ACS Case Flashcards
What are the risk factors for CAD?
Age >65, M>F, smoking, dyslipidemia, HTN, DM, abdominal obesity, family hx, cocaine use
What labs should be drawn for initial assessment?
CBCD, BMP, Troponin, +/- CKMB or BNP
What diagnostics need to be ordered upon initial assessment?
12-lead EKG, CXR
According to AHA guidelines how soon upon arrival should EKG be done?
10 minutes
EKG findings with suspected UA/NSTEMI
Normal, ST depression, transient ST elevation, T wave inversion in lead 3 is normal new T-wave inversion is abnormally, marked t wave inversion >2mm suggests ischemia
EKG should be repeated @ what intervals?
15-30 minutes during the first hour
Initial ED intervention
Peripheral IV access, telemetry monitoring, O2
What meds should be given initially?
MONA: Morphine, O2, Nitro, Aspirin
What is the mechanism of action of NTG?
Decreases cardiac pre-load and afterload
How should the orders for NTG be prescribed for pt in ED?
NTG 0.4mg Q 5 minutes X 3
OR
400mcg Sublingual Hold if BP less than 100/50
What should NOT be given in potential ACS/NSTEMI?
Ibuprofen
What type of XRay should be ordered?
Portable!! Done in AP format
If pt has relief of pain form NTG, does it indicate a cardiac process?
No, NTG was originally designed for GI stuff, used for acid reflux
Pt presents with chest pain, have normal EKG in ED and first troponin negative, painfree now can they be discharged?
No
What is the army risk stratification for prognosis?
Perform rapid determination of likelihood, 12 lead EKG within 10 mins
Troponin should be ordered for all pts with what?
Symptoms consistent with ACS
How often should troponin be ordered?
At presentation and 3-6 hours after onset
Obtain supplemental EKG leads V7-9 in who?
Pts with initial nondiagnostic EKG at intermediate/high risk for ACS
High likelihood history for ACS
Chest or left arm pain, prior documented angina
High likelihood on exam for ACS
Transient MR murmur, hypotension, diaphoresis, pulmonary edema, or rales
High likelihood EKG findings for ACS
New or transient ST segment deviation or T wave inversion in multiple precordial leads
What cardiac markers will be high for high likelihood of ACS?
Elevated troponin or CKMB
Intermediate likelihood for ACS for history
Chest or left arm pain or discomfort as chief symptoms
Intermediate likelihood on exam for ACS
Extracardiac vascular disease
Intermediate likelihood on EKG for ACS
Fixed Q waves
Intermediate likelihood for cardiac markers ACS
Normal
Low likelihood on history for ACS?
Probably ischemic symptoms in absence of any of the intermediate characteristics
Low likelihood on exam for ACS
Chest discomfort reproduced by palpation
Low likelihood on EKG for ACS
T-wave flattening or inversion in leads with dominant R waves or normal EKG
What risk score predicts the risk of death or MI at 30 days after admission
PURSUIT
What does TIMI predict?
Risk of all cause mortality, MI and severe recurrent ischemia requiring urgent revascularization within 14 days after admission
What does GRACE predict?
Risk of hospital death and post-discharge death at 6 months
What does HEART predict?
Prediction of combined endpoint of MI, PCI, CABG, or death within 6 weeks after presentation
Which scoring method is widely-used and most well known?
TIMI
TIMI
Better suited for pt with confirmed NSTEMI or known unstable angina
GRACE score
Risk stratification for patients with CONFIRMED ACS
HEART score
Better suited for undifferentiated pt with possible acute coronary syndrome
Which scoring method is better suited for pts with confirmed dNSTEMI or known unstable angina?
TIMI
Which scoring method is used for pts with confirmed ACS?
GRACE
Which scoring method is better suited for undifferentiated pts with possible ACS?
HEART score
What does HEART stand for for the scoring methods?
H: History E: EKG A: Age >65 R: Risk factors T: Troponin
What is the scoring for HEART?
0-3, discharge home
4-6 admit for clinical observation
7-10 early invasive strategies
What is the scoring for TIMI?
Low: 0-2
Intermediate: 3-4
High: 5-7
What is the treatment for possible ACS?
MONA, provocative testing within 72 hours (stress test)
What is the treatment for definite ACS (NSTEMI/UA)?
Aspirin, P2y12 inhibitors, anticoags, NTG, BB
Cath lab, stent, medically managed
What 3 things make up ACS?
- Unstable angina
- NSTEMI
- STEMI
What is the dosing for morphine?
2-4mg PRN
What is the dosing for antiplatelet therapy?
Aspirin 325 + Ticagrelor 180mg QD
What anticoag should be used for ACS?
Lovenox 1mg/kg/SC Q 12 hours
What BBs should be used for ACS?
Lopressor 5mg IV NPO or 25mg PO BID
What can be given for cholesterol management for ACS?
Lipitor (Atorvastatin 80mg)
What is the dosing for aspirin?
162-325mg
What is the dosing for Plavix (Clipidogrel)
300 or 600mg loading dose; 75mg/daily
What is the dosing for Brilinta (Ticagrelor)?
180mg loading dose; 90mg BID
What is the dosing for Enoxaparin (anticoag)
1mg/kg SC Q12hr
What is used to remember the discharge plan of action?
ABCDEFHI
Discharge plan of action
A: Aspirin, NTG, ACEI/ARB B: BB/BP Metoprolol C: Cholesterol + cigarette cessation Lipitor D: Diet and DM E: Education and exercise F: Follow up care H: hospitalization course and HTN management I️: immunizations
What is a thrombus?
Platelet aggregation + fibrin formation
Fibrin creates what?
Meshwork which allows for platelet to adhere together
What are the anti-platelet drugs?
ADP receptor antagonists, GP 2b/3a antagonists
What are the ADP receptor antagonists?
Plavix (Clopidogrel)
Effient (Prasugrel)
Brilinta (Ticagrelor)
What are the GP 2b/3a antagonists?
Reopro (Abciximab)
Aggrastat (Tirofiban)
Integrilin (Eptifibatide)
What are some other anti-platelet drugs?
Persantine (Dipyridamole), Aggrenox (Dipryidamole/ASA), Pletal (Cilostazol), Pentoxifylline
When is aspirin given for NSTEMI/UA?
Given prior to PCI full dose, then given low dose daily
When are the P2y12 inhibitors given with NSTEMI/UA?
Prior to PCI, then provided daily for up to one year
What is the exception to the P2y12 inhibitors?
Prasugrel, if used will be given right at PCI then daily for up to on year
When should the GP2b/3a be given for NSTEMI/UA?
Given during coronary angioplasty or stent placement in pts with ACS
What are the pros of choosing Ticagrelor?
Rapid and extensive platelet inhibition, reversible inhibition and rapid offset effect, less susceptible to genetic variation and DDIs, reduction in ischemia event rates vs clopidogrel, similar overal bleeding risk vs clopidogrel, proven efficacy regardless of txt strategy
What are the pros of choosing Prasugrel?
Rapid and extensive platelet inhibition, less susceptible to genetic variation and DDIs, reduction in ischemic event rates following PCI vs Clopidogrel, greatest efficacy in pts with DM and STEMI, once-daily dosing
What are the pros of choosing Clopidogrel?
Affordable, long hx of use, only agent with proven efficacy in pts undergoing thrombolytic, once-daily dosing
Cons of choosing Ticagrelor?
Expensive, increased risk of non-CABG surgery bleeding vs Clopidogrel, twice-daily dosing, dyspnea and ventricular pauses
What are the cons of choosing Prasugrel?
Expensive, high risk of major bleeding, especially in pts undergoing CABG, coronary anatomy should be defined by angiography before initiation, questionable utility it pts undergoing procedures other than PCI
What are the cons of choosing Clopidogrel?
Response variability, with a poor response assocaited with increased risk of thrombosis, susceptible to genetic variation and DDIs, questions regarding appropriate dosing
What is the function of anticoagulants?
Decrease formation of clots
Anticoagulants primary ADR
Increased bleeding risk, less clotting = more bleeding
What are the indirect thrombin inhibitors?
Heparin/Enoxaparin/Fondaparinux
How do indirect thrombin inhibitors work?
Work on anti-thrombin and inactivate factor Xa
What are the direct thrombin inhibitors?
Bivarlirudin (Angiomax)
Argatroban
Dabigatran (Pradaxa)
What must be monitored for UFH unfractionated heparin?
PTT; concern for HIT
Heparin
Rapid onset, IV administration, unpredictable anticoag effect, risk of HIT, greater bleeding risk than LMWH
Enoxaparin
No PTT monitoring, less protein binding, less inactivation, less HIT risk, SQ administration, simpler dose calcs, caution with elderly and renal impairment
