ACS Flashcards
What is Acute Coronary Syndromes?
- It is the IMBALANCE between the myocardial oxygen supply and demand
What is meant by Spontaneous MI?
- The atherosclerotic plaque ruptures
How is the atherosclerotic plaque formed and how does it cause ischemia?
- Atherosclerotic plaque is formed by monocytes entering the cell and becoming macrophages. These macrophages then eat up all the cholesterol becoming a fatty streak. That fatty streak becomes the plaque and when it ruptures is when ischemia occurs.
What is meant by MI secondary to ischemic imbalence?
- The mismatch between the oxygen supply and demand [the heart is wanting my oxygen but cant get it]
What are some risk factors for ACS?
Smoking, sedentary lifestyle, improper diet, MALE, family history…
What are some precipitating factors for ACS?
Exertion, physical activity, weather [Hot and Cold], sexual activity, shoveling snow, large meals…
What are some signs and symptoms for ACS?
Substernal chest pain that then can radiate down the LEFT arm and also up into the lower jaw
- Also some SOB, nausea/vomiting, sweating, dizziness…
- Should go away at rest
How do we diagnose ACS?
Give the patient a ECG within 10 minutes of arrival to the ER [look at ST interval[]
- ST Elevation = STEMI [may also have Q wave changes]
- ST Depression = NSTEMI
What is the one Myocardial Injury Biomarkers that test for at the ER?
Troponin: sees how much necrotic myocytes are in the blood stream
- High Sensitivity Troponin: PREFERRED - <14 ng/L
- Conventional Troponin: <0.05 ng/mL
What is the difference between Stable & Unstable Angina?
Stable Angina:
- Chest pain that occurs during EXERTION; has a fixed stable plaque [relieved at rest and short duration]
Unstable Angina:
- Chest pain that can occur any time really; at REST, SLEEP or with LITTLE EXERTION; has a ruptured plaque [last a longer time, >30 mins]
What is the difference between Unstable Angina & NSTEMI?
Both have very similar conditions: Chest pain that can occur any time really; at REST, SLEEP or with LITTLE EXERTION; has a ruptured plaque
Unstable Angina:
- Less Ischemia [not blocked as bad]
- NO troponin
NSTEMI:
- More blocked
- Elevated Troponin
What is the difference between NSTEMI & STEMI?
NSTEMI:
- NO elevated ST Interval [ST Depression]
- Elevated Troponin
STEMI:
- ST Elevation
- Possible Q Elevation
- Elevated Troponin
What is a TIMI score?
- Risk of experiencing either death, MI or Urgent need for revascularization within 14 days
[Low Risk: 0-2, Medium Risk: 3-4, High Risk: 5-7]
How do we determine the TIMI score?
- AGE >65
- > risk factors for CAD [HLD, HTN DM, Smoking, Family history]
- Known CAD
- Use of Aspirin
- ST Depression
- Chest Discomfort within 24 hr
- Positive Biomarker
Other than the ECG, what is some other early hospital care we should do for ACS patients?
MONA
What is MONA?
DO IMMEDIATELY
- Morphine 4-8mg IV, then 2-8mg IV q15min
- Oxygen [O2 sat >90%]
- Nitrate Tab 0.3-0.4mg every 5 min x 3
- Aspirin 325mg, then 81mg indefinitely
What is Reperfusion?
- Medical treatment to restore blood flow, either through or around, blocked arteries, typically after a heart attack; either procedural or medical
What are the Procedural reperfusion strategies?
PCI [Percutaneous Coronary Intervention] or CABG [Coronary Artery Bypass Graft]
What is a PCI?
A PCI is when the cardiologist goes into the arteries of the heart and puts in a stent [something to help hold the arteries open]
What is a CABG?
A CABG is basically open heart surgery [they take arteries or veins from either the radial or femoral and “bypass” the blockages in the heart]
What is the Medical reperfusion strategies?
Fibrinolytics
What is a Fibrinolytic?
- A way to prevent clots from growing and becoming a problem [the “-plase” & SHOULDN’T be given to patients that are high risk of bleeding]
What is the most appropriate reperfusion strategy for STEMI patients?
- The PCI is PREFERRED over the Fibrinolytic [due to less bleeding, recurrent ischemia and death]
*Door-to-needle: 30 minutes after getting to hospital [MONA, ECG, Troponin]
*Door-to-balloon: 90 minutes after getting to hospital [PCI + STENT]
If the patient arrives at a NON-PCI capable hospital, what should happen?
- Transfer then to a PCI capable hospital, as long as its >120 minutes away [If <120 minutes away, then just give fibrinolytic]
What is the most appropriate reperfusion strategy for NSTEMI & Unstable Angina patients?
- NO fibrinolytics
- Either Ischemia Guided Strategy or Early Invasive Strategy
What is Ischemia Guided Strategy?
- Basically just giving the patients the proper medications to help manage any symptoms or problems [the patient wants a less invasive approach]
What is Early Invasive Strategy?
- Giving the patient that is very high risk either a CABG or PCI [patients that have new HF, High Troponin, new ST Depression]
What are some the the Antiplatelets that we would use in ACS?
Aspirin, P2Y12 Inhibitors, GPIIb/IIIa Inhibitors
How should we appropriately give the patient Aspirin for ACS?
- Want to give 325mg IMMEDIATELY upon arrival [MONA] then give 81mg Once Daily Indefinitely [the higher dose literally doesn’t give an advantage]
What are the P2Y12 Inhibitors?
Clopidigrel, Ticagrelar, Cangrelor, Prasugrel
What are the LOADING dose and MAINTENANCE dose for the P2Y12s?
- Clopidogrel 300-600mg LD* & 75mg daily MD
- Ticagrelor 180mg LD & 90 BID MD
- Praugrel 60mg LD & 10mg MD
- Cangrelor 30mcg/kg LD & no MD
What is important to know about Clopidogrel’s Loading Dose?
- Should just give the 600mg as LD since there isn’t really about benefit about giving the 300mg
- DON’T give 600mg during fibrinolytic
– Fibrinolytic + >75yo = NO Loading Dose
– Fibrinolytic + <75yo= 300mg Clopidogrel
What is important to know about Prasugrel?
- NOT recommended for Ischemia Guided Therapy
- Has greater platelet aggregation
- CONTRAINDICATED with stroke
- DO NOT give to anyone >75yo, <60kg, or high bleed risk
Which P2Y12 Inhibitor should you use in NSTEMI/UA?
Ischemia Gudied Therapy:
- Ticagrelor or Clopidogrel
Early Invasive Strategy [PCI]
- Any; Ticagrelor or Prasugrel are preferred
What P2Y12 Inhibitor should you use in STEMI?
Fibrinolytic:
- Clopidogrel [HUGE bleeding risk]
PCI
- Ticagrelor or Prasugrel
How should Antiplatelets be handled for someone undergoing a CABG?
- Aspirin; DO NOT HOLD
- P2Y12 Inhibitors: HOLD [Ticagrelor - 3d, Clopidogrel - 5d, Prasugrel - 7d]
What are the GPIIb/IIIa’s?
- Abciximab, Eptifibatide, Tirofiban
What is the mechanisam of Action for the GPIIb/IIIa’s
- Inhibits the platelet aggregation
When should GPIIb/IIIa’s be given?
- In ADDITION to Aspirin and P2Y12 Inhibitors [really only used when there is a NEW thrombus that has formed]
What is the purpose of Anticoagulation in the therapy of ACS?
- To improve vessel patency and prevent reocclusion
What do Unfractionated Heparins [UFH] do?
- Its a penta-saccaride that binds to AT inhibiting its activation, inhibiting thrombin [IIa] and Xa
- Risk if HIT
- 4T’s: Thrombocytopenia, Timing, Thrombosis, oTher
What is Enoxaparin?
- A LMWH
- Its a smaller penta-saccaride that binds to AT inhibiting its activation, inhibiting thrombin [IIa] and Xa; BUT has a greater effect on Xa
What is Bivalirudin?
- A direct thrombin inhibitor [IIa] so it prevents the clotting ability of the blood and help prevents any harmful clots from forming
What is Fondaparinux?
- A Xa inhibitor so it helps prevent deep vein thrombosis
- DO NOT use in PCI alone
When should Anticoagulation be used in patients with UA & NSTEMI?
Ischemia Guided Therapy:
- UFH: Yes [48 hr]
- Bivalirudin: No
- Enoxiparin: Yes [8d in Hospital]
- Fondaparinux: Yes [8d in Hospital]
Early Invasive Strategy:
- UFH: Yes [Until PCI]
- Bivalirudin: Yes [Until PCI]
- Enoxiparin: Yes [Until PCI]
- Fondaparinux: No
When should Anticoagulation be used in patients with STEMI?
Fibrinolytics:
- UFH: Yes [48 hr]
- Bivalirudin: No
- Enoxiparin: Yes [8d in Hospital]
- Fondaparinux: Yes [8d in Hospital[]
PCI:
- UFH: Yes [Until PCI]
- Bivalirudin: Yes [Until PCI]
- Enoxiparin: No
- Fondaparinux: No
When should the Beta-Blockers be initiates for ACS?
Within 24 hours
What would be a reason to not start a Beta-Blocker?
- Bradycardia, AV Block, Asthma
Describe the receptor selectivity of the Beta-Blockers?
B1: Metoprolol, Atenolol, Bisoprolol, Nebivolol
[Heart]
B2: Propranolol, Sotalol, Nadolol
[Lungs]
Mixed: Carvedilol, Labetolol
[B1, B2, Arteries]
What are some of the Loading and Maintenance Dosages for Beta-Blockers?
-Metoprolol: 25-50mg q6-12h LD & 100mg BID MD
- Carvedilol: 6.25mg BID LD& 25mg BID MD
- Propranolol: 40mg BID-TID LD & 80mg QID MD
- Atenolol: 25-50mg Daily LD & 100mg Daily MD
What is important to know about Beta-Blockers and Cocaine?
- Cocaine is an Alpha and Beta receptor stimulater, so together they can cause chest pain or even MI [since the beta receptor is blocked, it all goes to the alpha receptor causing it]
What to counsel the patient on for Beta-Blockers?
- Life long medication
- Will lower BP and HR; so it you feel dizzy maybe too low
- If you have diabetes, may mask hypoglycemia; NO COLD SWEAT
What are the hold parameters for Beta-Blockers?
???
- Holding Parameters: if BP and HR are too low; hold the medication.
- TOO LOW? – <90-120 SBP or < 50-60 BPM
- HOLD FOR:
~ SBP < 90 & DBP < 60
~ SBP < 90 & HR < 60
When should Calcium Channels Blockers be used?
- Really should be used when the patient has recurrent ischemia or contraindicated to Beta-Blockers [ONLY the NON DHP: Verapamil or Diltiazem]
What is the Mechanism of Action for the Statins?
- Inhibit the conversion of HMG-CoA to Mevalonic Acid; decreasing the formation of Cholesterol and stopping the formation of plaques
What are the statins that should be used?
High Intensity Statins:
- Atorvastatin: 40-80mg Daily
- Rosuvastatin: 20-40mg Daily
What is some patient counseling for Statins?
- Life long medication to prevent heart attack
- Lower cholesterol; even if normal take it
- Most common side effect is MUSCLE PAIN
What is the Mechanism of Action for the ACEi?
- Blocks the conversion of Angiotensin I to Angiotensin II
What are the ACEi?
- “-pril”
- SHOULD be give to all patients as they help decrease mortality
When should ACEi not be use?
- During hypotension, renal failure, angioedema
What are some monitoring parameters with ACEi?
- Increased Creatinine [decreased pressure in glomerulus]
- Increased Potassium [do not give to hyperkalemics]
- Decreased BP [Hypotension]
- Angioedema [swelling of the face]
What is some patient counseling for ACEi?
- Life long medication; helps you live longer
- Dizziness from the decreased BP
- Dry Cough [Switch to ARBs]
- Angioedema [medical emergency]
What should we do about Nirtoglyercin?
- SHOULD be given to every patient
- 0.3-0.4mg under tongue q5 mins for chest pain [max dose 3, then call 911]
What is some counseling for NTG?
- Keep on you
- Keep stored in amber glass or airtight container
What else should we discuss with the patient about prevention of MI?
- STOP SMOKING, medication adherence, healthier diet
