Acute Coronary Syndrome Flashcards
Treatment of Takotsubo Cardiomyopathy dynamic LVOT obstruction
In contrast to hypotension due only to pump failure, hypotension associated with moderate to severe LVOT obstruction should not be treated with inotropic agents, because they can worsen the degree of obstruction. Therapy includes the use of beta blockers, which can improve hemodynamics by causing resolution of the obstruction. In addition, in the absence of significant pulmonary congestion, preload should be increased with leg elevation and fluid resuscitation. In patients with LVOT obstruction and severe hypotension who either do not tolerate or do not adequately respond to beta blockers, an alpha agonist may be added with caution and close monitoring. Phenylephrine is a pure alpha-adrenergic agonist that may reduce the gradient by increasing afterload, thereby improving overall hemodynamics. In patients with LVOT obstruction with severe hypotension that is unresponsive to initial medical therapy and volume resuscitation, we suggest the use of an IABP.
Further imaging in MINOCA
CMR is a key diagnostic tool in the evaluation of patients presenting with MINOCA. CMR is recommended within 7 days of presentation because delayed imaging can sometimes result in some features no longer being evident.
Contraindications to cholesterol therapy
Coadministration of CYP3A4 substrate statins (atorvastatin, lovastatin, and simvastatin) with medications that are potent 3A4 inhibitors (diltiazem, erythromycin, -azoles) may result in increased serum concentrations with increased risk of side effects. A reduced dose may be appropriate or a selection of an alternative statin that does not undergo metabolism via the 3A4 pathway.
Administration with other drugs associated with myopathy requires caution. Simvastatin and gemfibrozil coadministration is contraindicated because of the risk of rhabdomyolysis. Dose restrictions are recommended with the coadministration of gemfibrozil or other fibrates with statins, and the use of more than one statin is not recommended.
Statins are contraindicated for use by patients with active hepatic disease or unexplained persistent elevations in aminotransferase levels.
Statins are contraindicated during pregnancy and while breastfeeding because of the effects on the cholesterol pathway. Cholesterol is an essential component for fetal and infant synthesis of steroids and cell membrane development.
statin therapy confers a small increased risk of developing diabetes and that the risk is slightly greater with intensive statin therapy than moderate statin therapy
TimingandTreatment of mechanical complications of MI
-rupture of the left ventricular free wall
-rupture of the interventricular septum
•Rupture of the left ventricular free wall, early intervention includes fluids, inotropic support, and vasopressors. Pericardiocentesis should be attempted. Occurs within first 5 days up to 2 weeks.
•Rupture of the left ventricular septum, inotropic agents and vasopressors should be tried in patients with cardiogenic shock. Occurs 24 hours up to 2 weeks post MI.
Contraindications to Type 1 ACS therapy
-Nitrates
Nitrates must be used with caution or avoided in settings in which hypotension is likely or could result in serious hemodynamic decompensation, such as right ventricular infarction or severe aortic stenosis. In addition, nitrates are contraindicated in patients who have taken a phosphodiesterase inhibitor for erectile dysfunction within the previous 24 hours.
Papillary muscle rupture/ Severe MI following MI
- timing
- treatment
Most commonly posteromedial papillary muscle, initial medical therapy may include afterload reduction using nitrates, sodium nitroprusside, and diuretics in patients with adequate blood pressure. Intra-aortic balloon pumping may be attempted. Occurs 2-7 days post MI. Harsh systolic murmur with a thrill helps to distinguish from acute MR. Needs emergency surgery.
Position: lying down = VSD, if sitting up Acute MR from pap muscle rupture
ICD with coronary vasospasm
Consider when medical therapy is ineffective. role of stenting is unclear.
