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Therapeutics > ACS > Flashcards

ACS Flashcards

1
Q

what are CAD risk factors?

A
  • age > 65
  • gender (M>F)
  • smoking
  • dyslipidemia
  • HTN
  • DM (CAD equiv)
  • central obesity
  • fam hx of 1st degree relative w/premature MI (men < 55, women <65)
  • cocaine
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2
Q

what is ordered upon initial assessment?

A

Labs:

  • CBC with diff
  • BMP
  • Troponin I or T
  • ± CK/MB <b>(with contemporary troponin assays, CK enzymes and myoglobin are not useful for ACS)</b>
  • ± Pro BNP

Diagnostics
-12- lead EKG -<b>DONE WITHIN 10 MINUTES </b>
-CXR - <b>portable AP CXR,
Because it is faster and do NOT have to move an unstable patient</b>

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3
Q

what are the lateral leads in EKG?

A

I, aVL, V5, V6

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4
Q

what are the inferior leads in EKG?

A

II, III, aVF

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5
Q

what are the anterior/septal leads?

A

V1, V2, V3, V4

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6
Q

EKG findings with suspected UA/NSTEMI

A
  • can be normal
  • ST depressions or transient ST elevations

new T-wave inversions

  • T wave inversion in III is normal variant
  • NEW T wave inversion is ALWAYS abnormal
  • marked T wave inversion > 2mm = ischemia
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7
Q

how often you do repeat EKG for UA/NSTEMI?

A

15-30 minute intervals during the first hour

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8
Q

if a patient has continued chest pain despite medications, what do you do?

A

repeat EKG

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9
Q

what should a pt always have when they are having initial ED intervention for chest pain?

A

peripheral IV access

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10
Q

initial ED intervention

A
  • peripheral IV access
  • continuous telemetry monitoring
  • supplemental oxygen (if O2 ≤ 90%)
  • meds (MONA)
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11
Q

what are the MONA meds?

A

Morphine (2-4mgPRN - hold if BP <100/50

Oxygen (if O2 ≤ 90%)

NTG (SL 0.4mg q 5 mins - hold if BP <100/50) - always try NTG first before morphine & don’t combine them

ASA - 162-324mg PO

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12
Q

why don’t you give NSAIDs for ACS instead of NTG?

A

NSAIDs block endothelial prostacyclin, leads to platelet aggregation b/c of an increase in TXA2

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13
Q

what supplemental EKG leads should you obtain for ACS and why?

A

Obtain supplemental EKG leads V7 to V9 in patients with initial nondiagnostic ECG at intermediate/high risk for ACS

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14
Q

BNP or NT-pro-BNP may be considered when?

A

BNP or NT-pro-BNP may be considered to assess risk in patient with suspected ACS

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15
Q

how often do you obtain serial cardiac troponin I or T?

A

at presentation and 3-6 hours after symptoms onset in all pts with ACS symptoms

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16
Q

if pt has possible ACS but non diagnostic EKG & normal initial cardiac markers, what do you do?

A

Observe serial EKGs and cardiac markers

  • If negative study to provoke ischemia or detect anatomic CAD if negative outpatient f/u
  • if positive admit to hospital.

Consider MPI to ID rest ischemia

  • If positive admit to hospital
  • If negative outpatient f/u
17
Q

any patient with possible ACS needs what within how many hours?

A

stress test within 72 hours

18
Q

what represents high likelihood that si/sx’s represent ACS secondary to CAD?

A

Hx: chest or left arm pain or discomfort as chief sx, reproducing prior documented angina; known hx of CAD including MI

Exam: transient MR murmur, hypotension, diaphoresis, pulmonary edema, or rales

Cardiac markers: <b>elevated cardiac TnI, TnT or CKMB</b>

19
Q

what represents intermediate likelihood that si/sx’s represent ACS secondary to CAD?

A

Hx: chest or L arm pain or discomfort as chief sx, age >70, male sex, DM

Exam:
-fixed q waves, ST depressions or T wave inversion

Cardiac markers: normal

20
Q

what represents low likelihood that si/sx’s represent ACS secondary to CAD?

A

Hx: probable ischemic sx in absence of any of the intermediate characteristics, recent cocaine use

Exam: T wave flattening or inversion in leads with dominant R waves or normal EKG

Cardiac markers: normal

21
Q

HEART risk assessment

A

History, ECG, Age, Risk Factors, Troponin

  • ID’s pts with unknown ACS, probably the best, TIMI #2
  • better suited for undifferentiated pt with possible ACS -> CP or angina equivalents
  • none talk about discharging the patient from the ED besides HEART
  • also the only one that takes into account clinical history
22
Q

TIMI risk assessment

A

Thrombolysis in myocardial infarction

  • most popular, validated, for people with known hx of ACS
  • First widely used and most well known
  • Better suited for patients with confirmed NSTEMI or known UA
  • Help risk stratify patients with angina sx
23
Q

GRACE risk assessment

A

Global Registry of Acute Coronary Events

  • not easily done at bedside, COMPLEX
  • for pts with CONFIRMED ACS
24
Q

PURSUIT risk assessment

A

outdated

25
Q

if pt is possible ACS case what is the txt?

A

MONA plus provocative testing w/in 72 hours

26
Q

if pt is definite ACS (UA/NSTEMI), what is the txt?

A

Meds???,P2Y12 inhibitors, anticoagulation, nitro PRN, beta-blockers

-cath lab, stenting, DAPT after

27
Q

what is possible ACS described as?

A

recent episode of CP at rest not entirely typical of ischemia but are pain free on initial eval or in ED, have a normal or unchanged ECG, no elevation of cardiac markers

28
Q

what is definite ACS (UA/NSTEMI) described as?

A

recent episode of typical ischemic discomfort that either is of new onset or severe or exhibit an accelerating pattern of previous stable angina, elevated troponin

29
Q

Immediate Invasive intervention for NSTEMI ACS (timing and indications)

A

Timing: immediate - within 2hrs

Indications: refractory angina, new onset HF, new or worsening MR, recurrent angina during max medical txt

30
Q

Early Invasive intervention for NSTEM ACS (timing and indications)

A

Timing: early - within 24hrs

Indications: high risk, rising TnI levels, new ST depression

31
Q

Delayed Invasive intervention for NSTEMI ACS (timing and indications)

A

Timing: delayed - within 25-72hrs

Indications: immediate risk (GRACE or TIMI), EF <40%, post-infarction angina, DM, renal insufficiency, prior CABG/recent PCI w/in 6 months

32
Q

Ischemia-guided intervention (timing and indications)

A

Timing: depends on spontaneous or provoked ischemia

Indications: low risk (TIMI=0), low-risk and troponin negative women, preference in absence of high risk feature, unavailability interventional facilities or expertise

33
Q

when do you start BB on pt with ACS?

A
  • start within first 24 hrs if NO HF, low output state, risk of shock or other sx
  • Reduce incidence of tachyarrythmias
34
Q

what do you give Non-DHP CCBs for ACS (NSTEMI/UA)?

A
  • Non-DHP (dilt or verapamil) for persistent ischemia when BB doesn’t work or C/I, DON’T COMBINE WITH BB
  • C/I = LV dysfunction, increased risk for shock, prolonged PR, 2nd or 3rd degree AVB
35
Q

coronary thrombus and ACS (NSTEMI/UA) txt

A

antiplatelet txt
-admin oral ASA (initial dose 162-325, then 81 to 325) AND P2Y12 inhibitor

anticoag txt
<b>-All pts get IV anticoagulant (HEPARIN)</b>

36
Q

unstable atheroma or disease progression and ACS (NSTEMI/UA) txt

A

Statin txt
-initiate or continue high intensity oral statin

ACE
-for all pts LVEF <40 and with HTN, DM, CKD

37
Q

what is the txt like for STEMi compared to NSTEMI/UA?

A

similar but CCB weekly recommended

Therapeutics (6 decks)

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