ACC AHA part 1 Flashcards
1
Q
2017 Recomendation of severe secondary vs primairy MR -
- ERO
- Regurgitant volume
A
Some data has suggested that with severe secondary MR, a smaller ERO should be used
(? weakend ventricle, correlates with regurg volume)
Recs unchanged:
ERO: >0.4cm2 (more specific), ERO 0.2cm2 (more sensitive)
Regurg volume > 60ml
2
Q
reccomendataion for patient with :
Decreased exercise tolerance
Exertional dyspnea
ERO = 0.5cm2
LVEF > 30
A
1B evidence for Surgery
Standing 2014 guideline -
Mitral valve surgery is recommended for symptomatic
patients with chronic severe primary MR (stage D) and
LVEF greater than 30%
3
Q
reccomendation for patient with:
no symptoms
Chronic severe MR
LVEF 45%
LVESD 40mm
A
1B recomendation is surgery.
The 2014 recs stand:
Mitral valve surgery is recommended for asymptomatic
patients with chronic severe primary MR and LV dysfunction
(LVEF 30% to 60% and/or left ventricular end-systolic
diameter [LVESD] ‡40 mm,
4
Q
Recomendation for a patient with:
no symptoms
Chronic severe primairy MR
LVEF: 65%
LVESD 35mm
A
Surgery:
- if the liklihood of a successful repair is >95% and expected mortality is <1% at a heart valve center of excellece:
IIa B recomendation is for mitral valve repair
5
Q
From a Mitral data perspective, what does an LVEF of 60% and a LVESD > 40 indicate
A
The presence of systolic LV dysfunction
6
Q
Mitral regurgitation:
Other than LVEF (<60) and LVESD > 40mm, what data can push a patient with primairy MR to surgery ?
A
- New onset atrial fibrillation
- Pulmonary artery systolic pressure > 50mmHg
IIa B recomendation:
Mitral valve repair is reasonable for asymptomatic patients
with chronic severe nonrheumatic primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) in whom there is a high likelihood of a successful and durable repair with 1) new onset of AF or 2) resting pulmonary hypertension (pulmonary artery systolic arterial pressure >50 mm Hg
7
Q
Anticoagulation for patients with rheumatic mitral stenosis and atrial fibrillation
A
Anticoagulation with vitamin K antagonist
8
Q
Reccomendatioins for antibotic prophylaxis with dental procedures IE prophylaxis ?
A
Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or
perforation of the oral mucosa in patients with the
following (13,15,23–29):
- Prosthetic cardiac valves, including transcatheterimplanted
prostheses and homografts.
- Prosthetic material used for cardiac valve repair,
such as annuloplasty rings and chords.
- Previous IE.
- Unrepaired cyanotic congenital heart disease or
repaired congenital heart disease, with residual
shunts or valvular regurgitation at the site of or
adjacent to the site of a prosthetic patch or
prosthetic device.
- Cardiac transplant with valve regurgitation due to a
structurally abnormal valve.
9
Q
DOAC
A
DOAC= Direct oral anticoagulants-
Apixaban (Eliquis®)
Dabigatran (Pradaxa®)
Rivaroxaban (Xarelto®)
10
Q
class IA reccomendations for TAVR
A
Class IA Recs
TAVR is recommended for symptomatic patients with severe AS (Stage D) and a prohibitive risk for surgical AVR who have a predicted post-TAVR survival greaterthan 12 months
11
Q
Valve hemodynamic criteria for Symptomatic severe high-gradient AS?
A
Valve hemodynamic criteria for Symptomatic severe high-gradient AS
- valve hemodynamics:
- aortic velocity 4.0 m/s or higher,
- corresponding to a mean trans-aortic gradient of 40 mm Hg or higher.
- valve area is <1.0 cm2 with an indexed aortic valve area of < 0.6 cm2/m2
- but it may be larger, with mixed stenosis and regurgitation.
12
Q
Valve hemodynamic criteria for Symptomatic severe high-gradient AS
valve hemodynamics:
velocity?
A
Valve hemodynamic criteria for Symptomatic severe high-gradient AS
valve hemodynamics:
aortic velocity 4.0 m/s or higher
13
Q
Valve hemodynamic criteria for Symptomatic severe high-gradient AS
valve hemodynamics:
mean transaortic gradient:
A
40 mm Hg or higher.
14
Q
Valve hemodynamic criteria for Symptomatic severe high-gradient AS
valve hemodynamics:
valve area: .
A
- valve area is <1.0 cm2
- indexed aortic valve area of < 0.6 cm2/m2
but it may be larger, with mixed stenosis and regurgitation.
15
Q
TAVI
Severe symptomatic low-flow low-gradient With low EF:
A
TAVI
Severe symptomatic low-flow low-gradient With low EF:
- severe AS with a low left ventricular (LV) ejection fraction (EF) (<50%)
- defined by a severely calcified valve with:
- reduced systolic opening and an aortic valve area <1.0 cm2.
- Aortic velocity is ≤4.0 m/s at rest but increases ≥4.0 m/s on low-dose dobutamine stress echocardiography.
16
Q
TAVI
Severe symptomatic low-flow low-gradient severe AS with a normal LVEF
ECHO CRITERIA
A
Severe symptomatic low-flow low-gradient severe AS with a normal LVEF
- aortic valve area <1.0 cm2 with a
- aortic velocity <4.0 m/s
- mean gradient <40 mm Hg.
- indexed aortic valve area <0.6 cm2/m2
- stroke volume index <35 ml/m2
17
Q
TAVI
Patient specific factors important to evaluating TAVI candidacy
A
Per 2014 Guidelines:
integrated assessment combining
- the Society of Thoracic Surgeons (STS) Predicted Risk of Mortality score
- the STS score: <4% (low risk),
- 4% to 8% (intermediate risk),
- >8% (high risk).
- frailty
- main organ system dysfunction
18
Q
TAVI Evaluation
Major CV comorbidities assessed?
A
Major CV Comorbidities assessed:
- Coronary artery disease
- LV systolic dysfunction
- Concurrent valve disease (MR/MS)
- Pulmonary hypertension
- Aortic disease (porcelain aorta)
- Peripheral Vascular disease
- Hostile chest / prohibitive previous open heart surgery
19
Q
TAVI Evaluation
Major non-CV comorbidities
A
- Malignancy (remote, active, impact on life expectancy)
- GI and liver Disease
- GIB, IBD, Cirrhosis,
- GFR < 30cc/min/1.73m2
- HD
- O2 requirement
- FEV1 < 50% predicted
- DLCO < 50% predicted
- Neurologic disorders
- Movement disorders, dementia
20
Q
TGA
what are the two major anatomic variants?
And their relative frequency
A
- Two major subdivisions
- “Simple TGA” – 60- 70%
- “VSD” 30-50%
21
Q
TGA
frequency of VSD + Pulmonary stenosis
A
- VSD and pulmonary stenosis : 10%
22
Q
TGA
frequency of a subaortic conus
A
Subaortic conus : 90%
23
Q
TGA
frequency of PFO
A
PFO in nearly all
24
Q
TGA
if left uncorrected, when does the LV thickness begin to decrease
A
1 month
25
TGA
## Footnote
what form of TGA presents with severe cyanosis after birth?
TGA + IVS
Cyanosis depends on the level of mixing --
no mixing
26
TGA
What form presents with mild cyanosis and heart failrue in the first month ?
Why?
TGA with a large PDA/VSD (and no LVOTO)
Cyanosis depends on mixing - large PDA or VSD permit mixing
LVTOTO would prevent the ammount of pulmonary over flow (pulmonary vascular bed has low resistance)
27
**TGA** Presentation of:
**TGA / Large VSD / LVOTO?**
Why?
severe cyanosis without heart failure
Cyanosis depends on the mixing
LVOTO controlls the over circulation through the pulmonary bed, which is controlled by the LVOTO
28
TGA Presentation of:
TGA / large VSD or PDA / NO LVOTO ?
Why?
Heart failure within the first month, mild cyanosis
cyanosis depends on mixing - provided by VSD/PDA
no LVOTO to inhibit the inhibit the overcirculation through the vascular bed.
29
TGA Presentation of:
TGA with IVS
Why?
Cyanosis
No mixing
30
TGA is what % of all CHD ?
7.8%
31
Dabigatran - commercial name
DOAC= Direct oral anticoagulants-
Apixaban (Eliquis®)
**_Dabigatran (Pradaxa®)_**
Rivaroxaban (Xarelto®)
32
What is the level of evidence for:
## Footnote
Mitral valve surgery is recommended for symptomatic patients with chronic severe primary MR (stage D) and LVEF greater than 30%
IB
33
what is the level of evidence for:
## Footnote
Mitral valve surgery is *recommended* for _asymptomatic_ patients with chronic severe _primary_ MR and LV dysfunction (LVEF 30% to 60% and/or left ventricular end-systolic diameter [LVESD] ≥40 mm, stage C2
IB
34
what is the level of evidence for
Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR limited to the posterior leaflet
?
IB
35
What is the level of evidence
## Footnote
Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR involving the anterior leaflet or both leaflets when a successful and durable repair can be accomplished (84,89,95,100–104).
IB
36
Class IB recomendations for MR
how many are there?
what are they?
There are 5 class IB recs
1. Mitral valve surgery is *recommended* for _symptomatic_ patients with _chronic_ severe _primary_ MR (stage D) and LVEF greater than 30%
2. Mitral valve surgery is *recommended* for _asymptomatic_ patients with chronic severe _primary_ MR and LV dysfunction (LVEF 30% to 60% and/or left ventricular end-systolic diameter [LVESD] \> 40 mm,
3. Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR limited to the posterior leaflet
4. Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR involving the anterior leaflet or both leaflets when a successful and durable repair can be accomplished
5. Concomitant mitral valve repair or MVR is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other indications (105).
37
What is the level of reccomendations for:
Mitral valve repair is reasonable for asymptomatic patients with chronic severe nonrheumatic primary MR (stage C1) and preserved LV function (LVEF \>60% and LVESD \<40 mm) in whom there is a high likelihood of a successful and durable repair with 1) new onset of AF or 2) resting pulmonary hypertension (pulmonary artery systolic arterial pressure \>50mm Hg) ?
IIaB
38
What is the level of recomendation for
Concomitant mitral valve repair or MVR is indicated in patients with chronic *severe* primary MR undergoing cardiac surgery for other indications
?
IB
39
what is the level of recomendation for:
## Footnote
Concomitant mitral valve repair is reasonable in patients with chronic *moderate* primary MR (stage B) when undergoing cardiac surgery for other indications.
IIaC
40
what is the level of reccomendation for
## Footnote
Mitral valve surgery may be considered in *symptomatic* patients with chronic severe primary MR and LVEF less than or equal to 30%
?
IIaC
41
what are the IIaB recomendation for mitral reccomendations
Just one, new, and for asymptomatic and specifies non-rheumatic
1. Mitral valve repair is reasonable for _asymptomatic_ patients with chronic severe *nonrheumatic* _primary_ MR (stage C1) and preserved LV function (LVEF \>60% and LVESD \<40 mm) in whom there is a high likelihood of a successful and durable repair with 1) new onset of AF or 2) resting pulmonary hypertension (pulmonary artery systolic arterial pressure \>50mm Hg)
42
Class IIa reccomendations for Mitral regurgitaion ?
**_IIa B_**
1. **Repair** is reasonable for **_asymptomatic_** patients with _chronic severe *nonrheumatic* primary MR (_stage C1) and:
1. **preserved LV** function (LVEF \>60% and LVESD \<40 mm)
2. a high **likelihood** of a successful and durable repair
* with
1. **new** onset of **AF**
2. resting **pulmonary hypertension (**pulmonary artery systolic arterial pressure \>50mm Hg)
**_IIa C_**
1. Concomitant mitral valve **repair** is reasonable in patients with chronic ***moderate*** primary MR (stage B) when undergoing cardiac **surgery for other indications.**
2. Mitral valve surgery may be considered in ***symptomatic*** patients with chronic **severe primary MR and LVEF less than or equal to 30%**
43
What are the IIaC reccomendations for MR ?
_IIa C_
1. Concomitant mitral valve repair is reasonable in patients with chronic *moderate* primary MR (stage B) when undergoing cardiac surgery for other indications.
2. Mitral valve surgery may be considered in *symptomatic* patients with chronic severe primary MR and LVEF less than or equal to 30%
44
what are the class II recomendations for mitral regurgitaion
_IIa B_
1. Mitral valve repair is reasonable for _asymptomatic_ patients with chronic severe *nonrheumatic* _primary_ MR (stage C1) and preserved LV function (LVEF \>60% and LVESD \<40 mm) in whom there is a high likelihood of a successful and durable repair with 1) new onset of AF or 2) resting pulmonary hypertension (pulmonary artery systolic arterial pressure \>50mm Hg)
_IIa C_
1. Concomitant mitral valve repair is reasonable in patients with chronic *moderate* primary MR (stage B) when undergoing cardiac surgery for other indications.
2. Mitral valve surgery may be considered in *symptomatic* patients with chronic severe primary MR and LVEF less than or equal to 30%
_IIb B_
Transcatheter mitral valve repair may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe primary MR (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic
despite optimal GDMT for heart failure (HF) (124).
45
CV conditions which require abx prophylaxis at the dentist (5) ?
in patients with the following:
1. *Prosthetic* _cardiac valves_, including transcatheter implanted prostheses and homografts.
2. *Prosthetic* _material_ used for cardiac valve _repair_, such as _annuloplasty rings_ and _chords_.
3. Previous _IE._
4. _Unrepaired_ *cyanotic* congenital heart disease
5. *Repaired* congenital heart disease, with *residual* shunts or valvular regurgitation at the site of or adjacent to the site of a *prosthetic* patch or *prosthetic* device.
6. *Cardiac transplant* with _valve regurgitation_ due to a structurally abnormal valve.
46
What dental procedures require ppx for endocarditis?
Dental procedures that involve:
* manipulation of gingival tissue
* manipulation of the periapical region of teeth
47
Apixaban - brand name
**_DOAC= Direct oral anticoagulants-_**
**Apixaban (Eliquis®)**
Dabigatran (Pradaxa®)
Rivaroxaban (Xarelto®)
48
Eliquis® - generic name
DOAC= Direct oral anticoagulants-
Apixaban (Eliquis®)
Dabigatran (Pradaxa®)
Rivaroxaban (Xarelto®)
49
Pradaxa - generic name
**DOAC**= Direct oral anticoagulants-
Apixaban (Eliquis®)
**_Dabigatran (Pradaxa®)_**
Rivaroxaban (Xarelto®)
50
Rivaroxaban
**DOAC**= Direct oral anticoagulants-
Apixaban (Eliquis®)
Dabigatran (Pradaxa®)
**_Rivaroxaban (Xarelto®)_**
51
Xarelto- generic name
DOAC= Direct oral anticoagulants-
Apixaban (Eliquis®)
Dabigatran (Pradaxa®)
Rivaroxaban (Xarelto®)
52
Stage A valvular heart Disease
A: At risk Patients with risk factors for development of VHD
53
Stage B heart valve disease
B: Progressive Patients with progressive VHD (mild-to-moderate severity and asymptomatic)
54
Stage C valvualr heart disease ?
Stage C : Asymptomatic severe
Asymptomatic patients who have the criteria for severe VHD:
C1: Asymptomatic patients with severe VHD in whom the left or right ventricle remain compensated
C2: Asymptomatic patients with severe VHD, with decompensation of the left or right ventricle
55
Stage C1 heart valve disease :
Stage C1: _Asymptomatic_ patients with _severe_ VHD in whom the left or right ventricle remain _compensated_
56
Stage C2 heart valve disease ?
C2: Asymptomatic patients with severe VHD, with decompensation of the left or right ventricle
57
Stage D heart valve disease
Symptomatic severe patients who have developed symptoms as a result of VHD
58
2017 Revised Valve Guidelines
1A Recomendations for AVR
Surgical AVR or TAVR is recommended for symptomatic patients with severe AS (Stage D) and high risk for surgical AVR, depending on patientspecific procedural risks, values, and preferences
59
*what is the level of recomendation for ?*
Surgical AR is recommended for _symptomatic_ patients with severe AS (Stage D)
I-B-NR
60
Aortic stenosis
- severe - high gradient
- symtoms on history.
1B reccomendation
AVR is recommended for symptomatic patients with severe high-gradient AS who have symptoms by history or on exercise testing (stage D1)
61
Aortic Stenosis
severe, high grade stenosis
symptoms on exercise testing
1B reccomendation
Surgery -AVR is recommended for symptomatic patients with severe high-gradient AS who have symptoms by history or on exercise testing (stage D1)
62
_Reccomendation for a patient with:_
severe AS (Stage c2)
No Symptoms
and an LVEF of \< 50%
Surgery - 1B reccomendation
AVR is recommended for *asymptomatic* patients with severe AS (stage C2) and LVEF \<50%
63
_Aortic Stenosis_
ACC/AHA Class 1B reccomendations (4)
1. _AVR_ is recommended for *symptomatic* patients with _severe high-gradient AS_ who have symptoms by history or on exercise testing (stage D1)
2. _AVR_ is recommended for *asymptomatic* patients with _severe AS_ (stage C2) **and** _LVEF \<50%_
3. _AVR_ is indicated for patients with severe AS (stage C or D) when undergoing other cardiac Surgery
4. AVR is reasonable for *asymptomatic* patients _with very severe AS (stage C1, aortic velocity 5.0 m/s) and low surgical risk_
64
Reccomendation for
## Footnote
*asymptomatic* patient
with an aortic velocity of 6.0 m/s
Class IB Reccomendation
1. AVR is reasonable for *asymptomatic* patients _with very severe AS (stage C1, aortic velocity 5.0 m/s) and low surgical risk_
65
Reccomendation for a patient
asymptomatic patients at baseline but decreased exercise tolerance
severe AS on ECHO
Class IIB reccomendation
AVR is reasonable in asymptomatic patients (stage C1) with severe AS and decreased exercise tolerance or an exercise fall in BP
66
Reccomendtion for asymptomatic patient
with very severe AS
if the patient:
a. Decreased systolic opening of a calcified valve;
b. An aortic velocity 5.0 m per second or greater or mean pressure gradient 60 mm Hg or higher;
c. A low surgical risk
then surgery IIA
67
Criteria for **Aortic Valve Stenosis** with _low-flow/low gradient severe AS_ with **reduced LVEF**
1. AVR is reasonable in *symptomatic* patients with _low-flow/low gradient severe AS_ with _reduced LVEF_
1. _**Baseline** characteristics set up:_
1. ***Valve structure:***
1. Calcified aortic valve with reduced systolic opening;
2. Resting valve area 1.0 cm2 or less;
2. ***LV Function***:
1. LVEF less than 50%
3. ***Hemodynamics***
1. velocity less than 4.0 m/s
2. mean pressure gradient less than 40mmHg;
2. *_Low-dose dobutamine stress study_*
1. aortic *velocity* \>=4.0m/s
2. mean *pressure gradient* \>=40 mmHg or higher
3. with a valve area =\< 1.0 cm2
4. at ***any*** dobutamine dose.
68
What is the level of reccomendation:
1. _AVR is reasonable in *symptomatic* patients with low-flow/low gradient severe AS (stage D3) with_:
1. an LVEF 50% or greater
2. a calcified aortic valve with significantly reduced leaflet motion
3. a valve area 1.0 cm2 or less only if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms and data recorded when the patient is normotensive (systolic BP \<140 mm Hg) indicate (Level of Evidence: C):
1. An aortic velocity less than 4.0 m per second or mean pressure gradient less than 40 mm Hg;
2. A stroke volume index less than 35 mL/m2; and
3. An indexed valve area 0.6 cm2/m2 or less.
IIA
69
when should _Aspirin_ be stopped preoperatively?
it shouldnt - cotinue through surgery
70
_tirofiban_
what is it?
when should it be stopped preoperatively?
1. _tradename_: **Aggrastat**: short-acting glycoprotein IIb/IIIa inhibitors
2. when to stop?
1. can be stopped 2-4 hours before surgery.
71
_eptifibatide_
what is it?
when should it be stopped preoperatively?
1. short-acting glycoprotein IIb/IIIa inhibitors
2. when to stop?
1. can be stopped 2-4 hours before surgery.
72
1. _Abciximab_
1. what is it?
2. when is stopped preoperatively
1. _Abciximab_
1. longer-acting glycoprotein IIb/IIIa inhibitor
2. when to stop preoperatively ?
can be stopped 12 hours before surgery
73
Prasugrel
what is it?
when should it be stopped preoperatively
1. Prasugrel should be held for at least 7 days before surgery.
Prasugrel
(trade name **Effient** in the US and India, and **Efient** in the EU)
an irreversible anatagonist of P2Y12ADP receptors
74
What is the Level of evidenc for :
asymptomatic patients with severe AS (Stage C) who meet an indication for AVR when surgical risk is low or intermediate?
I-B-NR
75
Reccomendations for use of COX-2 inhibitors for analgesia following CABG surgery
Class III (Harm) B
76
Reccomendations for the use of IMA (left or right) in bypassing the LAD
**Class I B**
If possible, the left internal mammary artery (LIMA) should be used
to bypass the left anterior descending (LAD) artery when bypass of
the LAD artery is indicated
**Class IIA**
The right internal mammary artery (IMA) is probably indicated to
bypass the LAD artery when the LIMA is unavailable or unsuitable as
a bypass conduit.
77
Reccomendations for use of a second IMA ?
**IIa (B)**
When anatomically and clinically suitable, use of a second IMA to graft the:
**left circumflex**
**or**
**right coronary artery (when critically stenosed and perfusing LV myocardium)**
is reasonable to improve the likelihood of survival and to decrease reintervention
78
ACC/AHA Recomendations for the use of IMA to graft to the right coronary artery
IIa *( AHA/ACC 2011)*
right coronary artery (when critically stenosed and perfusing LV myocardium)
79
2011 ACC/AHA Reccomendations for complete arterial revascularization
IIb (C) - 2011
Complete arterial revascularization may be reasonable in patients
**less than or equal to 60 years of ag**e with **few or no comorbidities**
80
2011 ACC/ AHA recomendations for arterial grafting to the right
IIb (B) - 2011
Arterial grafting of the right coronary artery may be reasonable
when a critical (90%) stenosis is present
81
_2011 ACC/AHA_ Recomendation for the use of a **RADIAL** artery
**_IIb (B) - 2011_**
Use of a radial artery graft may be reasonable when:
grafting **left-sided coronary arteries with severe stenoses (70%)**
and
**rightsided arteries with critical stenoses (90%) that perfuse LV myocardium**
82
Class III Reccomendations for using artery bypass conduit
An arterial graft should not be used to bypass the right coronary
artery with less than a critical stenosis (90%)
83
_**2011 ACC AHA** reccomendations for **ischemic conditioning**_
**II B**
1. The effectiveness of *prophylactic **_pharmacological_** therapies* or controlled reperfusion strategies aimed at inducing preconditioning or attenuating the adverse consequences of myocardial reperfusion injury or surgically induced systemic inflammation is **uncertain**(182–189). (Level of Evidence: A)
2. **Mechanical preconditioning** might be considered to reduce the risk of perioperative myocardial ischemia and infarction in patients **undergoing off-pump CABG (**190–192). (Level of Evidence: B)
3. **Remote ischemic preconditioning** strategies using peripheralextremity occlusion/reperfusion _*might* be considered_ to attenuate the adverse consequences of myocardial reperfusion injury (193– 195). (Level of Evidence: B)
4. The effectiveness of **postconditioning** strategies to attenuate the adverse consequences of myocardial reperfusion injury is **uncertain**
84
2013 ACC/AHA Broad Definition of NSTEMI Syndrome
clinical syndrome defined by:
Characteristic symptoms of myocardial ischemia in association with:
Persistent electrocardiographic (ECG) ST elevation
85
* 2013 ACC AHA guidelines for ST - ECG changes necessiry for STEMI Diagnosis
- generic definition
**ST- ELEVATION**
new ST elevation at the J point in at least 2 contiguous leads
2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3
and/or
1 mm (0.1mV) in other contiguous chest leads or the limb leads
86
ST depression in 2 precordial leads (V1–V4);
*_ACC/AHA 2013 STEMI Recs_*
ST depression in 2 precordial leads (V1–V4) may indicate:
**transmural posterior injury;**
87
multilead ST depression with
coexistent ST elevation in lead aVR
multilead ST depression with coexistent ST elevation in lead aVR
has been described in patients with-
**left main** or **proximal left anterior descending** artery occlusion .
*ACC/AHA 2013 STEMI Recs*
88
ACC/AHA 2013
if fibrinolytics are chosen as therapy when should they be used
Fibrinolytics shold be given within 30 minutes of arrival to the hospital
89
ACC AHA 2013 - NSTEMI
Recomendation for reperfusion therapy (interventional) in the setting of a STEMI
Reperfusion therapy is reasonable for patients with:
STEMI
&
Symptom onset within 12-24 h who have clinical or ECG evidence of ongoiong ischemia
90
Fondaparinux
Fondaparinux (trade name Arixtra) is an anticoagulant medication chemically related to low molecular weight heparins. It is marketed by GlaxoSmithKline. A generic version developed by Alchemia is marketed within the US by Dr. Reddy's Laboratories.
ACC/AHA 2011 Class III Rec: should not be used as a sole anticoagulant to support PCI
91
_Class I Recomendations_ for **CABG** in the Setting of **STEMI**
*_AHA/ACC 2013 Class 1 Rec for STEMI_*
1. **Urgent CABG** is *indicated* in patients with **STEMI** and **coronary anatomy not amenabl**e to PCI who have **ongoing or recurrent ischemia**, **cardiogenic shock,** **severe HF**, or other **high risk features** (Level of Evidence: B)
2. **CABG** is recommended in patients with STEMI at time of **operative repair of mechanical defect**s (Level of Evidence: B)
92
Level of evidence for the use of **MCS** in patient with **STEMI**
**_ACC/AHA 2013_**
*Class IIa Reccomendation:*
Use of MCS is reasonable in patients with STEMI who are hemodynamically unstable and require CABG
93
New York State Criteria
Cardiogenic Shock
**_Cardiogenic Shock:_**
1. episode of systolic BP \< 90mmHG
2. CI \< 2.2L / min/m2
determined to be secondary to cardiac dysfunction
*and*
the requirment for parenteral inotropic or vasopressor or MCS (IABP, VAD, ECMO) to maintainain BP above these levels
94
**_Xarelto_** mechanism of action
Rivaroxaban
inhibits both free Factor Xa and Factor Xa bound in the prothrombinase complex.
