ACS Part 2 Flashcards
Short term goals of therapy for ACS
-Restore blood flow
-Provide relief of ischemia
-Prevent morbidity
-Prevent re-occlusion of artery
-Prevent mortality
Initial recommended tests for a patient suffering from ACS
-12-lead ECG within 10 minutes of arrival
-Serial troponin levels 3-6 hours after symptoms onset
What is MONA?
-Morphine
-Oxygen
-Nitrogen
-Aspirin
What is the initial dose of morphine for a patient with ACS?
4-8 mg IV, followed by 2-8 mg IV every 5-15 minutes
Why give morphine to patients with ACS?
To relieve chest pain
Side effects of morphine
-Sedation
-Respiratory depression
-Nausea/vomiting
Why should NSAIDs be avoided in patients with ACS?
Lead to sodium and water retention leading to an increased risk of MACE
What is the target oxygen saturation
Over 90%
Why is nitroglycerin used in patients with ACS?
It is a vasodilator that increases blood flow to the heart
What is the dose of SL nitroglycerin recommended for a patient with ACS?
0.3-0.4 mg every 5 minutes
What is the dose of IV nitroglycerin recommended for a patient with ACS?
Start at 10 mcg/min then titrate up every 5 minutes to a max dose of 200 mcg/min
Side effects of nitroglycerin
-Headache
-Hypotension
Is transdermal nitroglycerin suitable for the treatment of ACS?
NO the onset of action is not rapid enough
When does nitroglycerin tolerance develop?
Over 24 hours of continuous use
What do you do when a patient begins to experience nitroglycerin tolerance?
increase the dose or change to intermittent administration and aim for more than 10 hours a day of nitroglycerin free period
Which drug are nitrates most contraindicated in?
phosphodiesterase inhibitors
How long after taking sildenafil is it safe to take nitroglycerin?
24 hours
How long after taking vardenafil is it safe to take nitroglycerin?
24 hours
How long after taking tadalafil is it safe to take nitroglycerin?
48 hours
Why are nitrates contraindicated with phosphodiesterase inhibitors?
Both medications cause vasodilation which will cause severe hypotension
What dose of aspirin should you give to a patient with ACS?
162-325 mg chewable aspirin for one dose
Which ACS patients are eligible to take aspirin?
ALL patients without contraindications
Can an enteric coated aspirin be used?
YES however it must be chewed to allow quicker absorption
If a patient already took a maintenance dose of aspirin that day would you still give a loading dose?
YES you would give three additional 81 mg tablets for a total dose of 324 mg
When should a patient receive MONA?
As soon as possible
Types of reperfusion strategies
-Percutaneous coronary intervention (PCI)
-Coronary artery bypass graft (CABG)
-Fibrinolytic therapy
What is a coronary angiography?
-A catheter is inserted into the radial and femoral artery and fed up to the heart
-Dye is injected into the coronary arteries
-An x-ray picture is taken and shows the blocked arteries
-A stent is placed in blocked arteries, if needed
What is a PCI?
This procedure uses a small balloon to reopen a blocked artery to increase blood flow. A stent is placed, if needed, to keep the artery open long-term
What is a CABG?
A vein or artery from another part of the body is removed and attached to the heart to “bypass” the blocked artery/arteries
What are the types of fibrinolytics?
-Tenecteplase (TNK-tPA)
-Reteplase (rPA)
-Alteplase (tPA)
Dosing for tenecteplase
-< 60 kg: 30mg
-60-69 kg: 35 mg
-70-79 kg: 40 mg
-80-89 kg: 45 mg
-90 or more kg: 50 mg
Dosing for reteplase
10 units for 2 doses 30 minutes apart
Dosing for alteplase
-15 mg bolus
-Then 0.75 mg/kg over 30 mins (max:50 mg)
-Then 0.5 mg/kg (max: 35 mg) over 60 min
-Max total dose of 100 mg
Contraindications for fibrinolytics
-History of intracranial hemorrhage
-Ischemic stroke within the past 3 months
-Presence of cerebral vascular malformation or a primary metastatic intracranial malignancy
-Aortic dissection
-Active bleeding
-Significant closed-head or facial trauma within the past 3 months
Why is a PCI preferred over fibrinolytics?
-Higher rates of infarct artery patency
-Lower rates of ischemia, reinfarction, and emergency repeat revascularization procedures
-Lower rates of intracranial hemorrhage
-Lower rates of death
Who should receive reperfusion therapy?
All eligible STEMI patients whose symptoms began in the past 12 hours
What is the door to needle time
Within 30 minutes of hospital arrival
What is the door to balloon time
Within 90 minutes of hospital arrival
When are fibrinolytics recommended?
STEMI patients who are not at a PCI-capable hospital and more than 120 minutes away from a PCI-capable hospital
What reperfusion methods are recommended for patients with NSTEMI/UA?
-Early invasive = coronary angiography +/- revascularization
-Ischemia-guided = “medical” management
When is early invasive reperfusion recommended?
-Preferred for patients with high-risk features such as:
-Refractory angina
-New-onset heart failure
-Rising troponin
-New ST-segment depression
