ACS maintenance Flashcards
goals of maintenance tx
-control CAD risk factors
-prevent MACE (reinfarction, stroke, HF)
-improve QOL
Maintenance therapy for ACS
-DAPT
-BB
-Statin
-ACE/ARB
-NTG prn
Beta-blockers for ACS
-initiate within first 24 hours of ACS
-list them?
-use CCB if CI
-consider IV only when HTN or ongoing ischemia (metoprolol tartrate 5mg IV q5min up to 3 doses)
BB selectivity
BB and cocaine
-consider non-selective BB like carvedilol (a-blockade)
-cocine stimulates a and B receptors so if u give BB, cocaine has way more alpha stimulation = HTN complications or inc troponin
BB and HF
-avoid starting or inc BB during acute HF exacerbation (pulmonary edema)
-BB slow down heart and can dec cardiac output
-safe to continue maintenance BB though, keep at home dose, dont inc, might be worse if you d/c
BB counseling
-lower BP and HR (dizziness)
-keep using even if BP is controlled, goal is to prevent heart attacks
-hypoglycemia sx masked except cold sweat
CCB use in ACS
-if contraindicated to BB
-use non-DHPs: diltiazem and verapamil
Do not use CCBs in patients with:
-LV dysfunction
-inc risk for cardiogenic shock
-PR interval >0.24s
-second or third degree AV block without cardiac pacemaker
Statins for ACS
-atorvastatin 40-80mg
-Rosuvastatin 20-40mg
-HMG-CoA-reductase inhibitors
Statin patient counseling
-lifelong
-keep taking even if cholesterol is normal
-most common side effect is muscle pain
ACEi for ACS
-all patients
-esp HFrEF, DM, CKD
-dec mortality and MACE
-caution in 1st 24h = hypotension or renal dysfunction
-may sub for ARB
ACE drugs
-captopril
-lisinopril
-ramipril
-trandolapril
-valsartan (ARB) 20-160mg
When to avoid ACE
-hypotension/shock
-bilateral renal artery stenosis or worsening of renal function w ACE/ARB exposure
-acute renal failure
-drug allergy/angioedema
ACE monitoring
-inc in SCr bc efferent arteriole vasodilation
-inc potassium (hyperkalemia)
-drop in BP (hypotension)
-angioedema (life-threateneing swelling of face and lips)
ACE pt counseling
-dec BP (dizziness)
-may cause dry cough in months, call dr and switch meds
-angioedema = STOP taking call 911
maintenance DAPT
-aspirin 81mg + P2Y12 12 months
Triple antithrombotic tx after ACS
-some pt require oral anticoagulation in addition to DAPT
-pt w AFib, VTE (DVT or PE), mechanical heart valve
-minimize duration
-in pt w AF: d/c aspririn 1-4 weeks after PCI and continue P2Y12 inhibitor and anticoagulant (NOAC preferred over warfarin to dec bleeding risk)
Nitroglycerin
-0.3-0.4mg SL NTG q5min for chest pain
-keep with you!!
-keep in airtight amber glass (refill q3-6 months)
-prime SL spray (5 for nitrolingual, 10 sprays for nitromist)
-spray under tongue
Prevention of recurrent MI
-stop smoking
-adherence to meds
-control BP
-healthy diet and exercise
