ACS Part 2 Flashcards by Corey Brend

Short term goals of therapy for ACS

-Restore blood flow
-Provide relief of ischemia
-Prevent morbidity
-Prevent re-occlusion of artery
-Prevent mortality

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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

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What is MONA?

-Morphine
-Oxygen
-Nitrogen
-Aspirin

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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

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Why give morphine to patients with ACS?

To relieve chest pain

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Side effects of morphine

-Sedation
-Respiratory depression
-Nausea/vomiting

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Why should NSAIDs be avoided in patients with ACS?

Lead to sodium and water retention leading to an increased risk of MACE

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What is the target oxygen saturation

Over 90%

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Why is nitroglycerin used in patients with ACS?

It is a vasodilator that increases blood flow to the heart

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What is the dose of SL nitroglycerin recommended for a patient with ACS?

0.3-0.4 mg every 5 minutes

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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

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Side effects of nitroglycerin

-Headache
-Hypotension

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Is transdermal nitroglycerin suitable for the treatment of ACS?

NO the onset of action is not rapid enough

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When does nitroglycerin tolerance develop?

Over 24 hours of continuous use

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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

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Which drug are nitrates most contraindicated in?

phosphodiesterase inhibitors

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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