ACS + 2P: 2

Question 1

ED: STEMI

Answer 1

-HEPARIN IV
+/-METOPROLOL IV

MONA:
1. Morphine
2. Oxygen
3. NTG SL/IV
4. Aspirin/Clopidogrel

Question 2

Morphine: STEMI

Answer 2

1-5 mg IV Q5-30min

AVOID in lethargy, low BP, bradycardia

Morphine + Clopidogrel = DDI caution

Question 3

Oxygen: STEMI

Answer 3

2-4 lpm if O2 < 90, HF, dyspnea

Question 4

NTG: STEMI

Answer 4

0.4 mg Q5min x3doses

IV: 10 mcg/min if pain not controlled

Don’t use if BP < 90 or < 30 below baseline

Question 5

Aspirin: STEMI

Answer 5

325 mg asap for STEMI

Question 6

Heparin: STEMI ED

Answer 6

If fibrinolysis:
-60 u/kg (max 4k)
-12 u/kg (max 1k)

If primary PCI/med man:
-60 u/kg (max 5k)
-12 u/kg (max 1k)

Question 7

BB: STEMI

Answer 7

Metoprolol Tartrate 5 mg IV up to x3d

Question 8

Reperfusion Therapy: ED for STEMI

Answer 8

– Door-2-Balloon: 90 minutes (primary PCI)
– Door-2-Needle: 30 minutes (thrombolysis)

Question 9

Characteristics of patients w/ higher risk of ICH with Fibrinolysis

Answer 9

-Female
-75+
-Cerebral vascular disease
-HTN

Question 10

Tenecteplase Dosing in ED for STEMI

Answer 10

• < 60 kg: 30 mg
• 60-69 kg: 35 mg
• 70-79 kg: 40 mg
• 80-89 kg: 45 mg
• > 90 kg: 50 mg

Question 11

STEMI - Primary PCI: Cath Lab: Antithrombotic Strategies

Answer 11

1. Continue heparin from ED as monotherapy
2. Continue heparin and add cangrelor
3. Stop heparin and start bivalirudin monotherapy
4. Stop heparin and start bivalirudin + cangrelor

Question 12

Clopidogrel: STEMI

Answer 12

Give in Cath lab if not given already in ED as part of early tx

Genetic variability with CYP2C19*2 (avoid omeprazole esomeprazole, can use pantoprazole/HSRA)

Dose: 300 mg LD (for fibrinolysis), 75 mg QD MD

Question 13

Prasugrel: STEMI

Answer 13

CI in TIA/STROKE history

LD 60 mg, 10 mg QD MD (< 60 kg: 5 mg)

Only indicated in ACS to be managed with PCI

Question 14

Ticagrelor: STEMI

Answer 14

Indicated for ACS (PCI or non-invasive medical management)

LD 180 mg, 90 mg BID MD

Dyspnea AE (caution asthma/copd)

Can’t use in ICH patients

Question 15

ICU/Ward: Later TX for 2ndary Prevention for STEMI

Answer 15

-ACEI (within 24 hr for AMI/STEMI/<40LVEF)

Question 16

NSTEMI: Early Pharm in ED

Answer 16

*Don’t use fibrinolytics

-Heparin IV: 60 u/kg (5k max), 12 u/kg (1k max)
+/- Metoprolol IV
-MONA

*Clopidogrel, ticagrelor, prasugrel, or cangrelor for PCI
*Clopidogrel or ticagrelor for med man only

Question 17

Secondary Prevention after MI: ICU/Ward

Answer 17

-Aspirin 81 mg
-Rivaroxaban (wait until DAPT complete)
-Clopidogrel, prasu, tica (tica/pras > clop if no CI for stroke/tia)
-BB (MC) for 1 year (up to 3) and indef for EF < 40
-ACEI (avoid renal failure/highK)
-Statins (high intensity)
-Spironolactone or Eplerenone (25 mg both)
-SGLT2is or GLP1RAs

= ABC RASSS