5 ACS part II Flashcards
initial recommendations
12 lead ECG
- within __ mins of arrival at an emergency facility
- if the initial ECG is not diagnostic but the patient remains symptomatic and there is a high clinical suspicion for ___ , serial ECGs should be performed every ___ - ___ min for the first hour
- 10
- ACS, 15-30
initial recommendations
serial troponin
- levels should be obtained at presentation and ___ - ___ hours after symptom onset
- ___ troponin is preferred
- repeating troponin levels will identify a rising and/or falling pattern
3-6
high sensitivity
UA/NSTEMI Treatment
MONA
Reperfusion
- early invasive strategy vs. ischemia guided strategy
- no ___
Antiplatelets
- DAPT = ___ and ___
- ___ month duration
- ___ or ___ preferred
- +/- GPIIb/IIIa inh (unlikely to use)
Anticoagulation
- LMWH or UFH
BB
ACEi or ARB
Statin
NTG prn
- fibrinolytic
- ASA, P2Y12
- 12
- ticagrelor, prasugrel
STEMI Treatment
MONA
Reperfusion
- ___ vs fibrinolytic
Antiplatelets
- DAPT = ___ + ___
- ___ month duration
- fibrinolytic: ___ preferred
- PCI: ___ or ___ preferred
- +/- GPIIb/IIIa inhibitior
Anticoagulation
- UFH or ___
BB
ACEi or ARB
Statin
NTG prn
- PCI
- ASA, P2Y12i
- 12
- clopidogrel
- ticagrelor, prasugrel
- bivalirudin
MONA
morphine
oxygen
NTG
ASA
early hospital care immediately upon arrival - MONA
morphine - to relieve chest pain
initial dose
- ___ - ___ mg IV
- followed by __ - __ mg IV q 5-15 min
SE
- seddation
- respiraotry depression
- N/V
Avoid NSAIDs during hospitalization (except ___ )
- NSAIDS lead to Na and water ___ = increase risk of ___
- 4-8, 2-8
- ASA
- retention, MACE
early hospital care - immediately upon arrival - MONA
oxygen
maintain O2 sat of > ___ %
90%
(dont need to initiate if above 90%)
pateints have trouble breathing due to impending feeling of doom
early hospital care - immediately upon arrival
Nitroglycerin (NTG)
- ___ = increase blood flow to the heart
SL NTG: ___ - ___ mg q __ min x 3 for angina
IV NTG: for persistent ischemia, HF, or HTN
- start at ___ mcg/min
- titrate by ___ mcg/min q 5 min (MAX: ___ mcg/min)
SE
- headache
- hypotension
vasodilator
0.3-0.4, 5
10
5
200
T or F: transdermal NTG is preferredd in the setting of ACS
FALSE
- has to absorb, not rapid, 15-60 min onset
NTG CI
nitrates are contraindicated with the use of a ___
sildenafil: within ___ hrs
vardenadil: within ___ hrs
tadalafil: within ___ hrs
PDEi
24
24
48
early hospital care - immediately upon arrival
ASA
___ - ___ mg chewable for 1 dose
- give to ALL patients without contraindications to ASA
162-325
if EC is all that is availabe, have pt chew
T or F: if the patient takes 81 mg ASA and they already too their dose that morning, we would still give a loading dose of 325 mg
T
the pt still needs a loading dose, If they just to their dose, you could give 3 additional 81 mg tabs (for a total dose of 324 mg)
Steps with Time
within 10 min of arrival: ___
- repeat q 15-30 min for 1 hour if patient remains symptomatic
at presentation: ___
- repeat q 3-6 hours for first 12 hours
immediately upon arrival: ___
ECG
high sensitivty troponin
MONA
reperfusion strategies
procedures: ___ and ___
PCOL: ___ therapy
PCI, CABG
fibrinolytic
Coronary Angiography - “heart cath”
shows which arteries in the heart have blockages
1) catheter is inserted into ___ and ___ artery and fed up to the heart
2) ___ is injected into coronary arteries
3) an ___ picture is taken and shows the blocked arteries
4) a ___ is place if needed
radial, femoral
dye
X-ray
stent
Fibrinolytics “clot busters”
convert ___ into ___ (the enzyme that degrades fibrin)
plasminogen, plasmin
Fibrinolytics
Tenecteplase (TNK-tPA)
just __ dose
Dosing:
- < 60 kg: ___ mg
- 60-69 kg: ___ mg
- 70-79 kg: ___ mg
- 80-89 kg: ___ mg
- 90 or > than 90 kg: ___ mg
1
30
35
40
45
50
Fibrinolytics
Reteplase (rPA)
Dosing:
- ___ units for ___ doses
- ( ___ min apart)
10 x 2
30
Fibrinolytics
Alteplase
(tPA)
- ___ mg bolus
- then ___ mg/kg over 30 mins (MAX: ___ mg)
- then ___ mg/kg (MAX: ___ mg) over 60 min
- max total dose: ___ mg
- 15
- 0.75, 50
- 0.5, 35
- 100
Fibrinolytics
TNK-tPA, rPA, and tPA are ___
- no strong ___ for one agent over another
Streprokinase (SK)
- first fibrinolytic
- less ___
- less ___ for fibrin
- not often used in the US
expensive
- preference
- expensive
- specific
absolute CI to Fibrinolytics
- history of ___ hemorrhage
- ischemic stroke within the past ___ months
- presence of a cerebral vascular malformation of primary or metastatic intracranial ___
- aortic ___
- active ___
- significant closed-head of facial trauma within the past ___ months
- intracranial
- 3
- malignancy
- dissection
- bleeding
- 3
relative CI to Fibrinolytics
- ischemic stroke > ___ months ago
- severe/uncontrolled HTN (SBP > ___ mmHg or DBP > ___ mmHg)
- dementia
- any intracranial disese that is not an absolute CI
- if cardiopulmonary resuscitation was administered for > ___ mins
- major surgery within the last ___ weeks
- internal bleeding within the last ___ - ___ weeks
- vascular punctures not able to be compressed if they were to bleed
- ___
- current ___ therapy
- previous allergic reaction to fibrinolytic drugs
- 3
- 180, 110
- 10
- 3
- 2-4
- pregnancy
- warfarin
Reperfusion Therapy: STEMI - PCI vs Fibrinolytic
reperfusion therapy should be administered to all eligible STEMI patients whose symptoms began in the past __ hours
PCI ___ fibrinolytic
- higher rates of infarct artery patency
- lower rates of recurrent ischemia, reinfarction, and emergency repeat revascularization procedures
- lower rates of intracranial hemorrhage
- lower rates of death
12
- (> > >)
Reperfusion Therapy: STEMI
door-to-needle time = within ___ min of hospital arrival
door-to-balloon time: within ___ min of hospital arrival
30
90
Reperfusion Therapy: STEMI
fibrinolytic is recommended for STEMI patietns at non-PCI-capable hospitals
- when patients are greater than ___ min away from PCI-capable hospital
- should be administered within ___ mins of hospital arrival
120
30
Reperfusion Therapy: NSTEMI/UA
early invasive vs. ischemia guided
- ___ are NOT recommended
early invasive = coronary ___ +/- revascularization
- preferred for patients with ___ risk features such as
- refractory ___
- new-onset ___
- rising ___
- new ST segment ___
Ischemia-Guided = “Medical” Management
- treatment with evidence-based madications
- no heart ___ (unless the patient has refractory or recurrent ischedmic symptmoms or becomes hemodynamically ___ )
fibrinolytics
angiography
- high
- angina
- HF
- troponin
- depression
- catheterization
- unstable
