- Abrupt - Persistient and lasts for 10 minutes or longer - Discomfort rather than pain (Elephant on chest) - Not tender to touch - Rapid acting nitroglycerin does not work

ACS Flashcards by Kevin Tea

Risk Factors

Male
Age
Family history of premature CAD

Smoking
Unhealthy Diet
Unhealthy Weight
Physical Inactivity
Alcohol

Hypertension
Dyslipidemia
Diabetes

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Symptoms of ACS

Abrupt
Persistient and lasts for 10 minutes or longer
Discomfort rather than pain (Elephant on chest)
Not tender to touch
Rapid acting nitroglycerin does not work

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Diagnosis of ACS

Increased Troponin
+ 1 of the following
- Symptoms or History
- ECG Changes
- Imaging shows loss of myocardium

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STEMI

Full occlusions
- Elevation of ST segment

Increased Biomarker Level
- Type 1

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NSTEMI

Partial occlusion
- Absence of ST segment

Increased Biomarker Level
- NSTEMI Type 1

No Increased Biomarker Level
- Unstable Angina

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Initial Management of ACS

Morphine IV PRN

Oxygen (If O2 < 90%)

Nitroglycerin 0.3-0.4 SL q5min PRN (Up to 3 doses)

Aspirin 162-325mg

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STEMI ACS Management

First Initiate Reperfusion Therapy:
- Primary PCI
- Fibrinolysis

Then:
- Parenteral anticoagulant (UFH, Enoxaparin)
- P2Y12 Inhibitor

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NSTEMI ACS Management

Risk Stratify into
- Low Risk
- Intermediate-High Risk

Then:
- Parenteral anticoagulant
- Aspirin
- P2Y12 Inhibitor

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Short Term Goals
- STEMI

Prevent death
Relieve ischemic chest discomfort

Rapid reperfusion to limit infarct size
- Use either PCI or Fibrinolysis

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Short Term Goals
- NSTEMI

Prevent death
Relieve ischemic chest discomfort

Prevent progression of thrombus into full occlusion and subsequent infarct expansion
Prevent plague thromboembolism

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Long Term Goals
- STEMI

Prevent major adverse cardiac events
Prevent recurrent infarction
Limit ventricular remodeling
Optimize long term measures to reduce cardiovascular risk

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Long Term Goals
- NSTEMI

Prevent major adverse cardiovascular events
Prevent recurrences of infarction
Prevent adverse ventricular remodeling
Optimize long term strategies to reduce cardiovascular risk

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Reperfusion vs Revascularization
- Definitions

Reperfusion: STEMI
- Restoring blood flow to an infarct-related artery

Revascularization: NSTEMI
- Restoring blood flow to a coronary artery that is blocked or narrowed by atherosclerosis

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Reperfusion vs Revascularization
- Management

Reperfusion:
- Primary PCI
- Fibrinolysis

Revascularization
- PCI
- Coronary Artery Bypass Graft

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Reperfusion
- Treatment Mechanisms

Primary PCI
- Stunts or balloons are inserted to open narrowed arteries

Fibrinolysis
- Activates plasminogen to bind to fibrin strands and break down thrombus

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Stent Thrombosis

Acute Stent Treatment
- Rare complication after 24 hours after stent insertion

Subacute Stent Treatment
- Caused by premature discontinuation of antiplatelet therapy

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In-Stent Restenosis

Neointimal proliferation leading to re- narrowing of the stent lumen

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Drug Eluting Stents

Uses zotarolimus, everolimus with a timed release polymer to inhibit neointimal hyperplasia
- Prevents

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Use of Statins in ACS

Prevent a larger cholesterol necrotic core
- Prevents plaque formation

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Use of Anticoagulants in ACS

Prevent progression of thrombus
Prevent plague thromboembolism
Maintains arterial patency

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Use of Beta Blockers in ACS

Prevents overactivations of Sympathetic Nervous System
- Preventing Ventricular remodeling

Relieves Ischemic Chest Discomfort

Use of ACEi/ARB in ACS

Prevents overactivation of RAASI
- Prevents Ventricular remodeling

ASA
- Dose

Loading dose: 162-325 mg po daily
Maintenance dose: 81 mg po daily

(Higher dose does not decrease bleeding risk, just increases GI side effects)

ASA
- Adverse Effects

Hypersensitivity
Bleeding
Dyspepsia, Ulcers

Clopidogrel - Dose

Loading Dose: 300-600 mg once daily Maintenance Dose: 75 mg daily

Clopidogrel - Considerations

P2Y12 binding is irreversible Is activated by CYP2C19 - A CYP2C19 inhibitor decreases amount of Clopidogrel - Ex. PPIs can decrease Clopidogrel activity

Ticagrelor - Dose

Loading Dose: 180 mg daily Maintenance Dose: 90 mg bid

Ticagrelor - Considerations

P2Y12 binding is reversible Is inactivated by CYP3A4 - A CYP3A4 inhibitor would increase amount of Ticagrelor Stronger bleeding risk than Clopidogrel Contraindicated in intracranial hemorrages

Clopidogrel - Adverse Effects

Rash - Presents after 6 days of initiation - Usually only used for 3 days in hospital

Ticagrelor - Adverse Effects

Dyspnea

DAPT - STEMI

If patient has gotten PCI - ASA 81 mg + Ticagrelor 90 mg bid If patient has gotten fibrinolytic therapy or no reperfusion therapy - ASA 81 mg + Clopidogrel 75 mg daily

DAPT - NSTEMI

ASA 81 mg + Ticagrelor 90 mg bid If patient can not tolerate Ticagrelor - ASA 81 mg + Clopidogrel 75 mg daily

DAPT - Duration

ASA should be continued indefinitely P2Y12 Inhibitor should be used for 12 months and then reassessed - Can de-escalate if needed (1-3 months) - Can extend if needed (3 years)

DAPT - De-escalating

Done for patients who: - High risk of bleeding - Do not have any ischemic or bleeding events in first month

DAPT - Extending

Done for patients who: - Not at high risk of bleeding - Tolerate 1 year of DAPT with no bleeding

Statins - Initiation

All patients with an ACS - Start high intensity statin as soon as patient is stabilized

Statins - Dose

Atorvastatin 80 mg daily Rosuvastatin 40 mg daily If statin intolerant go with moderate-intensity statin or lower dose of high intensity statin

Statins - Duration

Continue indefinitely Assess at 6-8 weeks lipid panel to decide on additional lipid lowering therapies

Beta Blockers - Initiation

All patients with ACS without contraindications - Signs of heart failure - Low cardiac output state - Asthma

Beta Blockers - Dose

Bisoprolol - Initial dose: 2.5 mg - Target dose: 10 mg Metoprolol - Initial dose: 12.5-25 mg bid - Target dose: 100 mg bid

Beta-Blockers - Duration

LVEF < 40% - Continued indefinitely LVEF > 40% - Low risk, Use for 1 year and then discontinue

ACEi/ARB - Initiation

Reasonable for all patients with ACS - STEMI: Anterior location, HF, LVEF < 40% - NSTEMI: CKD, DM, HTN

ACEi/ARB - Dose

Ramipril: - Initial Dose: 2.5 mg BID - Target Dose: 5 mg BID Perindopril - Initial Dose: 2-4 mg daily - Target Dose: 8 mg daily Valsartan - Initial Dose: 20 mg BID - Target Dose: 160 mg BID

ACEi/ARB - Duration

Continue indefinitely - Especially if LVEF < 40%, CKD, DM, HTN

Aldosterone - Initiation

Post MI and is already on ACEi and BB - LVEF < 40% - No renal dysfunction or hyperkalemia - Has symptomatic HF or diabetes Initiated within first 14 days after MI

Aldosterone - Dose

Spironolactone: - Initial Dose: 12.5-25 mg daily - Target Dose: 25-50 mg daily

Aldosterone - Duration

Continue indefinite if LVEF is < 40%

Nitroglycerin - Initiation

Should be started in all patients to relieve acute angina symptoms

Nitroglycerin - Dose

0.3-0.4 mg SL q5m (up to 3 doses)