ACS/AMI IV Flashcards
in post-STEMI pt’s, which media indicated for “infarct size limitation?”
BB
can you give clopidogrel at the time of PCI?
yes
which trial showed a benefit with prasugrel over clopidogrel for CV death/MI?
TRITON TIMI 38
which trial showed that ticagrelor pt’s had less IST than clopidogrel?
PLATO
When can you give prasugrel after fibrinolytic therapy?
After 24h
which trial showed that clopidogrel lowers CV death/MI/urgent revascularization/recurrent ischemia after lytic therapy?
CLARITY TIMI 28
what are the Class I recommendations for GP IIbIIIa inhibitors post STEMI and PCI?
none
what is the strongest rec class for GPIIBIIIa inhibitor use?
Class IIa
if pt is given fibrinoytic Rx for STEMI, how long do you continue A/C for?
at least 48h, preferrably for entire hospitalization, or until PCI
which Anticoagulants should you use if need them for >48h
lovenox
fondaparinux
(avoid HIT)
what did HORIZONS-AMI trial show for bivalirudin vs hep + GPIIbIIIa inhibitors?
that bivalirudin alone decreased 30d mortality and had less major bleeding.
although bivalirudin alone is superior to Hep + GP2b3a, why was there an early hazard with it?
due to no preload of thienopyridine
name 5 factors that increase the risk of cardiogenic shock during STEMI
age > 70
HR < 60 or HR>110
late stemi
SBP < 120
when are ACEI a Class I rec in AMI?
STEMI
AMI w/ EF<40%
list the 5 known mech complications of AMI
shock RV infarct free wall rupture VSD pap m. rupture
Dr. Killip classification
I - no S3 or rales
II- basilar rales not above 1/2 lung fields
III- rales above 1/2 lung fields
IV- cardiogenic shock
Bezold-Jarish reflex
HoTN/bradycardia s/p RCA PCI
hemodynamic criteria for shock
PCWP > 15
CI < 2.2
what do you have to rule out before diagnosing cardiogenic shock?
hypovolemia
brady or tachyarrhythmias
Bezold-Jarish reflex
incidence of cardiogenic shock post MI?
10%
mortality of ? in cardiogenic shock with conservative therapy?
80%
*does thrombolytic therapy alone in cardiogenic shock improve survival?
No!
when is non culprit PCI ok to do?
shock
5 causes of cardiogenic shock in Shock Trial Registry (in order of most common to least)
LV failure Acute MR VSD RV infarct Tamponade
Shock trial results
emergency early revasc (PCI or CABG) in AMI and shock reduced mortality by 20% c/t thrombolysis or just medical stabilization at 6 months
in Shock trial, which subset of pt’s did worse with emergency revascularization?
age > 75
from the Shock trial, what is the window of time to revascularize in STEMI w/ shock? (Class I)
36h
in STEMI and shock, should outside institutions give both thrombolysis and IABP?
yes
in whom do you suspect RV infarction?
inferioir MI and HoTN
ekg in RV infarction
ST elev in V3R and V4R
hemodynamics in RV infarction
RA > 12
CI < 2.2
PCWP<12
echo findings in RV infarction
RV dilation and HK
4 PE findings in RV infarction
hypotension
JVD (b/c RAP>12)
TR murmur (possible)
clear lungs and CXR
RV infarction Rx
PCI
IVF’s to PCWP of 18
dobutamine (dopa if BP<90)
how long can it take to see signs of RV infarct resolution?
2-3d
when, after an AMI, does free wall LV rupture occur?
two peaks: within 24h and again at 4-7d
risk factors for free wall rupture post-MI
steroids female large MI w/ minimal salvage (late) age> 70 HTN during STEMI
what is the different in wall composition of true vs pseudo LV aneurysms?
true- myocardium
pseudo thrombus and pericardium
which is more likely to rupture: true or pseudo LV aneurysm?
pseudo
does a true LV aneurysm have a high or low risk of rupture?
low
acute VSD clinical presentation (triad)
HoTN
new pan systolic murmur w/ thrill
RV failure
2 risk factors for acute VSD
transmural MI
HTN
swan finding in acute VSD
step up in O2
true/false: ALL post-MI VSD’s need to be surgically closed
true (b/c shear forces can suddenly enlargen it and destabilize)
Rx for post-MI VSD
IABP and Sx
when does post-MI MR occur?
within 1 week
size of infarct in patients w post-MI pap m rupture/MR
can be small
does loudness of MR murmur correlate with severity?
no
how often are thrills present in post-MI MR?
rarely
clinical hallmark of post-MI papillary m rupture
sudden pulmonary edema
causes of acute MR post-MI
pap m ischemia/fibrosis
pap m rupture (partial or full)
dilation of mitral annulus 2/2 to LV failure
which papillary m accounts for 90% of post- MI rupture? which vessel supplies it?
Posteromedial
PDA
why is rupture of the posteromedial pap m survivable?
multiple heads
which papillary m accounts for just 10% of post-MI ruptures? what is its blood supply?
anterolateral
LAD and LCX
on hemodynamics, what is a rare finding that can confuse acute post-MI MR and VSD
O2 step up if the MR is transmitted to PA
*what are mortality rates, even with Sx, for pap m. rupture?
40-90%
what is surgical mortality for post MI VSD?
50%
what is mortality on medical Rx for post-MI VSD, free wall rupture, or pap m rupture?
90%
4 class I indications for IABP
cardiogenic shock
refractory post-MI angina (until revasc)
mech complications post-MI
intractable ventricular arrhythmias w/ hemodynamic instability
75-75 rule
if a pt is >75 y/o and got lytics, give only 75mg plavix (no load)
What is the class I rec for loading dose of Plavix WITHIN 24h after fibrinolytics in age<75?
300mg
How much Plavix load do you give for PCI >24h after fibrinolytics?
600mg
Bivalirudin dosing
.75mg/kg bolus then 1.75 mg/kg/hr (1mg/kg/h if CrCl<30)
Lovenox dosing after fibrinolytic therapy
If age >75 : no bolus, .75mg Q12
If age < 75: 30mg IV Bolus, then 1mg/kg Q12
(If CrCl< 30 : 1mg/kg qd)
Class I indication for giving eplerenone in STEMI
If EF<40% AND HF sxs or DM
Ephesus trial showed what as optimal time to start eplerenone post MI to reduce mortality?
Within 7 days
What are the high dose statins (w/ doses)? How much do they lower LDL by?
Atorvastatin 40-80mg
Rosuvastatin 20-40mg
> 50%
Are Zocor and Pravachol high dose statins?
No
Is cardiogenic shock increasing or decreasing in incidence?
Decreasing
What class rec is IABP in shock post STEMI?
IIa
Most sensitive ECG findings in RV infarction?
> 1mm ST Elev in V1, V4R
DDx of RV Infarction
PE
constrictive pericarditis
Tamponade
Telemetry finding with free wall LV rupture
PEA
Time frame for post STEMI VSD
3-5d (<24h w/ fibrinolytics)
Should all post-MI VSDs be closed?
Yes
What region of myocardium that has a STEMI is most likely to cause acute MR from pap m rupture?
Inferior wall
