear to benefit from routine angiography and PCI, suggesting that it is reasonable to pursue stress testing in these low-risk patients with intervention reserved for patients with significant ischemia on functional testing. Notably there was no mortality benefit with an early invasive approach, and this strategy was associated with a 2% absolute increase in protocol-defined bleeding. This benefit was most apparent in patients presenting with ST segment changes, troponin elevation at presentation, and patients with intermediate or high TIMI risk scores (3 or greater). TACTICS-TIMI 18 demonstrated a clear reduction in major adverse cardiovascular events with an early invasive approach, driven primarily by a reduction in nonfatal MI and recurrent ischemia. Overall, 60% of patients in the early invasive arm underwent revascularization versus 36% in the conservative arm. In the conservative strategy, patients underwent coronary angiography only if noninvasive stress testing was positive or there was failure of medical therapy (prolonged angina at rest, hemodynamic instability, recurrent angina or MI). In the early invasive strategy arm, 97% of patients underwent coronary angiography a median of 22 hours (all within 48 hours) after presentation with PCI or CABG to culprit lesions. The 2001 Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy – Thrombolysis in Myocardial Infarction 18 (TACTICS-TIMI 18) trial randomized 2220 patients to either a protocolized early invasive strategy versus a delayed selectively invasive strategy with each arm receiving the IIb/IIIa inhibitor tirofiban. Unlike patients presenting with STEMI in which there is a clear mortality benefit to emergent coronary angiography and PCI, it is less clear whether patients with non-STEMI ACS (unstable angina or non-ST segment elevation MI) also benefit from routine early angiography and intervention.
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![]() We are running a 1GB network on the PC's. Hi Adrian, thank you for your reply! we are using the free VAW 3. The outcome became obvious to the issues.especially on first day.backup jobs got delayed to almost 1am but all was successful.mainly due to NAS slow in writing but there was no cannot find NAS issue as probably the NIC teaming prevented the "network path not found" error What we changed.NAS to use RAID 10 & use all 4 NIC ports (teamed).PCs to run at 6pm & lappy to run at 7pm. ![]() The next day only 8 machines backup successfully (the 5 from day 1 with 3 more).the following day only 12 (8 from previous days with 4 more).the previous days successfully backup machines started to use increment backup instead of full. ![]() The machines will be powered off after backup and skip backup when powered on. In the beginning, there were many failures as the network gets too congested and the NAS box gets too busy also.at most 5 machines can backup (each machine have at least 100GB of files for example). This is what I have and seen.150 PCs and 120 lappy backing up (personal files only) to a Synology NAS with only 1 LAN (RAID 5 12x4TB HDD).all set to run at 6pm. Other issues maybe that the backup repository IO is too busy to respond to these machines. The more common issue is that you have configured backup of a few machines to run at same time such that the network or the backup repository network is too congested such that these machines cannot see the backup repository. What type of network are running on these machines and/or your backup repository ? tr:Error code: 0x00000035 -tr:FC: Failed to check whether file or folder '' exists. ![]() Unable to perform threshold check for location "": failed to query backup repository disk spaceĮrror: The network path was not found. tr:Error code: 0x00000035 -tr:FC: Failed to check whether file or folder. Exception from server: An unexpected network error occurred. We have set these ones up the exact same was as the other ones so not sure what the error message actually means or why there even is an error.Įrror: Shared memory connection was closed. Lower Backup TCO with Self-Protecting Storage.We recently set up Veeam Backup Agent for Windows on a few of our PC's.Īll seem to be working perfectly fine, except for a couple that we received errors messages for as the backups failed. Retaining multiple copies of data provides the insurance and flexibility to restore to a point in time not affected by data corruption or malicious attacks. The more time passes between backup copies, the more potential for data loss when recovering from a backup. The possibility of weather-related events may justify having copies of data at remote locations.įor best results, backup copies are made on a consistent, regular basis to minimize the amount data lost between backups. The alternate medium can be in the same location as the primary data or at a remote location. This additional medium can be as simple as an external drive or USB stick, or something more substantial, such as a disk storage system, cloud storage container, or tape drive. Storing the copy of the data on separate medium is critical to protect against primary data loss or corruption. Backup copies allow data to be restored from an earlier point in time to help the business recover from an unplanned event. Primary data failures can be the result of hardware or software failure, data corruption, or a human-caused event, such as a malicious attack (virus or malware), or accidental deletion of data. The purpose of the backup is to create a copy of data that can be recovered in the event of a primary data failure. Recovery from a backup typically involves restoring the data to the original location, or to an alternate location where it can be used in place of the lost or damaged data.Ī proper backup copy is stored in a separate system or medium, such as tape, from the primary data to protect against the possibility of data loss due to primary hardware or software failure. This is sometimes referred to as operational recovery. Backup and recovery describes the process of creating and storing copies of data that can be used to protect organizations against data loss. |
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