ACS and CV drugs Flashcards by Rebecca Lea

clinical suspicion or confirmation of acute myocardial ischemia or infarction

definition of ACS

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reversible ischemia w/out injury

unstable angina

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myocardial ischemia w/ injury

myocardial infarction

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initial management of ACS

A, E, I, O, N

preliminary H and P
ASA 325 mg PO (chewed)
EKG
IV access and bloodwork
O2 (keep sat above 90)
nitrates (unless contraindicated)
consider morphine if severe persistent CP

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unstable angina

EKG?

cardiac enzymes?

EKG- normal usually

cardiac enzymes- normal

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NSTEMI

EKG?

cardiac enzymes?

EKG- ST depression or T wave changes

cardiac enzymes- elevated

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STEMI

EKG?

cardiac enzymes?

EKG- ST elevation

cardiac enzymes- elevated

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anterior wall MI shows on leads

V2- V4

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septal wall MI shows on leads

V1 and V2

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lateral wall MI shows on leads

1, aVL, V5 and V6

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inferior wall MI shows on leads

2, 3, and aVF

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posterior wall MI shows on leads

V1 to V4

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anterior wall MI vessel

LAD- diagonal branch

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septal wall MI vessel

LAD- septal branch

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lateral wall MI vessel

Left Coronary Artery- circumflex branch

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inferior wall MI vessel

Right Coronary Artery- posterior descending branch

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posterior wall MI vessel

Left Coronary Artery- circumflex branch

Posterior Descending Artery- posterior descending branch

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ACS initial drugs if

meets criteria for STEMI

antiplatelet/ anticoagulant (ASA, clopidogrel, heparin, etc)

BB (if not contraindicated, such as in HF)

IV nitro (if not contraindicated for persistent CP)

PCI (w/in 90 mins)

thrombolysis (w/in 30 mins)

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ACS initial drugs if

you have strong suspicion for ischemia despite lack of persistent ST elevation

antiplatelet/ anticoagulant (ASA, clopidogrel, heparin, etc)

BB (if not contraindicated, such as in HF)

IV nitro (if not contraindicated for persistent CP)

catheterization (if high risk)

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ACS initial drugs if

normal EKG

nondiagnostic EKG + normal cardiac enzymes

eval and monitor

repeat EKG and cardiac enzymes Q 6-12 hours

if no evidence of ischemia then perform stress test/ imaging study

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MI antiplatelet options

aspirin

clopidogrel

abciximab/ eptifibatide/ tirofiban

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MI anticoagulant options

unfractionated heparin

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MI beta blocker options

metoprolol

atenolol

(cardio-selective BB’s)

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MI statin options

atorvastatin

rosuvastatin

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thiazides indications

hypertension edema

potassium sparing diuretic indications

HF liver failure w/ ascites

common potassium sparing diuretic

triamterene

aldosterone antagonist indications

hypertension

common aldosterone antagonist

spironolactone

loop diuretic indications

HF hypertension

common loop diuretics

furosemide bumetanide

thiazides adverse reactions

hypokalemia hypotension (orthostatic) hyperuricemia

potassium sparing diuretic adverse reactions

hyperkalemia

aldosterone antagonist adverse reactions

hyperkalemia gynecomastia

loop diuretic adverse reactions

hypokalemia hypomagnesemia hypocalcemia

thiazide contraindications

allergy to sulfa

potassium sparing diuretic contraindications

use caution when combining with: ACE/ARB potassium supplements

aldosterone antagonist contraindications

renal impairment DM w/ proteinuria

loop diuretic contraindications

allergy to sulfa

nitrates MOA

relax vascular smooth muscle dilates coronary arteries decreases preload

nitrate routes

oral parenteral topical

nitrates indications

**ACS** **angina** HTN HF pulmonary hypertension esophageal spasm

nitrates adverse reactions

**HA** hypotension tachycardia dizziness

nitrates contraindications

**SBP \< 90** bradycardia \< 50 **tachycardia \> 100** RV infarction use of **phosphodiesterase inhibitor** (ED drug) w/in 24 hours hypertrophic cardiomyopathy severe aortic stenosis

BB MOA

blocks the activity of catecholamines at the beta adrenoreceptors decreasing HR decreasing CO decreasing myocardial demand

commonly used cardioselective BB

**atenolol** **metoprolol** **nebivolol** *(selective for B1)*

commonly used NON-cardioselective BB

propranolol nadolol *(hits B1 and B2 receptors)*

BB indications

**stable HF** **post-MI** **angina** arrhythmias HTN

BB adverse reactions

**bronchoconstriction** bradycardia AV block **fatigue** ED depression dizziness/ hypotension

BB absolute contraindications

hypotension/ cardiogenic shock active bronchospasm severe bradycardia 2nd or 3rd degree heart block overt HF

BB relative contraindications

COPD asthma diabetes

BB may mask symptoms of _____ in \_\_\_\_\_

BB may mask symptoms of **hypoglycemia** in **diabetics**

abrupt withdrawal of BB can cause what

**acute coronary events** and **severe increases in BP** (so AVOID)

BB should be used with caution in pts with

depression

ACE-i MOA

by inhibiting the coversion of angio 1 to angio 2, they cause **vasodilation**

commonly used ACE-i

**lisinopril** enalapril quinapril

ACE-i indications

**HTN** HF post-MI **diabetic nephropathy** **CKD**

ACE-i adverse reactions

hyperkalemia hypotension **cough** **angioedema**

ACE-i contraindications

**pregnancy** hx of angioedema renal artery stenosis

you should consider ACE-i for renoprotection in who?

diabetics

ARBs MOA

antagonize angio 2 AT2 receptors, causing **vasodilation**

commonly used ARBs

**valsartan** losartan olmesartan

ARBs indications

**HTN** **post-MI** HF diabetes **CKD**

ARBs adverse reactions

hyperkalemia hypotension angioedema

ARBs contraindications

**pregnancy** renal artery stenosis hx of angioedema

CCB MOA

inhibit calcium influx into arterial smooth muscle cells, relaxing coronary smooth muscle, ## Footnote **decreasing peripheral vascular resistance**

commonly used dihydropyridine CCBs

**amlodipine** felodipine nifedipine

commonly used NON-dihydropyridine CCB

verapamil diltiazem

dihydropyridine CCB indications

**HTN** **angina**

NON-dihydropyridine CCB indications

**angina** **rate control** for a-fib/a-flutter HTN

dihydropyridine CCB contraindications

acute MI

NON-dihydropyridine CCB contraindications

severe LV dysfunction sick sinus syndrome AV block WPW

CCB adverse reactions

**constipation** **peripheral edema** **flushing** dizziness/hypotension

what drugs are recommended for the treatment of HTN during pregnancy

**nifedipine** (CCB) **methyldopa** (alpha agonist)

first line tx for essential HTN

thiazide diuretcis ACE-i / ARBs CCB

CV drugs for initial tx for ACS

nitrates BB CCB

CV drugs contraindicated in pregnancy

ACE-i ARBs

fibrinolytic absolute contraindications

hx of intracranial hemorrhage hx of additional prior ischemic stroke in the past 3 months cerebral vascular malformation intracranial malignancy sxs of aortic dissection bleeding disorder/ traumatic bleeding closed head/ facial trauma in the past 3 months

risk factors for aortic dissection

marfans cartilage issue fam hx

risk factors for herpes zoster

pregnancy stress

primary causes of pericarditis

idiopathic viral

primary causes of cardiac tamponade

**trauma** (incl. cardiac sx) pericardial effusion infection

what does the pt with a pneumothorax look like

tall thin male

tingling in fingers palpitations CP

panic disorder CP presentation

why is cocaine bad for the heart

increased O2 demand coronary artery vasoconstriction

young anxious diaphoretic CP

cocaine/meth

with herpes zoster, which comes first- rash or sxs

sxs

does every ACS pt get MONA

no just NA (nitrates, ASA) only pts w/ sat less than 90 get O2 only pts who really need it and pain is refractory to nitrates get Morphine

anti-hypertensive drug that causes gynecomastia

aldosterone antagonist

anti-hypertensive drugs that cause hyperkalemia

potassium sparing diuretic aldosterone antagonist ACE ARB *(so don't combine)*

anti-hypertensive drugs that cause bronchoconstriction