268 NSTEMI Flashcards
Topical or oral nitrates can be used when the pain has resolved or they may replace intravenous nitroglycerin when patient has been symptom free for how long?
12-24 hours
Most common etiology of coronary thrombosis
Plaque rupture
Vulnerable plaques
Eccentric stenosis with scalloped or overhanging edges and a narrow neck
Lipid core with thin fibrous cap
Genetic variant related to Inadequate response to clopidogrel
CYP450 involving 2C19
Demonstrates the transient coronary spasm in Prinzmetal variant angina
Coronary angiography
Main therapeutic agents in Prinzmetal Variant Angina
Nitrates and calcium channel blockers
Most dangerous manifestation of ischemic heart disease
Acute coronary syndrome
Mode of action of nitrates
Venous vasodilation with concomitant reduction in LV end diastolic volume
A 50M complains of chest heaviness associated with shortness of breath and diaphoresis 5 hours PTC. He lost consciousness and pronounced dead at the ER. Which type of myocardial infarction will you classify the patient? A. Type 1 B. Type 2 C. Type 3 D> Type 4
Type 3
pathophysiology of NSTE-ACS
disruption of an unstable coronary plaque due to plaque rupture, erosion or a calcified protruding nodule tat leads to intracoronary arterial vasoconstriction, 2. coronary arterial vasoconstriction, 3. gradual intraluminal narrowing, 4. increased myocardial oxygen demand
most common etiology of coronary thrombosis
Plaque rupture
description of the vulnerable plaque
eccentric stenosis with scalloped or overhanging edge and narrow neck on coronary angiogrpahy
True or false. Vulnerable plaques are composed of lipid rich core with thin fibrous cap
True.
True or false. NSTE-ACS is based largely on clinical presentation.
True.
Typical chest discomfort.
one of three features: 1. occurrence at rest or with minimal exertion lasting more than 10 mins 2. of relatively recent onset within the prior 2 week and 3. a crescendo pattern, distinctly more severe, prolonged or frequent than previous episodes
Location of chest discomfort
substernal region, radiates to left arm, left shoulder, and/or superiorly to the neck and jaw
anginal equivalents
dyspnea, epigastric discomfort, nausea or weakness
subset of patients who may present with anginal equivalent
women, elderly, patients with diabetes
ECG findings of NSTE ACS
deep t wave inversion of more than 0.3 mV;
True or false. New ST segment depression occurs in one third of patient with NSTE-ACS
True.
minor elevations in cTn in patients without clinical history of myocardial ischemia
seen in patients with heart failure, myocarditis, pulmonary embolism
characteristic temporal rise and fall post onset of symptoms
Peaking 12-24 hrs post onset of symptoms
Non cardiac or systemic causes of elevated cTn
pulmonary embolism, trauma, hypo or hyperthyroidism, renal failure, sepsis, shock, stroke, rhabdomyolysis
when to take or repeat cardiac biomarkers
obtained at baseline and at 4-6 hour and 12 hours after presentation
True or false. Patients with NSTE ACS should be placed at bed rest with continuous ECG monitoring for ST segment deviation and cardiac arrhytmias, preferably a specialized cardiac unit
True.
when is ambulation permitted in the patient with NSTE ACS
no recurrence of ischemia and does not develop an elevation of biomarker of necrosis for 12-24 hours
when is oxygen supplementation given
O2 sat less than 90% and or in those with heart failure and rales
absolute contraindication to nitrates
hypotension and recent use of PDE5 inhibitor within the 24 hr
how should nitrates be given
Nitroglycerin 03.-0.6 mg q 5mins apart
how to give nitroglycerin IV
10 ug/min every 3-5 mins until symptoms are relieved, or SBP falls to less than 90 mmHg or dose reaches 200 ug/min
max dose of nitroglycerin
200 ug/min
when is IV nitrate be shifted to oral
patient has been symptom free for 12-24 hrs
mainstay of anti ischemic treatment
beta blockers
target heart rate
50-60 bpm
when is beta blocker avoided
severe heart failure, low cardiac output, hypotension, active bronchospasm, high degree AV block
recommended for patients who have persistent symptoms or ECG signs of ischemia after treatment with full dose nitrates and beta blockers and in patients with contraindications to either drug class
calcium channel blockers like verapamil
add on medication if LDL C is not on target with statin
Ezetimibe 10 mg OD
drug that causes irreversible blockade of the platelet PY212 receptor
clopidogrel
loading and maintenance dose of clopidogrel
600 or 300 mg loading dose then 75 mg OD maintenance dose
relative reduction in cardiovascular death, MI, stroke compared to aspirin alone vs DAPT
20.00%
Drugs commonly used in intensive medical management of patients with UA and NSTE ACS
nitrates, beta blockers, calcium channel blockers, morphine sulfate
dose of metoprolol
25-50 mg q6hrs
dose of morphine
2-5 mg IV every 5- 30mins as needed
initial treatment for NSTE ACS
- aspirin, 2. P2Y12 inhibitor: clopidogrel or ticagrelor; 3. anticoagulant: enoxaparin, fondaparinoux, bivalirudin, 4. GP Iib/IIIa receptor inhibitor in high risk patient fot early invasive strategy: epitifibatide or tirofiban
During hospitalization. Medically treated.
aspirin, P2Y12 inhibitor, anticoagulant.
During hospitalization. PCI treated
aspirin, P2Y12 inhibitor, anticoagulant, GP Iib/IIIa inhibitor
Long term. Medically treated
aspirin and clopidogrel for 12 months
long term. PCI treated
aspirin and clopidogrel for 12 months
oral antiplatelets
aspirin, clopidogrel, prasugrel, ticagrelor
intravenous antiplatelet
abciximab, eptifibatide, trifiban, cangrelor
anticoagulants
UFH, enoxaparin, fondaparinaux, bivalirudin
Dose prasugrel
loading pre PCI: 60 mg then 10 mg OD
Dose ticagrelor
Loading 180 mg then 90 mg BID
dose aspirin
325 mg nonenteric formulation then 75-100 mg OD
dose clopidogrel
300-600 mg loading dose then 75 mg OD
dose abciximab
0.25 mg/kg bolus then 0.125 ug/kg per min for 12-24 hr
max dose of abciximab
10 ug/min
dose of eptifibatide
180 ug/k bolus then 10 min later second bolus of 180 ug/kg then 2 ug/kg per min for 72-96 hr following first bolus
dose of tirofiban
25 ug/k per min then 0.15 ug/kg per min for 48-96 hrs
dose of cangrelor
30 ug/kg followed by 4 ug/kg per min
dose of enoxaparin
1 mg/kg SQ q12hrs
when to dose adjust enoxaparin
CrCl less than 30 ml/min
renal dose of enoxaparin
1 mg/kg SQ OD
dose of fondaparinaux
2.5 mg SC OD
dose of bivalirudin
0.75 mg/kg bolus then 1.75 mg/kg per hour
dose of UFH
Bolus 70-100 U/Kg followed by infusion of 12-15 U/Kg per hour titrated to ACT250-300 s
max bolus of UFH
5000 U
target ATC in UFH
250-300 s
potent reversible P2Y12 inhibitor
ticagrelor
genetic variant that leads to inadequate response to clopidogrel
P450 2C19
intravenous direct and rapidly activing P2Y12 inhibitor
cangrelor
indirect factor Xa inhibitor
fondaparinux
most important adverse effect of all antithrombotic agents
excessive bleeding
when to do immediate invasive strategy for patients with NSTE ACS
refractory angina, signs or symptoms of heart failure or new or worsening mitral regurgitation, hemodynamic instability, sustained ventricular tachycardia or ventricular fibrillation
when is immediate invasive
Within 2 hr
when is early invasive
Within 24 hrs
when is delayed invasive
Within 25-72 hrs
when to do early invasive
Grace score more than 140; temporal change in troponin, new ST segment depression
when to do delayed invasive
eGFR less than 60, EF less than 40%, early postinfarction angina, PCI within 6 months prior, GRACE score 109-140 or TIMI score than 2
what is the target LDL-C
less than 70 mg/dL
severe ischemic pain that usually occurs at rest and is associated with transient ST segment elevation
Prinzmetal variant angina
what causes prinzmetal variant angina
focal spasm of an epicardial coronary artery with resultant transmural ischemia and abnormalities in left ventricular function
diagnostic hallmark of Prinzmetal variant angina
coronary angiography demonstrates transient coronary spasm
main therapeutic agents for prinzmetal variant angina
nitrates and calcium channel blocker
most dangerous manifestation of ischemic heart disease
ACS
most common cuase of nontraumatic chest pain presenting in the ER
gastrointestinal
True or false. Myocardial ishcemic discomfort does not radiate to the trapezius muscle
True.
Differential if the chest pain radiates to the trapezious muscle
pericarditis
Canadian Cardiovascular Society Functional Classification. Experiences limitation in physical activity. Chest heaviness when climbing more than 1 flight of stairs
CCS III
Canadian Cardiovascular Society Functional Classification. Angina present with strenuous or rapid or prolonged exertion at work or recreation
CCS I
Canadian Cardiovascular Society Functional Classification. Comfortable at rest but walking more than two blocks on the level and climbing more than 1 flight of stairs at normal pace and in normal condition
CCS II
Canadian Cardiovascular Society Functional Classification. Marked limitation in ordinary physiscal activity. Walking one block on the level and climbing one flight of stairs causes angina
CCS III
Canadian Cardiovascular Society Functional Classification. Inability to carry on any physical activity without discomfort. Anginal syndrome may be present at rest
CCS IV
