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Clinical 2 (Sam) > 4 - ACS Part 1 > Flashcards

4 - ACS Part 1 Flashcards

1
Q

What are the 3 types of ACS?

A

1) unstable angina
2) Non ST segment elevation MI (NSTEMI)
3) ST segment elevation MI (STEMI)

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2
Q

What type is the most serious and why?

A

STEMI bc the vessel is completely occluded (lots of fibrin)

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3
Q

What tests are used to differentiate between the 3 types of ACS?

A
  • if troponin is elevated, it rules out UA (troponin is released when cardiac cells die)
  • if ST is elevated = STEMI, if not = NSTEMI
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4
Q

What is a STEMI caused by?

A

complete occlusion of a coronary after by clot (rupture of atherosclerotic plaque)

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5
Q

Along with troponin T (TnT) what is another test/maker of cardiac death?

A

CK-MB (the most specific CK isoenzymes for myocardium)

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6
Q

What are some classic symptoms that appear in all ACS?

A
  • chest pain typically radiating to shoulder down left arm
  • shortness of breath
  • nausea or vomiting
  • diaphoresis (sweating)
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7
Q

1/3 of all MIs are _____ type

A

silent

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8
Q

What groups of people are less likely to have classic symptoms?

A

-elderly, diabetic, and women

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9
Q

What are some signs that they are actually experiencing ACS?

A
  • syncope
  • bradycardia, tachycardia or other arrhythmias
  • high or low BP
  • diffuse rales, wheezing or respiratory distress usually indicate pulmonary deem and CHF
  • jugular venous distension indicates right atrial hypertension, usually from RV infarction or elevated LV filling pressure
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10
Q

When is CK-MB detectable in serum?

A

within 3-6 hours after MI, peaks in 12-24 hours, and stays elevated for 2-3 days

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11
Q

When is TnT detectable in serum?

A

4-12 hours after MI onset, peaks in 12-48 hours, and stays elevated for 7-10 days

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12
Q

When should biomarker essays be done?

A

STAT on presentation, then repeated Q4-6H for the first 12-24 hours, then periodically

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13
Q

What is needed for diagnosis of STEMI or NSTEMI?

A

At least 2 elevated CK-MB or 1 TnT exceeding the upper reference range

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14
Q

When should a 12-lead ECG be done ?

A

within 10 min of presentation to Emergency Department

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15
Q

What is an ECG used for?

A

distinguishing between STEMI and NSTEMI

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16
Q

What other types of ECG abnormalities may be observed for NSTEMI

A
  • ST depression

- T wave inversion

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17
Q

What is the initial management?

A
  • oxygen at 4L/min by nasal prong to maintain O2 saturation > 90%
  • ASA 162 - 325 mg PO chew/shallow (if not already given by EMS)
  • nitroglycerin SL or IV
  • morphine 2 - 5 mg IV q5-30 min prn

MONA

  • morphine
  • oxygen
  • nitrates
  • ASA
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18
Q

Why is morphine given as part of initial management?

A
  • bc pain increases sympathetic NS which increases oxygen demand
  • so treating pain will bring oxygen demand back down
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19
Q

STEMI: time = _____

A

muscle

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20
Q

What are the 2 types of repercussion strategies in STEMI?

A

1) PCI - primary percutaneous coronary intervention

2) fibrinolytics

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21
Q

Goals of Therapy of Reperfusion?

A
  • decrease mortality and complications
  • reduce or contain infarct size
  • salvage functioning myocardium and prevent remodelling
  • re-establish potency of the infarct-related artery
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22
Q

Reperfusion therapy should be administered to all eligible patients with symptom onset within the prior____ hours

A

12

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23
Q

What is the recommended method of repercussion when it can be performed in a timely fashion by experienced operators?

A

primary PCI

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24
Q

What is the ideal door-to-balloon (medical contact to device) time for primary PCI?

A

< 90 mins

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25
Q

If a STEMI initially presents to a non-PCI capable hospital, immediate transfer to a PCI capable hospital for primary PCI should be considered if a medical contact-device time of _______ can be achieved.

A

< 120 mins

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26
Q

When fibrinolytic therapy is indicated or chosen as the primary repercussion strategy, it should be administered within ______ mins of hospital arrival

A

30

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27
Q

Describe the TIMI Grade Flow

A

adopted scoring system for 0-3 referring to the level of coronary blood flow assessed during PCI
0 = bad (no flow)
3 = good (complete perfusion)

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28
Q

What is a DES

A

drug eluting stent

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29
Q

Patients who received DES will require dual-antiplatelet therapy (DAPT) for a minimum of ??

A

1 year

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30
Q

Greatest mortality reduction is achieved when fibrinolytics is given within _____ hours

A

0-2

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31
Q

fibrinolytics are only administered to patients with ______

A

STEMI

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32
Q

Why are fibrinolytics not administered to NSTEMI/UA patients?

A

bc there is not much fibrin in NSTEMI and UA, mostly made up of platelets

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33
Q

What is the fibrinolytic of choice?

A

Tenecteplase (TNK)

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34
Q

List some points about Tenecteplase (TNK)? (3)

A
  • 5 second singel bolus
  • weight-tired dosing
  • most fibrin-specific agent
  • more on slide 29
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35
Q

What is the major concern of fibrinolytic therapy?

A

bleeding complications

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36
Q

What are some absolute CI to fibrinolytic use?

A
  • any prior ICH (intracranial hemorrhage)
  • suspected aortic dissection
  • severe uncontrolled hypertension
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37
Q

What are some relative CI to fibrinolytic use?

A
  • dementia
  • pregnancy
  • active peptic ulcer
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38
Q

What types of meds should be administered to STEMI patients getting a PCI?

A
  • ASA 162 - 325 mg given before PCI
  • loading dose of P2Y12 receptor inhibitor (ex. clopidogrel 600 mg) as early as possible before PCI
  • ASA 81 - 162 mg PO daily PLUS a P2Y12 receptor inhibitor at maintenance dose should be considered (ex. clopidogrel 75 mg daily)
  • LMWH or UFH is usually initiated on presentation and discontinued after PCI
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39
Q

What types of meds should be administered to STEMI patients receiving fibrinolytics?

A
  • ASA 162 - 325 mg given on presentation
  • Clopidogrel 300mg LD in patients < 75 or Clopidogrel 75 mg LD in patients > 75
  • Clopidogrel 75 daily should be continued for 14 days unless pt undergoes subsequent PCI
  • LMWH or UFH should be initiated at time of fibrinolysis and continued for a minimum of 48 hours and up to 8 days (or until revascularization with PCI)
40
Q

What is the dose of enoxaparin in STEMI patients < 75?

A
  • Give enoxaparin 30mg IV bolus before TNK
  • continue enoxaparin 1mg/kg SC q12h after TNK
  • maximum dose enoxaparin 140 mg SC q12h after the first 24 hours
41
Q

What is the dose of enoxaparin in STEMi patients > 75?

A
  • do not give enoxaparin IV bolus
  • enoxaparin 0.75mg/kg SC q12h after TNK
  • maximum dose enoxaparin 100 mg SC q12h after the first 24 hours
42
Q

Heparin is used in patients > _____kg.

A

149

*little evidence to support LMWH in these patients

43
Q

Heparin is used in those with renal impairment, a CrCl of ______.

A

< 30 mL/min

44
Q

Dose of heparin?

A

UFH 60 units/kg IV load, followed by 12 units/kg/hr IV infusion
*target aPTT 49-65 seconds

45
Q

What are the new P2Y12 antagonists?

A

prasugrel and ticagrelor

46
Q

For DAPT (dual anti platelet therapy), what is the best P2Y12 antagonist to be combined with ASA?

A 
ASA + prasugrel
OR
ASA + ticagrelor 
are both more efficacious compared to:
ASA + clopidogrel
47
Q

What types of patients should prasugrel not be used in?

A

patients with history of stroke or TIA due to higher rates of major bleeding in these populations

48
Q

In ACS, patients who undergo PCI should receive DAPT for ?

A
  • minimum of 1 year (PCI with DES)
  • minimum of 1 month, but 1 year recommended (PCI with Bare metal stent)
  • minimum of 1 year (CABG in the setting of ACS)
49
Q

In ACS, ASA should be continued _______

A

forever

50
Q

For STEMI patients who are treated medically with fibrinolytics, how long is DAPT?

A

it is not warranted - but many of these patients will continue to have a PCI and prescribed clopidogrel or prasugrel

51
Q

What is triple therapy?

A

DAPT + warfarin

52
Q

Who is triple therapy indicated for?

A

STEMI patients with low ejection fraction or has concurrent AF

53
Q

Reperfusion (PCI or fibrinolytics):

How do we monitor efficacy?

A

signs and symptoms of ongoing chest pain, eCG changes, serial monitoring of biomarkers

54
Q

Reperfusion (PCI or fibrinolytics):

Complications?

A

arrhythmias, HF, pericarditis, major and minor bleeding complications

55
Q

What are clinical signs of bleeding?

A

-bloody stools
-melena (dark, tarry stools)
-hematuria (blood in urine)
hematemesis (vomiting blood)
-bruising
-oozing form arterial or venous puncture sites

56
Q

List some STEMI complications

A
  • heart failure
  • cardiogenic shock
  • arrhythmias
  • pericarditis
57
Q

Goals of adjunct therapy?

A
  • reduce the risk of short term and long term complications associated with STEMI
  • slow progression of coronary heart disease and minimize the risk of future CV events and other morbidities
  • improve mortality and restore quality of life
58
Q

MOA of B blockers

A

reduce oxygen demand

59
Q

When should B blockers be initiated and who should get them?

A

Everyone post MI unless contraindicated should get a BB within 24 hours after onset
*start at low dose and titrate to maintain resting heart rate of 55-60 bpm

60
Q

Who are BB CI for?

A
  • hypotension (SBP < 90)
  • bradycardia (HR < 50 bpm)
  • acute heart failure (requiring inotropes)
  • cardiogenic shock
  • asthma
  • 2nd or 3rd degree AV block
61
Q

What do you monitor for patients on B blockers?

A

BP, HR, signs/symptoms of HF

62
Q

Dose of Metoprolol?

A

Start at 25mg BID, titrate to max 100mg PO BID

63
Q

Dose of Atenolol?

A

12.5-25 mg daily, up to 100 mg daily

64
Q

Dose of Carvedilol?

A

3.125mg BID, titrate to 25mg BID

65
Q

MOA of ACEi

A
  • reduce ventricular remodelling

- reduce oxygen demand and myocardial wall stress by decreases both preload and afterload

66
Q

When should ACEi be initiated?

A

24 hrs post MI once BP has been stabilized unless CI

67
Q

ACEi:

Use with caution in those with ??

A

renal impairment and hyperkalemia

68
Q

What do you need to monitor for ACEi?

A

SCr, electrolytes, watch for hyperkalemia ( K > 5.5) especially with concurrent spironolactone

69
Q

Dose of ramipril?

A

1.25 - 2.5 mg daily, target 10mg/day

70
Q

Dose of enalapril?

A

2.5mg BID, target 10-20 mg BID

71
Q

Dose of lisinopril?

A

2.5 - 5mg daily, target 40 mg daily

72
Q

Dose of captopril?

A

6.25mg TID, target 25-50 mg TID

73
Q

Who are ARBs indicated for?

A

ACEi intolerant patients

74
Q

Monitoring for ARBs?

A

SCr, electrolytes, watch for hyperkalemia ( K > 5.5) especially with concurrent spironolactone

75
Q

Dose of candesartan?

A

4mg daily, target 32 mg daily

76
Q

Dose of telmisartan?

A

40mg daily, target 80 mg daily

77
Q

Dose of valsartan?

A

20mg PO BID, target 160 mg BID

78
Q

What is the goal LDL for pts on statins?

A

< 2 mmol/L or < 1.8 mmol/L in very high risk patients

79
Q

Monitoring for statins?

A
  • Lipid panel
  • CK
  • LFTs ???
  • signs of myopathy and rhabdomyolysis
80
Q

Dose of atorvastatin?

A

20-80 mg daily

81
Q

Dose of fluvastatin?

A

20-80 mg daily

82
Q

Dose of pravastatin?

A

20-40 mg daily

83
Q

Dose of lovastatin?

A

20-80 mg daily

84
Q

Dose of simvastatin?

A

20-80 mg daily

85
Q

Dose of rosuvastatin?

A

5-40 mg daily

86
Q

What is evolocumab?

A

monoclonal antibody (biologic) that inhibits PCSK9 - lowers LDL

87
Q

Why is evolocumab not cost-effective?

A

$1.2 million per year to prevent one MI

88
Q

List 2 mineralocorticoid receptor/aldosterone antagonists?

A
  • spironolactone

- eplerenone

89
Q

Who is an aldosterone antagonist recommended for?

A

patients with significant LV dysfunction (EF < 40%)

90
Q

Who are aldosterone antagonists cautioned in?

A

CrCl < 30 mL/min

K > 5 mEq

91
Q

When do you check potassium for an aldosterone antagonist?

A

at baseline and within 1 week of initiation

92
Q

Dose of spironolactone?

A

12.5 mg daily, titrate to 25 mg daily

93
Q

Dose of eplerenone?

A

25mg daily, titrate to 50mg daily

94
Q

Non-pharm therapy for ACS?

A
  • Weight management
  • Physical exercise
  • Stress management
  • Depression screening
95
Q

What are some modifiable risk factors for CHD?

A
  • smoking cessation
  • hypertension
  • dyslipidemia
  • obesity
  • sedentary lifestyle
  • stress

Clinical 2 (Sam) (18 decks)

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