ACS: NSTEMI Flashcards
Type of MI
Atherosclerotic plaque rupture, ulceration, fissure, ore erosion with resulting intraluminal thrombus in >/=1 coronary arteries leading to decreased mocardial blood flow &/or distal embolization & subsequent myocardial necrosis
Type I
Type of MI
myocardial necrosis when condition other than coronary plaque instability causes imbalance b/t myocardial oxygen supply & demand (hypotension, HTN, tachy/bradyarrhythmias, anemia, hypoxemia, coronary artery spasm, spontaneous coronary artery dissection (SCAD), coronary embolism, & myocardial dyfxn)
Type 2
Type of MI
death when biomarkers not available & types 4 & 5 MI (r/t PCI & CABG)
Type 3
Differential Dx of ACS in setting of acute CP
Cardiac
Myopericarditis
Cardiomyopathies
Tachyarrhythmias
Acute HF
HTN emergency
Aortic valve stenosis
Takotsubo syndrome
coronary spasm
cardiac trauma
Differential Dx of ACS in setting of acute CP
Pulmonary
PE
Tension PTx
Bronchitis, Pneumonia
Pleuritis
Differential Dx of ACS in setting of acute CP
Vascular
Aortic dissection
Symptomatic aortic aneurysm
Stroke
Probability of Ischemia
Central
Pressure
Squeezing
Gripping
Heaviness
Tightness
Exertional/stress-related
Retrosternal
High
Probability of Ischemia
Left sided
Dull
Aching
Moderately High
Probability of Ischemia
Stabbing
Moderate
Probability of ischemia
Right-sided
Tearing
Ripping
Burning
Mild
Probability of Ischemia
Sharp
Fleeting
Shifting
Pleuritic
Positional
Low
Summary of Recommendations for Early Hospital Care
Administer Supplemental O2 only with what?
SpO2 < 90%
Respiratory distress
Other high-risk features for hypoxemia
Summary of Recommendations for Early Hospital Care
Administer sublingal NTG how often and how many doses for continuing ischemic pain and then assess the need for what?
5min x 3
IV NTG
Summary of Recommendations for Early Hospital Care
Administer IV NTG for?
persistent ischemia
HG
or HTN
Summary of Recommendations for Early Hospital Care
Nitrates are contraindicated with recent use of what?
A phosphodiesterase inhibitor
Summary of Recommendations for Early Hospital Care
IV morphine sulfate may be reasonable for what?
continued ischemic CP despite maximally tolerated anti-ischemic medications
Summary of Recommendations for Early Hospital Care
Initiate oral beta blockers w/n 24 hours in the absence of?
HF
low-output state
risk for cardiogenic shock
other contraindications to BB use
Summary of Recommendations for Early Hospital Care
Use of what is recommended for beta-blocker therapy w/ concomitant NSTE-ACS, Stabilized HF, and reduced systolic fxn?
sustained-release metoprolol succinate
carvedilol
bisoprolol
Summary of Recommendations for Early Hospital Care
Administer initial therapy with non-DHP CCBs w/ recurrent ischemia and contraindications to BB in the absence of what?
LV dysfxn
increased risk for cardiogenic shock
PR interval > 0.24s,
second or third degree AV block w/o a cardiac pacemaker
Summary of Recommendations for Early Hospital Care
Administer oral non-DHP CCB w/ recurrent ischemia after use of what in the absence of contraindications?
BB
Nitrates
Summary of Recommendations for Early Hospital Care
Long-acting CCB and nitrates are recommended for patients w/ what?
coronary artery spasm
Summary of Recommendations for Early Hospital Care
Initiate or continue high-intensity statin therapy in patients w/ what?
no contraindications
Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
Aspirin
Non-enteric-coated aspirin to all patients promptly after presentation?
Aspirin maintenance dose continued indefinitely?
162-325mg
81-325mg
Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
P2Y12 inhibitors: Clopidogrel
Loading dose followed by daily maintenance dose in patients unable to take aspirin?
75mg (loading dose 300-600mg)
Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
P2Y12 inhibitor, in addition to ASA, for up to 12 mo for patients treated initially w/ either an early invasive or initial ischemia guided strategy?
Clopidogrel - loading dose of 300-600 mg, then 75mg daily
Ticagrelor - 180 mg loading dose, then 90 mg BID
Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
GP IIb/IIIa inhibitor in patients treated with an early invasive strategy and DAPT w/ intermediate/high-risk features (eg positive troponin)
Preferred options are?
Eptifibatide
Tirofiban
Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
Parenteral anticoagulation and fibrinolytic therapy
SC enoxaparin for duration of hospitalization or until PCI is performed
1mg/kg SC q 12h (reduce dose to 1mg/kg/d SC in patients w/ CrCl < 30ml/min)
Initial 30 mg IV loading dose in selected patients
Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
Parenteral anticoagulation and fibrinolytic therapy
Bivalirudin until diagnostic angiography or PCI is performed in pts w2/ early invasive strategy only
Loading dose 0.1 mg/kg followed by 0.25mg/kg/h
Only provisional use of GP IIb/IIa inhibitor in patients also treated w2/ DAPT
Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
Parenteral anticoagulation and fibrinolytic therapy
IV UFH for 48h or until PCI is performed
Initial loading dose 60 IU/kg (max 4000 IU) w/ initial infusion of 12 IU/kg/h (max 1000 IU/h)
Adjust to therapeutic aPTT range
What scoring system provides an estimation of the 6mo mortality for patients w/ ACS based on patients risk factors?
The GRACE scoring system
Factors Associated w/ Appropriate Selection of Early invasive strategy or Ischemia-guided strategy in patients w/ NSTE-ACS
Immediate invasive (w/n 2 hr)
Refractory angina
S/sx of HF or new or worsening mitral regurge
Hemodynamic instability
Recurrent angina or ischemia at rest or w/ low-level activites despite intensive medical therapy
Sustained VT or VF
Factors Associated w/ Appropriate Selection of Early invasive strategy or Ischemia-guided strategy in patients w/ NSTE-ACS
Ischemia-guided strategy
Low-risk score (eg, TIMI [0-1], GRACE [<109])
Patient or clinician preference in the absence of high-risk features
Factors Associated w/ Appropriate Selection of Early invasive strategy or Ischemia-guided strategy in patients w/ NSTE-ACS
Early invasive (w/n 24hr)
None of the above, but GRACE risk score > 140 Temporal change in Tn
New or presumably new ST depression
Factors Associated w/ Appropriate Selection of Early invasive strategy or Ischemia-guided strategy in patients w/ NSTE-ACS
Delayed invasive (w/n 25-72h)
None of the above but DM & Renal insufficiency (GFR < 60mL/min/1.73msquared)
Reduced LV Systolic fxn (EF <40%)
Early post-infarction angina
PCI w/n 6mo
Prior CABG
GRACE risk score 109-140; TIMI score >/= 2
In patients who have received prior anticoagulation therapy during PCI
Enoxaparin
For prior treatment w/ enoxaparin, if last SC dose was administered 8-12 h earlier or if < 2 therapeutic SC doses of enoxaparin have been administered an IV dose of enoxaparin at what dose should be given?
0.3mg/kg
In patients who have received prior anticoagulation therapy during PCI
Enoxaparin
If the last SC dose was administered w/8 h, what dose should be given?
no additional enoxaparin should be given
In patients who have received prior anticoagulation therapy during PCI
Bivalirudin
For patients who have received UFH, wait 30 min then give what loading dose and what infusion dose?
Loading dose - 0.75mg/kg
Infusion dose - 1.75mg/kg/h
In patients who have received prior anticoagulation therapy during PCI
Bivalirudin
For patients already receiving bivalirudin infusion give how much additional loading dose and increase infusion dose to how much?
loading dose - 0.5mg/kg
infusion dose - 1.75mg/kg/h
In patients who have received prior anticoagulation therapy during PCI
UFH
IV GPI planned: additional UFH as needed (eg 2000-5000 U) to acieve ACT of what?
200-250s
In patients who have received prior anticoagulation therapy during PCI
UFH
No IV GPI planned: additional UFH as need (eg 2000-5000 U) to achieve ACT of ____ for HemoTec, or ____ for Hemochron
250-300s
300-350s
NSTE-ACS Definite or Likely
Ischemia-Guided Strategy
Initiate what?
DAPT and Anticoagulant therapy
NSTE-ACS Definite or Likely
Early Invasive Strategy initiate what?
Can consider what if high risk?
DAPT and anticoagulation therapy
GPI
NSTE-ACS Definite or Likely
If medical therapy is ineffective and patient goes for PCI w/ Stenting Initiate/continue what?
GPI indicated if not treated with what at time of PCI?
DAPT and anticoagulation therapy
Bivalirudin
NSTE-ACS Definite or Likely
If medical therapy is ineffective and patient goes for CABG initiate/continue what? and discontinue what?
ASA therapy
P2Y12 inhibitor and GPI
