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