4 Acute Coronary Syndrome, part 2 Flashcards
Door-to-balloon (PCI) time for a patient who arrives at a PCI-capable hospital
≤90 minutes
Door-to-balloon (PCI) time for a patient who arrives at a non-PCI-capable hospital
≤120 minutes
If PCI cannot be accomplished within the recommended PCI timeframes, fibrinolysis should be given within:
(door-to-needle time)
≤30 minutes
Fibrinolytic therapy is indicated for STEMI patients if time from symptoms onset to treatment is:
<6 to 12 hours
Alteplase dose in STEMI
Body weight >67 kg:
15 mg initial IV bolus;
50 mg infused over next 30 mins;
35 mg infused over next 60 mins
Body weight <67 kg:
15 mg initial IV bolus;
0.75 mg/kg invused over next 30 mins;
0.5 mg/kg infused over next 60 mins
(max 100 mg)
Alteplase dose in Acute Ischemic Infarct
0.9 mg/kg IV, with a max dose of 90 mg
Administer 10% of the dose as a bolus over 1 minute,
with the remaining amount infused over 60 minutes.
Dose of Clopidogrel in ACS
STEMI:
Loading dose of 600 mg PO followed by 75 mg PO daily.
No loading dose is administered in patients >75 y/o receiving fibrinolytics.
NSTEMI/UA:
Loading dose of 300-600 mg PO followed by 75 mg/day
Dose of enoxaparin in ACS
STEMI:
30 mg IV bolus followed by 1 mg/kg SC every 12 hours
NSTEMI/UA:
1 mg/kg SC every 12 hours
Dose of nitroglycerin in ACS
Sublingual: 0.4 mg every 5 mins x 3 prn for pain
IV: start at 10 mcg/min,
titrate to 10% reduction in MAP if normotensive,
30% reduction in MAP if hypertensive.
In AMI, titrate IV nitroglycerin to BP reduction rather than to symptom (chest pain) resolution
Dose of morphine in ACS
2-5 mg IV every 5-15 mins PRN for pain
The early invasive approach depolyed in STEMI is recommended in NSTEMI patients only in those with:
refractory angina, or
hemodynamic instability, or
electrical instability,
risk for clinical events
AHA/ACC guielines recommend early (within 24 hours) invasive thearpy in UA/NSTEMI patietns with:
recurrent angina/ischemia
elevated cardiac troponins
new or presumably new ST depression
high-risk findings on noninvasive stress testing
depressed LV function
hemodynamic instability
sustained V tach
PCIs within the previous 6 months
prior CABG
If patients with UA/NSTEMI are hemodynamically unstable, guidelines recommend invasive strategy within ______
2 hours
Most common PCI
Coronary angioplasty with or without stent placement
alternatives: atherectomy and laser angioplasty
Mechanism of action of fibrinolysis
- Fibrinolytic agents are tissue plasminogen activators.
- Plasminogen, an inactive proteolytic enzyme, binds directly to fibrin during thrombus formation to form a plasminogen-fibrin complex.
- This complex incorporated into the clot is more susceptible than circulating plasma plasminogen to activation (thus, the concept that fibrinolytic agents are to a varying degree “clot specific”, promoting fibrin proteolysis).
Most catastrophic complication of fibrinolytic therapy
intracranial bleeding
Absolute contraindications for Fibrinolysis
Any prior ICH
Known structural cerebral vascular lesion (e.g., AVM)
Known intracranial neoplasm
Ischemic stroke **within 3 months)
Active internal bleeding (excluding menses)
Suspected aortic dissection
Suspected pericarditis
Relative contraindications for fibrinolysis
Severe uncontrolled BP (>180/100)
Current use of anticoagulants with known INR >2-3
Known bleeding diathesis
Noncompressible vascular punctures (including subclavian and internal jugular central lines)
Patients treated previously with streptokinase should not receive streptokinase a second time
Prolonged CPR (>10 mins)
Recent trauma (past 2 weeks)
Major surgery (<3 weeks)
Recent internal bleeding (within 2-4 weeks)
Prior ischemic stroke >3 months
Pregnancy
Active PUD
Other medical conditions likely to increase risk of bleeding (e.g., diabetic retinopathy)
