Acute Cardio Flashcards
when do you use TIMI score?
NSTEMI 30day and 1yr death risk
how to calculate TIMI score?
> 65 yo
3+ risk factors for CAD
prior coronary stenosis 50% or >
STEMI
angina twice in past 24 hrs
asa in previous 7 days
elevated cardiac biomarker
0-2 = low risk
3 = intermediate
4+ = high risk
TIMI score cutoff to see benefit of treatment
3 or more
time goals with STEMI
90mins PCI from first medical contact
if cannot do PCI in 120mins then door to needle of 30 mins for lytic therapy
reasons MONA should get rid of morphine
morphine may slow absorption of anticoagulants
increased risk of death
reduces time to peak antiplatelet activity
contraindications to Nitro drip
SBP < 90 or 30 less than baseline
HR < 50 or >100 w/o symptomatic HR
Right ventricular infarct
PDE5 inhibitors
beta blockers for HFrEF
toprol
carvedilol
bisoprolol
Which P2Y12 should not be used in strike or TIA?
Prasugrel
Which P2Y12 for ischemia guided therapy in NSTEMI?
Plavix or Effient
ACS p2Y12 dosing
Plavix 600mg, then 75 daily
Effient 180mg then 90mg BID
Prasugrel 60mg then 10mg daily
Which P2Y12 is reversible bc it’s not a pro drug?
Ticagrelor
Ticagrelor drug interactions
3A4 drugs
DNE 40mg simvastatin/lovastatin
Limit aspirin { 100mg
Monitor digoxin concentrations
Ticagrelor side effects
Dyspnea
Bradycardia
How many days do you hold plavix before surgery?
5 days
Cangrelor use setting
Can be used when NPO and PCI only really
Must be loading dose and infusion
GP IIb/IIIa inhibitors use
Eptifibatide (Integrilin)
Tirofiban (Aggrastat)
Last line high risk pts not treated appropriately with plavix
Treat at time of PCI, not before
Renal dose adjustments, CrCl { 60 cut in half
Bivalirudin
Direct thrombin inhibitor
Can be used with HIT history
Given by bolus and infusion at fixed rate
Continue until end of PCI
Anticoagulant for ischemia guided ACS therapy
Enoxaparin, Fondaparinux, heparin
Anticoagulant for PCI (invasive strategy) ACS
Heparin
Enoxaparin
Bivalirudin
If used Fondaparinux must give extra heparin before PCI
Lovenox dosing with PCI
1mg/kg sq 12h
If 8-12 hrs before PCI then give extra 0.3mg/kg IV enoxaparin - also if only had one sq dose before PCI
Time to perform PCI or switch to fibrinolytic therapy
120 mins
Door to needle 30min goal
Fibrinolytic dosing in STEMI
Heparin 60u, then 12u/kg/hr, 1.5-2x base
Lovenox 30mg IV, 15min later do 1mg/kg sq q12h, max 100mg first two doses
Fondaparinux 2.5mg IV then SQ next day
Fibrinolytic dosing in STEMI
Heparin 60u, then 12u/kg/hr, 1.5-2x base
Lovenox 30mg IV, 15min later do 1mg/kg sq q12h, max 100mg first two doses
Fondaparinux 2.5mg IV then SQ next day
Fibrinolytic dosing
Alteplase 15mg over 2mins, then 50mg over 30mins, then 35mg over 1hr, total 100mg
Reteplase 10u, then 10u in 30 mins
Tenecteplase weight based, 30-50mg IVP
Fibrinolytic contraindications
Bleeding strokes
Ischemic stroke in last 3mo
Bleed
BP over 180/110
Long CPR
Pregnancy
Dementia
Oral anticoagulants
How to calculate DAPT Score
Age over 75 -2
Age 65-74 -1
1 pt for each…. Tobacco, DM, MI, small stent, drug eluting stent
2 pts each for CHF or LVEF less than 30%, PCI saphenous graft
DAPT Score cutoff for extended DAPT tx
2 or greater
anticoagulant of choice for mechanical heart valve and severe mitral stenosis
warfarin
medications that may affect BNP and lab preferred in this case
ARNI’s
prefer NT-proBNP
diuretic conversions based on furosemide 40mg tablet
furosemide 20mg IV
torsemide 20mg PO
bumetanide 1mg IV
bumetanide 1mg PO
ceiling effect on diuretic doses
furosemide 160 - 200mg IV
bumetanide 1-2mg IV
torsemide 10-20mg PO
duration of amiodarone affects - hyperthyroidism
6 months-ish to pull out of fat and eliminate half lifes
some will be kept in tissues for life
Drugs of choice for AFib over 7 days and cardioversion
Dofetilide
Amiodarone
Ibutilide
Drugs of choice in short AFib (less than 7 days)
Flecainide
Propane one
Dofetilide
Ibutilide
Amiodarone
QRS width to determine narrow it wide
120ms
hypertensive emergency vs urgency
emergency shows signs of end organ damage or worsening
HTN emergency goals
lower MAP by 25% first hour (no more than)
then < 160/110mmHg over 2-6 hours
normal range in 24-48 hrs
contraindications for lowering HTN emergency slowly
pheochromocytoma crisis
eclampsia
aortic dissection
HTN crisis: aortic dissection DOC
Labetalol
Esmolol
SBP less than 120 in 20 mins
HTN Crisis: Acute coronary syndrome DOC
Esmolol
Nitroglycerin
Can do labetalol or nicardipine
HTN Crisis: pulmonary edema DOC
Clevidipine
Nitroglycerin
Nitroprusside
Beta blockers contraindicated
HTN Crisis: renal failure DOC
Clevidipine
Fenoldopam
Nicardipine
HTN Crisis: eclampsia DOC
Labetalol
Nicardipine
Hydralazine
HTN Crisis: perioperative HTN
Clevidipine
Esmolol
Nicardipine
Nitroglycerin
HTN Crisis: pheo DOC
Clevidipine
Nicardipine
Phentolamine
Make it quick lowering
HTN Crisis: intracranial hemorrhage
Continuous infusion
Avoid hydralazine, nitroglycerin and nitroprusside
Cautions with clevidipine
Heart failure
Beta blocker use with it
Reflex tachy
Rebound HTN
Pancreatitis or lipid disorders
Nicardipine cautions
Reflex tachycardia
N/V
Headache
Flushing
Angina/MI
Fenoldopam cautions
Contraindicated in increased ocular and intracranial pressure
Nitroprusside cautions
ART line required
Cyanide toxicity
Contraindicated in renal and hepatic failure
Nitroglycerin cautions
Use in ACS or pulmonary edema
Do not use if volume depleted
Tachyphylaxis
Hydralazine caution
Slower onset and long duration means less desirable first choice in crisis
Reflex tachycardia
HA, flushing
Contraindicated in MI, angina, elevated ICP, aortic dissection
Enalaprilat cautions
Lasts 12-24 hrs and doses not easily titrated
Can cause renal failure and High K
