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Year 3 - Clinical > 19 - NSTEMI > Flashcards

19 - NSTEMI Flashcards

1
Q

Risk factors for ACS

A
  • Atherosclerosis

- Same risk factors as in other manifestations of ASCVD

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2
Q

Acute coronary syndrome (ACS)

A
  • Spectrum of conditions involving abrupt reduction in coronary perfusion, usually due to thrombus formation secondary to unstable atherosclerotic plaque
  • Divided into non-ST elevation acute coronary syndrome (NSTE ACS) & ST-elevation MI (STEMI)
    • NSTE ACS further divided into unstable angina & non-ST elevation MI (NSTEMI)
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3
Q

Difference in ECG between NSTE ACS and STEMI

A
  • NSTE ACE = lack of ST-segment elevation (may have ST depression and/or T-wave inversion)
  • STEMI = ST-segment elevation in 2 or more contiguous ECG leads or new left bundle branch block (LBBB)
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4
Q

Difference in biomarkers between NSTE ACS and STEMI

A
  • NSTE ACS = troponin elevated in NSTEMI, no in unstable angina
  • STEMI = troponin elevated
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5
Q

Difference in physiology between NSTE ACS and STEMI

A
  • NSTE ACS = partial occlusion of larger artery or total occlusion of small artery
  • STEMI = total or near-total occlusion of larger artery
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6
Q

Difference in ischemia between NSTE ACS and STEMI

A
  • NSTE ACS = partial-thickness myocardial ischemia w/ (NSTEMI) or w/o (UA) infarction
  • STEMI = full-thickness MI
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7
Q

Difference in incidence between NSTE ACS and STEMI

A
  • NSTE ACS = approx. 2/3 of ACS

- STEMI = approx. 1/3 ACS

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8
Q

Difference in ECG between unstable angina and NSTEMI

A

Both have presence or absence of markers of ischemia (ST depression or T-wave inversion)

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9
Q

Difference in biomarkers between unstable angina and NSTEMI

A
  • Unstable angina = no significant troponin increase

- NSTEMI = troponin increased

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10
Q

Difference in physiology between unstable angina and NSTEMI

A

Both have partial occlusion of larger artery or total occlusion of small artery

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11
Q

Difference in ischemia between unstable angina and NSTEMI

A
  • Unstable angina = ischemia but not infarction (yet)

- NSTEMI = ischemia w/ infarction

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12
Q

Difference in incidence between unstable angina and NSTEMI

A
  • Unstable angina = minority

- NSTEMI = majority

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13
Q

ECG features of NSTE ACS

A
  • ST-segment depression
  • T-wave inversion
  • Non-specific changes may be present; may be normal
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14
Q

How is NSTE ACS diagnosed?

A
  • Symptomatic presentation similar to angina sx, although pain/discomfort unremitting (> 20 min) & may be more severe
    • Px more likely to lack classic sx = elderly, diabetics, female, renal failure, & dementia
  • 12-lead ECG (completed & read w/in 10 min); ST-depression and/or inverted T-waves
  • Troponin measured 2x (perhaps more)
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15
Q

Goals of therapy for NSTE ACS

A
  • Increase myocardial O2 supply (prevent thrombus progression)
  • Decrease myocardial O2 demand
  • Overall goal = minimize myocardial necrosis
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16
Q

Initial tx for acute management of NSTE ACS

A
  • ASA + P2Y12 inhibitor (clopidogrel, ticagrelor)
  • Anticoagulant (fondaparinux subcut, enoxaparin subcut, UFH infusion)
  • Nitroglycerin subling prn
  • O2 if O2 sat < 90%
  • Morphine or fentanyl prn for severe pain
17
Q

Antiplatelet therapy for initial tx of NSTE ACS

A
  • ASA 160-325 mg once (chew & swallow, non-EC) then 81 mg daily
  • P2Y12 inhibitor
    • Clopidogrel 300-600 mg once (give 600 mg if urgent angiogram required), then 75 mg daily
    • Ticagrelor 180 mg once, then 90 mg BID
    • Prasugrel rarely used b/c dramatically increases surgical bleeding risk for 7 days after giving it
18
Q

Anticoagulant therapy for initial tx of NSTE ACS

A
  • Fondaparinux 2.5 mg subcut q24h if CrCl > 30 mL/min; avoid if weight > 120 kg
  • Enoxaparin 1 mg/kg subcut q12h if CrCl > 30 mL/min; avoid if weight > 150-160 kg
  • Unfractionated heparin (UFH) IV; preferred if CrCl < 30 mL/min or weight > 150-160 kg
19
Q

Other agents for initial tx of NSTE ACS

A
  • Nitroglycerin (0.4 mg spray or 0.3 mg tab subling q5min prn chest pain/discomfort) if SBP > 90 mmHg
  • Morphine or fentanyl IV prn (only if needed; never use NSAIDs or COX-2 inhibitors)
  • BZDs may be given to mitigate anxiety
20
Q

Describe PCI for acute management of NSTE ACS

A
  • Percutaneous coronary intervention (PCI)
  • Allows for:
    • Confirmation of diagnosis or to rule out a coronary origin
    • Identification of culprit lesion(s)
    • Assessment for PCI or CABG
    • Stratify px short- & long-term risk
  • If angiography identifies a culprit lesion & anatomy is amenable to PCI, one or more intracoronary stent(s) are placed
  • 2 types of stents:
    • Bare metal (more likely to have restenosis; require shorter minimum duration DAPT)
    • Drug-eluting (DES) *most common (impregnated w/ antiproliferative drug to minimize restenosis; require longer minimum duration DAPT)
21
Q

Describe CABG for acute management of NSTE ACS

A
  • If anatomy is not amenable to PCI, coronary artery bypass grafting may be considered (approx. 10% of NSTE ACS may require urgent CABG)
  • 3 types of grafts:
    • Internal mammary (usually left internal mammary); most reliable, usually grafted to LAD
    • Saphenous vein
    • Radial artery
  • P2Y12 inhibitor should be held prior to CABG if possible (clopidogrel x 5 days; ticagrelor x 5 days; prasugrel x 7 days)
  • Anticoagulants should be managed as follows pre-CABG if possible
    • UFH – continue uninterrupted
    • Enoxaparin or fondaparinux – last dose 24 h pre-op
  • CABG should be performed w/o delay in px w/ hemodynamic instability, ongoing MI, or very high-risk coronary anatomy, regardless of antiplatelet or anticoagulant tx
22
Q

In-hospital goals of therapy for NSTE ACS

A
  • Prevent recurrent ischemia
  • Prevent cardiac arrhythmias, heart failure/cardiogenic shock, & other complications
  • Initiate therapies for secondary prevention
23
Q

In-hospital strategies for management of NSTE ACS

A
  • Antithrombotics (antiplatelets & anticoagulants) part of initial tx
  • Beta-blocker & statin (may be part of initial tx)
  • ACE inhibitor or ARB
  • Rapid acting nitroglycerin (part of initial tx)
  • Maybe MRA
24
Q

Antiplatelet therapy for in-hospital tx of NSTE ACS

A
  • DAPT regardless of tx approach (PCI, CABG, or medical management)
    • ASA 81 mg for maintenance dose & ticagrelor may be preferred P2Y12 inhibitor
    • ASA + (clopidogrel or ticagrelor) are acceptable choices for medical management
  • PPI indicated in combination w/ DAPT in px at risk of GI bleeds (history of GI ulcer/hemorrhage, anticoagulant therapy, chronic NSAID/corticosteroid use)
25
Q

Anticoagulant therapy for in-hospital tx of NSTE ACS

A
  • Anticoagulants d/c after revascularization
  • For medical management:
    • UFH continued for 48 h to 7 days
    • Enoxaparin & fondaparinux continued for up to 8 days or hospital discharge
  • Following d/c of full anticoagulation, initiate VTE prophylaxis & continue until discharge
26
Q

Beta-blocker therapy for in-hospital tx of NSTE ACS

A
  • Reduce early post-ACS mortality (reduce risk of ventricular arrhythmias)
  • Recommended w/in 24 h of hospital admission for NSTE ACS in the absence of CIs or risk factors for cardiogenic shock (age > 70, HR > 110 beats/min, SBP < 120 mmHg)
    • Avoid early beta-blockers in above px if LV function poor or unknown
  • Preference for beta 1-selective agents (bisoprolol, metoprolol); carvedilol may also be used if LVEF = 40% or less
27
Q

Statin therapy for in-hospital tx of NSTE ACS

A
  • Indicated in all px w/ CAD
  • Should be initiated early in hospital course (may be part of initial therapy)
  • High-potency preferred, regardless of LDL-C
  • Weeks to months to achieve significant benefit
28
Q

ACE inhibitor/ ARB therapy for in-hospital tx of NSTE ACS

A
  • ACE inhibitors strongly recommended in px w/
    • LV systolic dysfunction (LVEF = 40% or less, hypertension, diabetes mellitus, chronic kidney disease)
  • ARB recommend in px intolerant of ACE inhibitors (ex: cough)
  • RAAS inhibition also used in absence of indications listed above for secondary prevention
  • Caution for acute kidney injury, hyperkalemia, hypotension
29
Q

Nitroglycerin therapy for in-hospital tx of NSTE ACS

A
  • Rapid acting sublingual nitroglycerin may be used to treat intermittent ischemic pain in hospitalized NSTE ACS px
    • *Doesn’t change outcomes
    • Px w/ unresolving or recurrent ischemic pain require urgent revascularization
  • IV infusion may allow for some delay until a pt is able to undergo revascularization if needed – still doesn’t change outcomes
30
Q

Mineralocorticoid receptor antagonist (MRA) therapy for in-hospital tx of NSTE ACS

A
  • Recommended in px w/ LV dysfunction (LVEF = 40% or less) & symptomatic heart failure or diabetes
    • Eplerenone was agent studied for this indication; spironolactone likely has similar benefit
  • Benefit long-term
31
Q

Which medications should be given at discharge from hospital after an NSTE ACS?

A

All px should receive (unless CI) (Mnemonic AABCC – ASA, ACE/ARB, beta-blocker, cholesterol, clopidogrel or alternative)

  • Antiplatelets (DAPT)
  • Beta-blocker
  • Statin
  • ACE inhibitor/ARB
  • Rapid-acting nitroglycerin
32
Q

Goals of long-term therapy for secondary prevention of NSTE ACS

A
  • Prevent harmful myocardial remodeling
  • Stabilize existing atherosclerotic plaque & impair growth of new plaque
  • Decrease risk of recurrent ASCVD events including ACS
  • Decrease long-term morbidity & mortality
33
Q

Which medications are used for secondary prevention of NSTE ACS?

A

Same medications as given as discharge

  • DAPT continued preferably for 1 year regardless of tx approach; life-long ASA 81 mg daily continued following DAPT
  • Ezetimibe = optional add-on in high-risk px willing/able to take
34
Q

Non-pharms for long-term therapy after NSTE ACS

A
  • Cardiac rehab
  • Smoking cessation
  • Diet, exercise
35
Q

Post-discharge LVEF assessment

A

Px w/ pre-discharge LVEF = 40% or less should have repeat ECG 6-12 weeks after MI, & after complete revascularization & optimal medical therapy

Year 3 - Clinical (30 decks)

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