ACS: STEMI Flashcards
Requirements for STEMI on ECG
> /= 2 contiguous leads w/ ST-segment elevation >/= 2.5mm in men < 40 years
/= 2 mm in men >/= 40 years
/= 1.5mm in women in leads V2-V3 &/or >/= 1mm in other leads (in absence of LVH or LBBB
STEMI occurs due to what?
Exposure of circulating blood to cholesterol-rich material w/n plaque stimulates what? which has what effect?
erosion or sudden rupture of atherosclerotic plaque w/n wall of coronary artery
blood clotting (thrombosis); obstructs blood flow w/n the coronary artery
STEMI is most often caused by what?
As soon as blood supply is interrupted what occurs?
In animal models of experimental coronary artery occlusion, a ‘wave-front’ of what goes where?
In those who survive STEMI, infarcted muscle is gradually replaced by what? & extent of damage will determine what? & is a determinant of what?
complete & persistent occlusion of a coronary artery thrombus.
myocardial damage begins & the longer the blood supply is occluded, the greater the amount of heart muscle lost.
myocardial injury spreads from inner layer of heart muscle (subendocardial myocardium) to outermost layer (sub-epicardial myocardium), whereupon the infarction is then said to be ‘full thickness’.
fibrosis; contractility; heart failure & longer-term survival
NSTEMI may be a flow-limiting condition such as?
stable plaque
vasospasm-Prinzmetal angina
coronary embolism
coronary arteritis
Non-coronary injury to heart can also produce NSTEMI, these injuries can include?
cardiac contusion
myocarditis
presence of cardiotoxic substances
Conditions unrelated to coronary arteries or myocardium itself can lead to NSTEMI because increased O2 demand cannot be met. These conditions include?
Hypotension
HTN
Tachycardia
AS
PE
STEMI patient who is a candidate for reperfusion.
Initially seen at PCI-capable hospital, what are the following steps?
Send to cath lab for primary PCI; FMC-deve time </= 90 min
Diagnostic angiogram
1 of the following 3:
Medical therapy only
PCI
CABG
STEMI patient who is a candidate for reperfusion
Initially seen at a non-PCI capable hospital, what decision is initially made?
Patient is either transferred for primary PCI; DIDO </=30 min; FMC-device time ASAP and </= 120 min
or
Administer fibrinolytic agent w/n 30 min of arrival when anticipated FMC-device time > 120 min
STEMI patient who is a candidate for reperfusion
For patients who receive fibrinolytic agent, what is the next step?
Urgent transfer for PCI for patients w/ evidence of failed reperfusion or reocclusion
or
Transfer for angiography and revascularization w/n 3-24 hrs for other patients as part of an invasive strategy
Primary PCI & STEMI should be done when:
Ischemic symptoms are < how long?
Ischemic symptoms are < how long and contraindications to what?
the patient experiences what irrespective of time delay from MI onset?
12 hours
12 hours and contraindications to fibrinolytic therapy irrespective of time delay from FMC
Cardiogenic shock or acute severe HF
Placement of what is useful in primary PCI for patients w/ STEMI?
bare-metal stent or drug-eluting stent
Bare Metal Stent (BMS) should be used in patients w/?
high bleeding risk
inability to comply w/ 1 yr of DAPT
anticipated invasive or surgical procedures in the next yr
Drug-eluting stent (DES) should not be used in primary PCI for patients w/ STEMI who are what?
unable to tolerate or comply w/ a prolonged course of DAPT because of the increased risk of stent thrombosis w/ premature discontinuation of one or both agents
Anti-Platelet therapy to use for STEMI patients
Aspirin
P2Y12 inhibitors
IV GP IIb/IIIa receptor antagonists in conjunction with UFH or bivalirudin in selected patients
Aspirin
Loading dose before PCI?
daily maintenance dose? Preferred maintenance dose?
162-325mg
81-325mg daily
81mg daily
P2Y12 inhibitors
Loading doses
Clopidogrel 600 mg as early as possible or at time of PCI
Prasugrel 60 mg as early as possible or at time of PCI
Ticagrelor 180 mg as early as possible or at time of PCI
P2Y12 inhibitors
Maintenance doses and duration of therapy
DES placed: Continue therapy for?
1 year
clopidogrel 75mg daily
prasugrel 10mg daily
ticagrelor 90 mg twice a day
P2Y12 inhibitors
Maintenance doses and duration of therapy
BMS placed: continue therapy for?
1 year
Clopidogrel 75mg daily
prasugrel 10mg daily
ticagrelor 90mg twice a day
P2Y12 inhibitors
Maintenance doses and duration of therapy
DES placed what medications are continued beyond 1 year?
Patients w/ STEMI or prior stroke or TIA should receive?
clopidogrel, prasugrel, ticagrelor
prasugrel
IV GP IIb/IIIa receptor antagonists in conjunction with UFH or bivalirudin in selected patients
What medications are used here?
Abciximab
Tirofiban
Eptifibatide
IV GP IIb/IIIa receptor antagonists in conjunction with UFH or bivalirudin in selected patients
Abciximab loading dose? maintenance?
Tirofiban loading dose? maintenance?
Eptifibatide loading dose? maintenance? what is administered 10 min after loading dose?
0.25mg/kg IV bolus then 0.125mcg/kg/min (max 10mcg/min)
25mcg/kg IV bolus then 0.15 mcg/kg/min
180mcg/kg IV bolus then 2mcg/kg/min followed by a second 180mcg/kg bolus 10 min after initial loading dose
IV GP IIb/IIIa receptor antagonists in conjunction with UFH or bivalirudin in selected patients
Tirofiban dose reduction for CrCl < 30ml/min?
Eptifibatide dose reduction for CrCl < 50 ml/min? avoid giving this in patients on?
reduce infusion by 50%
reduce infusion by 50%; Hemodialysis
Anticoagulation therapy
UFH
With GP IIb/IIIa receptor antagonist planned what dose is administered to achieve therapeutic what?
W/o GP IIb/IIIa receptor antagonist planned what does is administered to achieve therapuetic what?
50-70 U/kg IV bolus to achieve therapuetic ACT
70-100 U/kg IV bolus to achieve therapuetic ACT
Anticoagulation therapy
Bivalirudin
what dose is given w/ or w/o prior treatment w/ UFH?
If needed an additional bolus of what can be given?
0.75mcg/kg IV bolus then 1.75 mcg/kg/hr infusion
0.3 mg/kg
Anticoagulation therapy
Bivalirudin
Reduce infusion to what w/ estimated CrCl < 30ml/min?
Preferred over UFH w/ GP IIb/IIIa receptor antagonist in patients w/ what?
1mg/kg/hr
high risk of bleeding
Anticoagulation therapy
What medication is not recommended as sole anticoagulant for primary PCI?
Fondaparinux
Recommendations for Reperfusion at a Non-PCI hospital:
Ischemic symptoms < how long?
Evidence of ongoing ischemia between how long after onset, and a large are of what, or the patient is experiencing what?
12 hours
12-24hours; myocardium at risk; hemodynamic instability
Recommendations for Reperfusion at a Non-PCI hospital:
Not recomended if ST depression except if?
or when associated w/ ST-elevation in lead?
true posterior (inferobasal) MI suspected
aVR
Doses of fibrinolytic therapy:
Streptokinase?
1.5 million units over 30-60 min IV
Doses of fibrinolytic therapy:
Alteplase (tPA)?
15mg IV bolus
0.75mg/kg IV over 30m min (up to 50 mg)
then 0.5mg/kg IV over 60 min (up to 35mg)
Doses of fibrinolytic therapy:
Tenectaplase
if < 60kg
if 60 to <70kg
if 70 to <80kg
if 80 to <90kg
if >/= 90kg
it is recommended to reduce dose to what in what patients?
30mg
35mg
40mg
45mg
50mg
half dose in patients >/= 75 years old
Doses of antiplatelet co-therapies w/ fibrinolytic therapy
Aspirin?
Starting dose of 150-300mg PO (or 75-250mg IV if PO is not possible), followed by maintenance dose of 75-100mg/day
Doses of antiplatelet co-therapies w/ fibrinolytic therapy
Clopidogrel loading dose then maintenance dose?
In patients >/= 75 years of age loading dose then maintenance dose?
Loading dose of 300mg PO followed by maintenance dose of 75mg/day.
75 mg followed by maintenance dose of 75mg/day
Doses of anticoagulant co-therapies w/ fibrinolytic therapy
Enoxaparin
In patients < 75 years of age
30 mg IV bolus followed 15 min later by 1mg/kg s.c. q12 hrs until revascularization or hospital dc for a max of 8 days.
the first 2 doses of s.c. should not exceed 100mg per injection
Doses of anticoagulant co-therapies w/ fibrinolytic therapy
Enoxaparin
In patients >/= 75 years of age
no IV bolus; start w/ first s.c. dose of 0.75mg/kg w/ max of 75mg per injection for the first two s.c. doses
Doses of anticoagulant co-therapies w/ fibrinolytic therapy
Enoxaparin
In patients w/ eGFR < 30ml/min/1.73cm2 regardless of age the s.c. doses are given at what frequency?
q 24 hrs
Doses of anticoagulant co-therapies w/ fibrinolytic therapy
UFH
Loading dose and maintenance?
Target aPTT?
60 IU/kg IV bolus w/ a max of 4000 IU follwed by IV infusion of 12 IU/kg w/ a max of 1000 IU/hour for 24-48 hours.
50-70s or 1.5-2.0 times that of control to be monitored at 3, 6, 12, and 24 hrs.
Doses of anticoagulant co-therapies w/ fibrinolytic therapy
Fondaparinux
Only given with what other medication?
loading dose then maintenance for how long?
Streptokinase
2.5mg IV bolus followed by a s.c. dose of 2.5mg daily up to 8 days or hospital dc
Indications for Transfer for Angio after fibrinolysis
Cardiogenic Shock or acute severe HF that develops after initial presentation
Intermediate- or high-risk findings predischarge noninvasive ischemia testing
Spontaneous or easily provoked myocardial ischemia
Failed reperfusion or reocclusion after fibrinolytic therapy
Stable patients after successful fibrinolysis before dc and ideally between 3 and 24 hrs
Absolute Contraindications for Fibrinolytic therapy
Any prior ICH
Known structural cerebral vascular lesion (eg, AVM)
Known malignant intracranial neoplasm (primary or metastatic)
Ischemic stroke w/n 3mo (except acute ischemic stroke w/n 4.5 hrs)
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed-head or facial trauma w/n 3 mo
Intracranial or intraspinal surgery w/n 2 mon
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase prior treatment w/n the previous 6 mo
Relative Contraindications for Fibrinolytic therapy
Hx of chronic, severe, poorly controlled HTN
Significant HTN on presentation SBP > 180 or DBP > 110)
Hx of prior ischemic stroke > 3 mo
Dementia
Known intracranial pathology not covered in absolute contraindications
Traumatic or prolonged (> 10min) CPR
Major surgery < 3wk
Recent (w/ 2-4wk) internal bleeding
Noncompressible vascular punctures
Pregnancy
Active peptic ulcer
PO anticoagulant therapy
Routine Medical Therapies: Beta-Receptor Antagonists
Indications
PO: All patients w/o contraindication; IV Patients with refractory HTN or ongoing ischemia w/o contraindication
Routine Medical Therapies: Beta-Receptor Antagonists
Dose/admin
Metoprolol Tartrate
Carvedilol
IV Metoprolol Tartrate
Metoprolol tartrate 25-50mg q6-12hr PO then transition over next 2-3days to BID dosing of metoprolol tartrate or to daily metoprolol succinate, titrate to daily dose of 200 mg as tolerated
Carvedilol 6.25mg BID , titrate to 25mg BID as tolerated
Metoprolol Tartrate IV 5mg q5min as tolerated up to 3 doses, titrate to HR and BP
Routine Medical Therapies: Beta-Receptor Antagonists
Avoid/Caution
Signs of HF
Low output state
Increased risk of cardiogenic shock
Prolonged First-degree or high-grade AV block
Reactive Airway disease
Routine Medical Therapies: ACE Inhibitors
Indications
For patients with anterior infarction
post-MI LV systolic dysfunction (EF</= 40%) or HF
May be given routinely to all patients w/o contraindications
Routine Medical Therapies: ACE Inhibitors
Dose/Admin
Lisinopril
Captopril
Ramipril
Trandolapril
2.5-5mg/d to start; titrate to 10mg/d or higher as tolerated
6.25-12.5 mg TID to start; titrate to 25-30mg TID as tolerated
2.5mg BID to start; titrate to 5mg BID as tolerated
test dose 0.5mg; titrate up to 4mg daily as tolerated
Routine Medical Therapies: ACE Inhibitors
Avoid/Caution
Hypotension
Renal failure
Hyperkalemia
Routine Medical Therapies: ARB
Indicaitons
For patients intolerant of ACE inhibitors
Routine Medical Therapies: ARB
Dose/Admin
Valsartan
20mg BID to start; titrate up to 160mg BID as tolerated
Routine Medical Therapies: ARB
Avoid/Caution
Hypotension
Renal failure
Hyperkalemia
Routine Medical Therapies: Statins
Indications
All patients w/o contraindications
Routine Medical Therapies: Statins
Dose/Admin
High dose atorvastatin 80mg daily
Routine Medical Therapies: Statins
Avoid/Caution
Caution w/ drugs metabolized via CYP3A4 fibrates
Monitor for myopathy, hepatic toxicity
Combine w/ diet and lifestyle therapies
Adjust dose as dictated by targets for LDL cholesterol and non-HDL cholesterol reduction
Routine Medical Therapies: Nitroglycerin
Indications
Ongoing chest pain
Hypertension and HF
Routine Medical Therapies: Nitroglycerin
Dose/Admin
0.4mg sublingual q5min up to 3 doses as BP allows
IV dosing to begin at 10 mcg/min; titrate to desired BP effect
Routine Medical Therapies: Nitroglycerin
Avoid/Caution
Avoid in suspected RV infarction
Avoid w/ SBP < 90 or if SBP >30mg below baseline
Avoid if recent (24-48 hr) use of 5-Phosphodiesterase inhibitors
Routine Medical Therapies: O2
Indications
Clinically significant Hypoxemia (SpO2 < 90%)
HF
Dyspnea
Routine Medical Therapies: O2
Dose/Admin
2-4 L/min via NC
Increase rate or change to face mask as needed
Routine Medical Therapies: O2
Avoid/Caution
COPD and CO2 retention
Routine Medical Therapies: Morphine
Indication
Pain
Anxiety
Pulmonary edema
Routine Medical Therapies: Morphine
Dose/Admin
4-8mg IV initially w/ lower doses in elderly
2-8mg q5-15min if needed
Routine Medical Therapies: Morphine
Avoid/Caution
Lethargic or moribund patient
Hypotension
Bradycardia
Known hypersensitivity
Class I Recs
Measurement of LVF
One of the strongest predictors of what?
Most commonly evaluated w/ what?
If significatn LV systolic dysfunction during initial hospitalization, LVF should be reevaluated when?
survival in patients w/ STEMI
contrast ventriculography during cardiac cath or TEE day 2-3
>/=40 days later to assess need for ICD therapy after allowance for recovery from myocardial stunning
Class I Recs
Type of rehab?
Education needed?
Cardiac rehab
med adherence, appointments, diet, exercise, smoking cessation
Complications of STEMI
Cardiogenic Shock
Definition:
Persistent Hypotension (SBP <90) despite adequate filling status w/ signs of hyoperfusion &/or if inotropes &/or mechanical support are needed to maintain SBP > 90
Complications of STEMI
Cardiogenic Shock
Causes
LV infarction or mechanical comps (papillary muscle rupture, vent septal rupture, free-wall rupture w/ tamponade, RV infarctions)
Complications of STEMI
Cardiogenic Shock
Occurs in what % of all STEMI cases & remains to be what?
6-10%; leading cause of death w/ in hospital mortality rates 50%
Complications of STEMI
Cardiogenic Shock
ID mechanism and correct any reversible causes such as?
hypovolemia
drug-induced hypotension
arrhythmias
tamponade
Complications of STEMI
Heart Failure
Treatment includes?
diuretics
vasodilators
inotropic agents when required
RAAS inhibitors as tol.
Beta blockers as tol.
Complications of STEMI
RV infarction
Occurs in ~ how many patients w/ what?
Associated w/?
Symptoms?
1/3 of patients w/ inferior STEMI d/t proximal occlusion of RCA
higher mortality risk
Hypotension, clear lung fields
elevated JVP are characteristic
Complications of STEMI
RV infarction
ECG shows?
Treatment?
1mm STEE in lead V1 & in R precordial lead V4R are most sensitive markers of RV injury
Maintenance of RV preload, reduction of RV afterload, restore NSR, Inotropic support, prn & immediate reperfusion if not already performed.
Complications of STEMI
RV infarction
AVOID what?
Nitrates and diuretics
Complications of STEMI
Mitral Regurgitation
Due to what?
S/Sx are?
Papillary muscle rupture or post-infarction LV remodeling w/ displacement of the papillary muscles, leaflet tethering, and annular dilatation
pulmonary edema & or Shock
Complications of STEMI
Mitral Regurgitation
Consider what while temporary stabilization is attempted w/ what?
Treatment?
urgent surgery; medical therapy & IABP
timely reperfusion, diuretics, afterload reduction
Complications of STEMI
Ventricle septal rupture
Usually c/w what?
what is necessary?
loud systolic murmur, HF, Shock
Emergency surgical repair
Complications of STEMI
Free-wall rupture
S/Sx?
Recurrent chest pain
ST-T wave changes rapid progression to HD collapse
Electromechanical dissociation
Death
Complications of STEMI
Free-wall rupture
Usually seen w/?
PSA w/ contained rupture & tamponade can be seen on what?
Consider what? Mortality rates as high as?
first MI, ant infarction, elderly, women
TTE
Emergency surgery; 60%
Complications of STEMI
Ventricular Arrhythmias
Due to what?
ICD is indicated before DC wwhen?
ongoing ischemia, HD & electrolyte abnormalities, reentry, enhanced automaticity
if sustained VT/VF > 48 hours after STEMI
Complications of STEMI
AF/SVT
Due to what?
excessive sympathetic stim
atrial stretch d/t LV or RV volume/pressure overload
Atrial infarction
pericarditis
electrolyte abnormalities
hypoxia
underlying lung disease
Complications of STEMI
Bradyarrhythmias
SB is common early after STEMI, Particularly with what location? d/t what?
Hold what?
Consider what for treatment?
inferior location d/t increased vagal tone
beta blockers
+/- atropine, temp pacing
Complications of STEMI
Bradyarrhythmias
AV block/BBB is associated w/ what?
AV block of varying degree and persistnet BBB develop in ~ what % of patients?
High-grade AV block & persistent BBB assoc. w/ what?
extent of infarction
5-7%
worse short- & long term prognosisT
Complications of STEMI
Bradyarrhythmias
Temp pacing is indicated for what?
symptomatic bradyarrhythmias unresponsive to medical treatment
Complications of STEMI
Pericarditis
Treatment?
ASA
Complications of STEMI
Thromboembolism
Prevention and treatment are similar to what?
other critically ill patients
Complications of STEMI
Bleeding
General rec is to transfuse when Hgb < what?
8mg/dL
Complications of STEMI
Renal complication?
Hyperglycemia: goal BG is what? Avoid what?
AKI
< 180mg/dL; hypoglycemia
