ACS pt2

Question 1

what are the short term goals of therapy?

Answer 1

restore blood flow
provide relief of ischemia (CP)
prevent morbidity
prevent re-occlusion of artery
prevent mortality

Question 2

what is the overview of treatment for a STEMI?

Answer 2

MONA
reperfusion (PCI vs fibrinolytic)
antiplatelets
anti-coag
BB
ACE inhibitor or ARB
statin
NTG prn

Question 3

what should be administered immediately upon arrival for ACS?

Answer 3

MONA

Question 4

what is dosing of morphine in MONA?

Answer 4

4-8mg IV followed by 2-8mg IV q5-15 minutes

Question 5

what is the SE of Morphine?

Answer 5

sedation
respiratory depression
NV

Question 6

how should NSAIDs be treated during hospitalization?

Answer 6

d/c home NSAID and do not initiate (besides aspirin)
can increase risk of MACE due to retention of sodium and water

Question 7

what should oxygen saturation be?

Answer 7

over 90%

Question 8

why should nitrates be utilized in MONA?

Answer 8

acts as a vasodilator
increases blood flow to heart

Question 9

what is the dosing for SL NTG in MONA?

Answer 9

0.3-0.4mg every 5 mintues for 3 doses for continuing ischemic pain

Question 10

what is the dosing for IV NTG in MONA?

Answer 10

start at 10mcg/min
titrate by 5mcg/min q5m with a max of 200mcg/min
for persistent ischemia, HF, or HTN

Question 11

what are the SE of NTG in MONA?

Answer 11

HA
hypotension

Question 12

what should be known with nitrate tolerance in early hospital care?

Answer 12

tolerance develops after 24hrs of continuous use
increase dose or change to intermittent admin

Question 13

when is combination use of nitrate and PDEi contraindicated?

Answer 13

within 24 hrs of sildenafil or vardenafil
within 48 hrs of tadalafil

Question 14

why is PDE and nitrate combination use contraindicated?

Answer 14

PDE cause vasodilation and will cause hypotension

Question 15

what is the dosing for aspirin in MONA?

Answer 15

162mg to 325mg chewable aspirin x1 dose
given to all pts without CI as soon as possible

Question 16

if a person took their aspirin 81 dose in the morning and then needed MONA, is it ok to give the loading dose?

Answer 16

yes it can be full of 325mg or 3 more baby aspirin of 81

Question 17

what are the types of reperfusion strategies?

Answer 17

procedures - PCI or CABG
pharmacological - fibrinolytic therapy

Question 18

what is a heart cath?

Answer 18

coronary angiography
shows which arteries in the heart have blockages

Question 19

what are the steps to a heart cath?

Answer 19

1. a catheter is inserted into the radial or femoral artery and fed up to the heart
2. dye in injected into the coronary arteries
3. x-ray picture is taken which will show blocked arteries
4. stent is placed to blocked arteries if needed

Question 20

what are the main arteries affected?

Answer 20

RCA - right coronary artery
LAD - left anterior descending
LCX - left circumflex

Question 21

what is a CABG?

Answer 21

coronary artery bypass graft
open herat surgery

Question 22

how is a CABG performed?

Answer 22

remove a vein or artery from another part of the body and attach to the heart to bypass the blocked arteries

Question 23

what is the main function of fibrinolytic drugs?

Answer 23

dissolve clots by blocking the conversion of plasminogen into plasmin

Question 24

what type of drugs are fibrinolytics?

Answer 24

tenecteplase (TNK-tPA)
reteplase (rPA)
alteplase (tPA)

Question 25

is one fibrinolytic preferred over the others?

Answer 25

no, all are expensive

Question 26

what is streptokinase (SK)?

Answer 26

first fibrinolytic that is less specific for fibrin thus not often used in the US

Question 27

when should a PCI be utilized in a STEMI?

Answer 27

administered to all eligible patients with. symptoms onset within the prior 12 hours preferred over fibrinolytic

Question 28

why is a PCI preferred over fibrinolytic therapy?

Answer 28

high rates of infarct artery patency lower rates of recurrent ischemia, reinfarction, and emergency repeat revascularization procedures lower rates of intracranial hemorrhage (ICH) lower rates of death

Question 29

what is the door to needle time for STEMI reperfusion?

Answer 29

within 30 minutes of arrival to hospital

Question 30

what is the door to balloon time for STEMi reperfusion?

Answer 30

within 90 minutes of arrival to hospital

Question 31

when is fibrinolytic therapy recommended over a PCI for a STEMI?

Answer 31

when over 120 minutes away from PCI capable hospital unless CI

Question 32

when should fibrinolytic therapy be administered once arrival to non-PCI capable hospital?

Answer 32

within 30 minutes

Question 33

what is the recommendation for reperfusion therapy in NSTEMI or UA?

Answer 33

no fibrinolytics ischemia guided strategy vs early invasive strategy

Question 34

what is ischemia guided strategy?

Answer 34

used in NSTEMI or UA also known as medical management when a patient is treated with evidence-based medications and no heart catheterization

Question 35

when is a heart catheterization indicated in ischemia guided strategy?

Answer 35

when there is refractory or recurrent ischemic symptoms or hemodynamic instability

Question 36

what is the early invasive strategy?

Answer 36

coronary angiography and/or revascularization in NSTEMI or UA high risk patients

Question 37

what NSTEMI or UA patients have a preference for early invasive strategy?

Answer 37

refractory angina new-onset HF rising troponin new ST-segment depression