ACSFC Flashcards
Classic signs and sx of ACS
chest pain, diaphoresis, N/V, numbness/tingling sensation, SOB, dyspnea. Pain is not relieved by NTG spray or SL
Diagnosis: UA/NSTEMI/STEMI
UA: Chest pain (10/10) crushing chest pain
NSTEMI: Chest pain & + biomarkers Troponin I or T, CK-MB
STEMI: Chest pain, + biomarkers, ECG changes (1mm ST elevations
Treatment of UA/NSTEMI and STEMI
UA/ NSTEMI: MONA + GAP-BA
STEMI: MONA + GAP-BA + thrombolytics
Risk factors for ACS
Age men >45 women >55 or early hysterectomy
Family hx of coronary events B4 age 55 in men and 65 in women. Smoking, HTN, hyperlipidemia, diabetes, chronic angina, known CAD
what does MONA + GAP-BA stand for?
Pre hospital care: Morphine
Oxygen
Nitrates
Aspirin
ER care: Glycoprotein IIb/IIIa inhibitors
Anticoagulants
P2Y12 inhibitors
Beta Blocker
ACEIs
Morphine
decreases O2 demand; vasodilator. used for chest discomfort. dosed 2-5mg IV PRN. s/e bradycardia, hypotension, respiratory depression, sedation.
Oxygen
give in pts O2 sat <90%. if cyanosis or respiratory distress
Nitrates, what types? when Do not use?
Acute SL or spray. take 1 dose if not better call 911. hospital IV drip to decrease chest pain. do not use if SBP <50
Aspirin
325mg chew if EC. Take indefinitely if tolerated but 81 mg dose
integrilin
eptifibatide
ReoPro
abciximab
Glycoprotein IIb/IIIa inhibitors MOA & CI
reversibly block platelet aggregation on binding site of fibrongen, von willibrand factor. , preventing thrombosis. C.I. active internal bleeding, uncontrolled BP S/E: Bleeding, thrombocytopenia esp abciximab), hypotension. Administration: Do not shake vial upon reconstitution.
Abciximab (Reopro) CI: w/ administration what should u do? when does plt function return to normal after d/c
C.I. w/ hx of CVA w/in 2 years. hypersensitivity to murine proteins, and thrombocytopenia. Must filter with administration. Platelet fxn returns in 24-48hrs after d/c abciximab
Eptifibatide (Integrilin)
CI:
what CrCL to reduce dose
CI in hx of stroke with 30 days or any hx of hemorrhagic stroke, renal dysfunction-reduce infusion rate by 50% in pts Crcl <50ml/min
Tirofiban (Aggrastat)
CI in hx of stroke with 30 days or any hx of hemorrhagic stroke, renal dysfunction-reduce infusion rate by 50% in pts Crcl <30ml/min
P2Y12 inhibitors MOA, lifespan of drugs? which one has fast onset and offset? lifespan of drugs
which one has fast onset and offset
inhibit platelet activation and aggregation on the ADP receptors on platelets. Clopidogel and Prasugrel are prodrugs and have irreversible binding to the receptor. Lifespan of platelet is 7-10days Ticagrelor had reversible binding and faster on and off set
Clopidogrel (Plavix)
dose
bbw
adr
when d/c in pts doing cabg?
LD: 300-600mg MD: 75mg d BBW: poor metabolizers of 2C19 allele b/c PRODRUG*. S/E- bleeding, TTP (rash), bruising. Do not start in pts likely to undergo CABG. D/C 5 days prior to any major surgery
Prasugrel (Effient)
do not use in what age
why not use in that age
when do you start givign after a pci has been given.
LD: 60mg MD: 10mg, 5mg 75 unless they have DM or MI. D/C 7 days prior to major surgery. if PCI, give dose no later than 1 hr
Ticagrelor (Brilinta)
LD: 180mg/d MD: 90mg bid. use w/ ASA 75-100mg. BBW: sever fatal bleeding. S/E bleeding, dyspnea. D/C 5 days prior to major surgery. MD of ASA above 100mg reduce effectiveness of ticagrelor-only 81 mg. used for just ACS pts
When do you use BB and CCB
use within the 1st 24hrs to prevent cardiac remodeling
When to use thrombolytics per guidelines?
*when you can’t perform PCI w/in 90 mins.
use thrombolytics within 12 hrs from sx onset.Door to balloon time should be <30mins (thrombolytics) if at a hospital. but thrombolytics should be beneficial as long as under 12 hrs of symptom onset.
Thrombolytics MOA
cause fibrinolysis by binding to fibrin in a thrombus (clot) and convertingp entrapped plasminogen to plasmin.
Thrombolytics
Alteplase (t-PA)
Reteplase (r-PA
Tenecteplase (TNKase)
Streptokinase (Streptase)
S/E intercranial bleeding, hypotension, fever, bleeding
Medications to avoid with ACS
NSAIDs, IR DHP (nifedipine) should not be used in the absence of b-blockers. IV fibinolytics is not indicated in pts w/o ST-segment elevation
What drugs should you avoid with clopidogrel?
cimetidine, azole antifungals, omeprazole, fluoxetine, fluvoxamine etc
What drugs should be continued when pt goes for CABG?
ASA, UFH
What drugs should be discontinued when pt goes for CABG?
Clopogrel and ticagrelor 5 days b4 and Prasagel 7 days B4. if enoxaparin: 12-24hrs B4, if fonda: 24hrs b4, if bivalirudin 3 hrs b4
Long term meds for status post MI?aspirin- bare metal stent, sirolimus eluting stent, and paclitaxel eluting stent.
ASA indefinitely 81mg, if stent placement use ASA 325mg: 1mos bare metal stent, 3 mos sirolimus- eluting stent, 6mos w/ paclitaxel-eluting.
Plavix 75mg or effient 10mg for at least 1mon and up to 12 mos to 15 mos if drug eluting stentstent.
NTG SL or spray, BB d, ACE-I < 40%, statin, warfarin, tylenol for pain relief.
acs cause
imbalance b/w oxy demand and supply due to athersclorosis–> infarction. this causes release of markers:
what markers are released after infarketion
troponin I or T and CK and Myocardial band (MB).
morphine moa
arteriolar and venous dilation , prompts a decrease in o2 demand and pain relief.
morphine adr
hypotension bradycardia, n/v/ resp depression
GAP-BA
- GP II/III receptor antagonist
Anticoagulant
P2y12 inhinitors (plavix, prasugrel)
Beta blockers
Ace inhibitors
glycoprotein II/II antag for who
those doing an intervention PCI or stent
which agents are glycoprotein
abciximab, eptifibatide, tirofab
**rmr eptifibatidde seen in the cath lab at slu
what are p2y12 inhibitors
clopidogrel or prasugrel (ticagrelor) - for all pts loading dose followed by maintenance dose unless undergoing cabg
medications to avoid is acs
nsaids including cox2
dhp clacium cahannel blockers
iv fibrinolytic therpay is not indicated.
prasugrel for who
reduction of thrombotic events in pts with ACS who have DONE A PCI
ticagrelo drug interaction what common drugs
simvastatin dont use more than 40 mg.
STEMI diagnosis
chest pain > 20 mins, shows ST elevation on ECG, toponin T or I elevation/CK MB elevation
fibrinolytics CI
History of CVA-
recent intracranial or intraspinal surgery w/in last 3 months
intracranial neoplasm
ischemic stroke w/in 3 months!!
aortic dissection
uncontrolled htn
careful if***SBP> 185
fibrinolytics side effects
bleeding, hypotension, intracranial hemorrage, fever*** thats why intracranial neoplasm and htn stuff are CI!!
plavix how often take
once daily
if you are using aspirin, clopidogrel and warfarin all three agents then maintain INR at
2-2.5
you would add on warfarin if afib or IF pt has LV thrombus.
