ACS pt2 Flashcards
What are the goals of therapy for ACS?
- Restore blood flow
- Provide relief of ischemia
- Prevent morbidity/mortality
- Prevent re-occlusion of artery
What are the initial recommendations within arrival to ED?
- 12 lead ECG
- Serial troponin levels
What is 12 lead ECG?
- Done within 10 min of arrival at an emergency facility
- If initial is not diagnostic but pt is symptomatic and has signs of ACS, do an ECG every 15-30 min for the 1st hour
When should serial troponin levels be taken?
Troponin levels should be obtained at presentation and 3-6 hrs after sx onset
What does MONA stand for?
Morphine, oxygen, NTG, ASA
When is MONA initiated?
Immediately upon arrival
What is morphine used for?
Relieve chest pain
What dose of morphine is given?
4-8 mg IV, followed by 2-8 mg IV q5-15 min
What are the SEs of morphine?
Sedation, respiratory depression, nausea/vomiting
Why must all NSAIDs except ASA be avoided during hospitalization and use with morphine?
NSAIDs lead to sodium and water retention which increases risk of MACE
What is the goal oxygen saturation?
To maintain pt’s oxygen saturation >90%
What is NTG used for?
To increase blood flow to the heart (vasodilator)
What is the dose of SL NTG?
0.3-0.4 mg q5min x 3 for ischemic pain
What is the dose of IV NTG?
- Start at 10 mcg/min
- Titrate by 5 mcg/min q5min (MAX: 200 mcg/min)
What are the SEs of NTG?
Headache, hypotension
Why is transdermal NTG not recommended?
- Onset of duration is not rapid enough
- Takes 15-60 min
What is a problem with NTG?
Tolerance develops after >24 hours of continuous use
How is NTG tolerance resolved?
- Increase dose or change to intermittent admin
- Aim for >10 hours of a NTG free period/day
What dose of ASA is given in MONA?
- 162-325 mg; 325 mg is most common loading dose
- Given to ALL pts w/o CI to ASA
Can enteric coated ASA be used?
- Yes
- Must be chewed
Is ASA still given even if pt has taken a dose of ASA before hospitalization?
- Yes
- Pt is given dose that is the difference of 325 mg and what the pt has already taken
How is a coronary angiography done?
- Cath is inserted into radial and femoral artery and fed up to heart
- Dye is injected into coronary arteries
- X-ray pic is taken and that shows blocked arteries
- Stent is placed into blocked arteries, if needed
What is a percutaneous coronary intervention (PCI)?
- Uses a small balloon to reopen a blocked artery to increase blood flow
- A stent is placed, if needed, to keep artery open long term
What is a coronary artery bypass graft (CABG)?
- Open heart surgery
- Vein or artery from another part of body is removed and attached to heart to “bypass” blocked artery/arteries
What are fibrinolytics?
Clot busters
What are the drugs in fibrinolytics class?
- Tenecteplase
- Reteplase
- Alteplase
How is tenecteplase dosed?
By pt’s actual weight
When should reperfusion therapy be administered in STEMI pts?
Reperfusion therapy should be admin to ALL eligible STEMI pts whose sxs began in past 12 hours
Why is PCI the preferred reperfusion therapy option over fibrinolytics?
- Higher rates of infarct artery patency
- Lower rates of recurrent ischemia, reinfarction, emergency repeat revascularization procedures
- Lower rates of intracranial hemorrhage
- Lower rates of death
What is the door to needle time in STEMI pts?
Fibrinolytics should be admin within 30 min of hospital arrival
What is the door to balloon time in STEMI pts?
PCI should occur within 90 min of hospital arrival
What reperfusion therapy should be done if pt is at a non PCI capable hospital?
Fibrinolytic therapy is recommended
When is fibrinolytic therapy recommended for a pt at a non PCI capable hospital?
> =120 min away from PCI capable hospital
What is early invasive reperfusion therapy that’s for UA/NSTEMI pts?
Coronary angiography +/- revascularization
When is early invasive therapy preferred?
For pts with high risk features:
- Refractory angina
- New onset HF
- Rising troponin
- New ST segment depression
What is ischemia guided reperfusion therapy that’s for UA/NSTEMI pts?
“Medical” management
What does ischemia guided therapy consist of?
- Tx w evidence-based meds
- No heart cath (unless pt has refractory or recurrent ischemic sx or becomes hemodynamically unstable)
