3: ACS Flashcards
pattern of pain with ACS
pain at rest of crescendo pattern of pain on minimal exertion
TIMI risk scores
count up the following risk factors:
- over 65 y/o
- at least 3 risk factors for CAD
- ST deviation on admit EKG
- priory coronary stenosis more than 50%
- at least 2 anginal episodes in last 24 h
- elevated cardiac markers
- use of ASA (aspirin) in last 7d
high risk for ACS
one of the following:
- accelerating tempo of ischemic sx in preceding 48h
- prolonged ongoing (>20min) rest pain
- pulm edema, most likely from ischemia
- new or worsening MR murmur
- S3 or new/worsening rales
- hypotension, bradycardia, tachycardia
- older than 75
- angina at rest with transient ST changes
- bundle branch block, new or presumed new
- sustained ventricular tachycardia
- elevated troponin
intermediate risk for ACS
one of the following:
- prior MI, peripheral or cerebrovasc disease, CABG, ASA use
- prolonged rest angina, now resolved, with mod-high risk of CAD
- rest angina less than 20min or relieved with rest/NTG
- age less than 70
- T wave inversions
- path Q waves
- slightly elevated cardiac markers
low risk for ACS
one of the following:
- new onset or progressive CCS class 3 or 4 angina the past 2 weeks w/o prolonged rest pain but with mod-high risk of CAD
- normal or unchanged EKG during episode of chest pain
- normal cardiac markers
ddx when: ST elevation everywhere w/ no reciprocal changes
pericarditis
- also associated with PR depression
- the ST elevation will be subtle
ddx when: DEEP, symmetric T wave inversion in multiple leads in a person w/ headache
intracranial hemorrhage
contraindications of nitrates in ACS
phosphodiesterase inhibitors
RV infarction
what does RV infarction look like?
hypotension
JVD
clear lungs
contraindications to B-blockers in ACS
hypotension
severe bronchospasm
bradycardia (heart block)
suspected coronary spasm (Prinzmetal angina or cocaine)
function of B-blockers in ACS
decreases demand and increases supply to decrease O2 deficit
- decreased: HR, afterload, contractility, O2 wastage, exercise vasoconstriction
- increased: heart size, diastolic perfusion, collaterals
what is considered standard of care now? aka your ass will get sued if you don’t give it to a patient with ACS
B-blockers
why use 81mg aspirin?
still get desired response + decreases risk of bleeding to use lower dose
what type of clopidogrel treatment is preferred?
pretreatment - reduces deaths
what about clopidogrel and CABG?
hold clopidogrel for 5d before CABG
what’s the deal with prasugrel? how do you dose it?
loading dose 60mg
maintenance 10mg daily
decreased combined endpoints of death/MI/revascularization than plavix, but higher bleeding complications
prasugrel indications
over 70 y/o
stroke
heparin deal? what kind of heparin?
heparin decreases risk of death/MI more than no heparin
low MW heparin better than un-fractionated heparin (UNH)
name 3 GPIIb/IIIa inhibitors
abciximab
integrilin (most used)
tirofiban
benefit of GPIIb/IIIa inhibitors
increased reduction in death/MI
best for stented diabetics (only use for high risk patients, not for everybody)
look up ticagrelor?
dunnnnnooo
who goes straight to cath lab?
recurrent ischemia despite treatment attempts CHF cardiogenic shock prior PCI w/i 6 mo (restenosis) prior CABG
when is there no benefit to aggressive strategy?
if no EKG changes + no troponins
early secondary prevention focuses on what two things?
early diabetes control
early cholesterol control
do you still use meds when you opt for invasive strategy?
yes - invasive strategy is not a substitute
medical therapy for long-term shit
