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Acute Care Cardiology Flashcards

1
Q

TIMI Score - What does it mean and what is a high score?

A

Thrombolysis in myocardial infarction - good at predicting a 30 day and 1 year mortality in patients with NSTE-ACS. High score is 3 or more and have greater benefit from LMWH, GP IIb/IIIa inhibitors and invasive strategies.

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2
Q

GRACE risk model

A

Predicts in hospital and post discharge mortality in patients with MI, greater than 140 you will want to treat with invasive strategies, less than ischemic strategies are adequate

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3
Q

NSTEMI

A

ST depression and T wave inversion - non specific changes but with positive biomarkers such as troponin

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4
Q

STEMI

A

ST segment elevation > 1mm above baseline on ECG, positive biomarkers

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5
Q

First thing you should do when suspicion of ACS

A

obtain ECG and aspirin within 10 minutes

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6
Q

Difference between UA and NSTEMI

A

NSTEMI will have + troponin

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7
Q

STEMI treatment overview

A

immediate reperfusion with PCI or fibrinolysis - primary PCI within 90 minutes is the goal, if cannot be done in 120 minutes then door to needle time of 30 minutes for fibrinolysis

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8
Q

What adjunctive treatment with primary PCI

A

heparin or bival

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9
Q

when to do PCI or CABG?

A

high risk, early invasive approach or intermediate risk (ischemia gu8ided approach) with positive stress test

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10
Q

What are patients with NSTE - ACS treated on

A

treated on the risk of TIMI or GRACE score (higher, more likely to treat with LMWH or intervention), if low or intermediate score (< 4 for TIMI and < 140 for GRACE) you should treat with ischemic strategies

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11
Q

initial anti-ischemic and analgesic therapies

A

MONA-B

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12
Q

Morphine for ACS - frequency and what does it do

A

morphine 1-5 mg IV every 5-30 minutes - analgesia and decreased pain sympathetic adrenergic tone, induces vasodilation and preload/afterload reduction. slows the absorption of the antiplatelet therapy

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13
Q

Oxygen for ACS - when to give

A

only give if sao2< 90%, helps w pain

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14
Q

Nitroglycerin for ACS- use and CI

A

helps with coronary vasodilation and severe pulmonary edema, spray or SL tab every 5 mins for 3 doses, IV NTG if persistent chest pain, HF, or HTN, CI w/ sildenafil in 24 hours or tadalafil in 48 hours

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15
Q

Aspirin - what does it do and what to give if allergy

A

inhibits the platelet activation, clopid if asa allergy- mortality reducing!!!

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16
Q

beta blocker - which ones??

A

initiated in 24 hours if patients do not have signs of HF or low output, or asthma, or reactive airway disease, or second or third degree heart block, use CMB beta blockers in HFrEF - IV beta blocker could be harmful if patient has risk factors for shock (low BP, age >70, SBP<120, HR>110)

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17
Q

Who receives ASA and P2Y12 in ACS??

A

ALL patients, minority benefit from GP IIb/IIIa

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18
Q

what antiplatelet can you give if NSTE-ACS ischemic guided?

A

ASA, Clopid, Tica

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19
Q

what antiplatelet can you give if STEMI primary PCI?

A

ASA, clopid, prasugrel

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20
Q

what antiplatelet can you give if NSTE-ACS invasive?

A

ASA, clopid, prasugrel, ticagrelor

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21
Q

what antiplatelet can you give if STEMI + Fibrinolytic?

A

ASA, Clopid

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22
Q

when should patients stop taking ASA after ACS?

A

never - take it forever

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23
Q

when should patients stop taking DAPT?

A

after 12 months

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24
Q

what patients is prasugrel CI in?

A

history of stroke or TIA

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25
when would you chose tica over clopid?
patients who are <75 yo with invasive NSTE or sTEMI
26
When would you chose prasugrel over clopid?
not at high risk of bleed, and PCI (think PCI = prasugrel!)
27
dose of clopid before a PCI or NSTE early invasive or ischemic guided
600mg followed by 75 daily
28
dose of PRA before a PCI
60mg followed by 10mg daily
29
dose of TIC before a PCI or NSTE invasive
180 followed by 90 BID
30
cyp enzyme with what P2Y12
clopidogrel - 2c19, increased bleeding with NSAIDs
31
clopid thoughts
not the best preferance for PCI, less bleeding risk than PRA and TICA, pro drug, LD 600mg, 5 day surgery hold time
32
PRA thoughts
prodrug, 7 day surgery hold time, higher risk than with clopid, TIA/CVA boxed warning, ACS with PCI preferred, lowest half life, 60mg LD 10mg daily
33
TICA thoughts
give this one in NCSTE invasive, 180 LD and 90 BID, not a prodrug but reversible (only one), 3-5 day surg hold time, ACS managing or with PCI, warning of ASA> 100mg, severe hepatic disease is a CI
34
cangrelor fun facts
do not give if with prasugral or clopidogrel because it has irreversible inhibition, associated with dyspnea, allows for a quick high degree of platelet inhibition with resolution of normal platelet function with one hour of ending the treatment, used as a bridge therapy
35
IV GP IIb/IIIa inhibitors - when to give???
give to high risk patients with NSTE-ACS treated with UFH and pretreated with clopid or ticagrelor - most studies give GP and UFH - double bolus eptifbatide and high dose bolus tiro are clase I options for invasive strategies
36
crcl adjustment for eptifbatide
crcl < 50 dec by 50% avoid in HD
37
crcl for tirofiban
if crcl <60 then reduce by 50%
38
dose of eptifbatide
180 mcg/kg if PCI; 2 mcg/kg/min
39
dose of tiro
PCI - 25 mcg/kg over 3 mins then 0.15 mcg/kg/min for 18 hours
40
anticoag choice: STEMI PPCI
UFH, bival
41
anticoag choice: fibrinolytic therapy
UFH, LMWH, fonda
42
anticoag choice: NSTE, early invasive strategy
enox, bival, UFH
43
anticoag choice: NSTE, ischemic guided
enox, fonda, UFH
44
How long is UFH continued
48 hours or until PCI
45
what is good about UFH?
not renally cleared!
46
UFH dose
60u/kg, then 12u/kg/min
47
fonda half life
17 hours - the longest of all of them
48
dosing of fonda
2.5 mg SQ for the duration of the hospitaliztion or until the PCI
49
when is fonda CI
<30ml/min, no risk of HIT
50
bival dosing PCI
0.75 mg/kg bolus, 1.75 mg/kg/hour IV - can extend to 4 hour infusion (primarily reserved for patient with HIT and PCI)
51
enox in PCI
ok to use, as they generally have adequate anticoagulation, if last dose < 8 hour use the 0.3 mg/kg IVB, use 30mg/kg
52
renal considerations for enox, fonda, bival
enox < 30 1mg/kg daily, fonda < 30 CI, bival < 30 reduce to 1mg/kg/hour and HD to 0.25 mg/kg/hr
53
what anticoags are recommended with fibrinolytic?
enox, UFH, fonda
54
how long should patients recieve anticoag after fibrinolytic?
48 hours, up to 8 days
55
max enox dosing?
100mg for the first two doses of 1mg/kg for a pci, and 75mg for patients >75
56
fonda with PCI dose
2.5 mg followed by 2.5 mg/day in 24 hours
57
tenecteplase dosing
< 60 kg: 30 mg IVP, 60-69 kg 35 IVP, 70-79 40mg IVP, 80-89kg 45 IVP >/ 50 kg 50 IVP
58
CI of fibrinolytic therapy
relative: DOAC, peptic ulcer, HX of ischemic stroke 3 mo before, CPR > 10 mins, pregnancy, dementia, vascular puncture, recent internal bleeding (2-4 weeks), BP>180/110 on presentation or history of poorly controlled HTN. absolute: hemorrhagic stroke, ischemic stroke, active internal bleed, aortic discection, trauma, spinal injury, uncontrolled htn
59
who should continue bblockers indefinetly?
patients with EF< 40%
60
who should contine ACEI indefinetly?
all patients with EF<40% or less and with HTN, DM, or CKD
61
DAPT score (what favors prolonging?)
>/ 2 favors prolonging DAPT
62
who should recieve an aldosterone receptor blocker
who are recieving an ACEI and beta blocker after MI and who have LVEF < 40%
63
CI for aldosterone
< 30, hyperkalemia
64
who should get a statin??
everyone in the first 24 hours
65
how should treat pain??
NOT with NSAIDs or COX2 inhibitors - higher risk of AE w/ CI, treat with apap, tramadol, narcotics
66
what vax should be given to patients with CV
pneumo vax if > 65 and patients with high risk (smokers and asthma)
67
antiplatelet discontinuation in patients with CABG
d/c GP I/II 204 hours, clopid/tica 3-5 days, prasugrel 7 days, urgent cabg - clopid/tica 24 hours before
68
what is the preferred anticoag in AF
doac, warfarin DOC in patients with mechanical heart valve
69
preferred P2Y12 in AF
clopidogrel, avoid prasugrel, tica may be ok - dc at 1 year in most patients
70
older patient considerations with ACS
CABG>PCI, enox should be 0.75 mg/kg Q12H (not to exceed 75 mg for first 2 dfoses, bival instead of GII/III
71
acute decomponsated heart failure - med related
nonadherence, excessive alcohol/drugs, recent ionotropic agents
72
acute decomponsated heart failure - disease related
fluid restriction, MI, uncorrected high blood pressure, pulmonary embolus, AF or other arrhythmias, infections, acute CV disorders
73
diagnosis of acute decomponsated heart failure
BNP is useful to support the diagnosis and establish the prognosis for ADHF (excluded when < 100 pg/ml for BNP and < 300pg/mL NT-proBNP) - may be elevated with older age, female, renal dys, cardio pulmnonary PEs, NT-proBNP preferred in patients with ARNI
74
ADHF - diuretic therapy
recommended in patients with fluid overload, sodium restriction, ultrafiltration
75
ADHF- inotropic therapy
considered to relieve patients of symptoms and help patients with LVEF esp if SBP <90, symptomatic hypotension, no response to or intolerance of IV vasodilators - may be considered in patients with fluid overload
76
ADHF- vasodilator
considered in addition of IV loop diuretics to improve symptoms in patients with pulmonary edema or hypertension (better than ionotropic drugs when needing something in adjunct to diuretics)
77
warm and dry
PCWP 15-18, CI > 2.2 - optimize guideline directed therapy (PO meds)
78
warm and wet (pulmonary or peripheral conjestion)
PCWP > 18, CI > 2.2, IV diuretics that equals or exceeds preadmission dose +/- IV vasodilators for rapid relieve of pulmonary congestion or arterial in the absence of hypotension, adjunctive
79
Cold and dry (hypoperfusion +/- orthostasis)
PCWP 15-18 and CI<2.2, if SBP<90 ionotrope, if SBP>90 IV vasodilator +/- IV vasopressor
80
cold and wet (congestion and hypoperfusion)
IV diuretics + >/ 90 IV vasodilator SBP < 90 IV ionotrope +/- IV vasopressor
81
digoxin serum concentration
0.5-0.8, dig withdrawl has been associated with worse outcomes
82
loop diuretics ADHF
most common diuretic in ADHF, lasix 40mg PO = lasix 20mg IV = bumex 1mg IV or PO = torsemide 20mg PO
83
thiazides ADHF
add on only, weak
84
acetazolamide ADHF
adjunct to loops, IV 500 AD
85
diuretic resistance
ceiling effect of lasix 160-200 of IV lasix, add a second with a different mech - metolazone (30 min before loop) or chlorothiazide 250-500mg
86
adverse effects of diuretics
electrolyte depletion, worsening renal function
87
Vasodilators in ADHF
use when wet patient PWCP > 18, use with diuretics, use in preference to ionotropic therapy when adequate BP (ex: nitropresside and nitroglycerin)
88
venodilators
limits ischemia and helps preserve the cardiac tissue, produces rapid symptomatic benefit by reducing pulmonary congestion,
89
nitroglycerin
used for those with hypertension, coronary ischemia, and mitral regugitation - tachyphylaxis may develop within 24 hours and may develop resistance - avoid inpatients with symptomatic hypotension - preferential venous vasodilator, greater than arterial vasodilator, arterial vasodilator at high doses
90
nitroprusside
alternative in patients with elevated SVR and low CO, used in patients without end organ damage, reverse pulmonary hpertension, avoid use inpatients with actived ischemia/ACS because of risk for coronary steal syndrome - avoid in patients with symptomatic hypotension, balanced arterial and venous dilation
91
ionotropic agents
used in hypoperfusion (cold), CI <2.2,confirm adequate filling pressures before administering ionotropic therapy
92
when is milrinone favored
to avoid tapering or d/c home b blocker, when pulmnoary artery pressures are high
93
when is dobutamine favored
severe hypotension, brady, renal impairment, renal impairment
94
dobutamine mechanism
beta 1 agonist, increases CO, slight peripheral vasodilation
95
milrinone
PDE inhibitor, inhibits cAMP breakdown in heart to increase CO and vascular smooth muscle SVR
96
is milrinone renal or hepatic
renali
97
is dobutamine renal or hepatic
hepatic
98
vasopressin antagonist
add on therapy to address the aggressive diuresis and not as initial or adjunctive therapy for fluid removal, strict free water restriction
99
tolvaptan
approved for clinically significant hyponatremia associated with HF
100
dose of tolvaptan and CI
15 mg, CYP3A4
101
lidocaine mexiletine, phenytoin
ventricular arrhythmia Ib (fast), dec QT interval
102
disopyramide, quinidine, procainamide
Ia (intermediate), inc QRS, inc QT, atrial and ventricular arrhythmias
103
flecanide, propafenone
Ic (slow), inc QRS, atrial and ventricular arrhythmias
104
metoprolol, esmolol, atenolol
class II bet blockers, dec HR, inc PR, atrial arrhthmias, ventricular arrhythmias
105
diltiazem, verapamil
Class IV calcium channel blockers, vent and atr arrhtyh, dec HR, inc PR
106
amio, dronedarone, sotalol, dofetilide, ibutilide
class III potassium channel blockers, inc QT, atr, ventr arrhythmias
107
ventricular arrhythmias - asymptomatic treatment
beta blockers treatment for survivors of MI and HFrEF
108
ventricular arrhythmias - symptomatic treatment
beta blockers considered for a therpautic trial, non DHP CCBs may be considered as an alternative to a beta blocker
109
flecanide / propafenone CI
not recommended in ventricular contractions
110
sotalol CI
should be used with caution in patients with CKD and avoided with prolonged QT intervals
111
meds used for defibrillator implantation
amio, sotalol, beta blockers
112
heart failure classes of agents to avoid in arrhythmias
avoid Ia and Ic agents - amio and dofetilide have a neutral effect on mortality in patients with LV dysfunction after an MI, dronedarone is CI in patients with symptomatic HF
113
acute MI things to avoid in arrhythmias
1a and Ic agents (flecanide), amio and dofetalide have a neutral effect
114
antidote for CCB toxicity (brady)
calcium
115
IV drugs for hypertensive emergency
nitroprusside, nitroglycerin, hydralazine, enalaprilat (dont use in MI), fenoldopam, nicardipine (CI in aortic stenosis), clevidipine (caution with bblocker use, tachy, rebound htn)
116
agent preferred - acute aortic dissection
labetalol, esmolol - beta blocker should be given before vasolilator if needed for BP control or to prevent the reflex tachy or ionotropic effect
117
agent preferred- acute coronary syndromes
esmolol, NTG, labetalol, nicardipine - CI betablocker with pulmonary edema
118
agent preferred- acute pulmonary edema
clevidipine, ntg, ntp, beta blockers Ci, NTG preferred
119
agent preferred - eclampsia or preeclampsia
labetalol, nicardipine, hydralazine, required BP lowering to < 140 mmHG within the first hour - acei/arb/ntp ar CI
120
perioperative HTN - preferred agent
clevidipine, esmolol, nicardipine, NTG
121
pheochromocytomoa, post-carotid, endarterectomy
clevipine, nicardipine, phentolamine, requires rapid lowering of bp
122
acute intracranial hemorrhage
nicardipine, clevidipine, labetalol (avoid hydral, ntg, ntp as they can worsen the ischemia)
123
acute ischemic stroke
no preference of the agent

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