Acute Coronary Syndrome Flashcards
Acute coronary syndromes include
Unstable angina, myocardial infarction (these are forms of coronary heart disease, which is the most common cause of cardiovascular disease death
typically results in an injury that transects the thickness of the myocardial wall. Pathologic Q-waves
STEMI
typically is limited to sub-endocardial myocardium. Patients do not usually develop the pathologic Q wave
NSTEMI
how is NSTEMI different from unstable angina
NSTEMI ischemia is severe enough to produce myocardial necrosis (need to draw blood, because they look alike on ECG)
general measures for patients presenting with ACS
oxygen stool softeners bedrest diet anxiolytics
this is generally preferred over fibrinolytic therapy for treating acute STEMI
primary PCI
what is PCI
percutaneous coronary intervention. Involves the placement of a coronary stent and percutaneous transluminal coronary angioplasty (PTCA)
dont give to a patient on a phosphodiesterase inhibitor
nitrates
there is no data demonstrating efficacy at reducing cardiac events, and is primarily used for symptom relief
nitroglycerin
this drug has sedative properties that tend to decrease anxiety and causes venodilation, decreases HR and BP
morphine
this drug class is shown to decrease mortality but had NO recommendation for NSTEMI/UA
fibrinolytics
therapy with this drug should be administered within 12 hours of symptom onset, should not be administered to pts whose symptoms begin more than 24 hours earlier
fibrinolytics
patients should take this drug if they cant chew an aspirin
clopidrogel
initial conservative therapy strategy that should be started ASAP after admission and continued for at least 1 month, ideally 1 year
clopidrogel plus ASA plus anticoagulant
initial invasive therapy strategy that should be given prior to diagnostic angiography or PCI
ASA plus either clopidregel or an IV GP IIaIIIb inh (such as abciximab)
for STEMIs, these drugs should not be given to patients aged over 75 years because of an increased risk of ICH
abciximab plus half dose reteplacse or tenecteplase
for STEMIs, full dose fibrinolytic therapy should not be followed by what
PCI (may be harmful)
NSTEMI- anticoagulant therapy should be added ASAP. For conservative therapy, which ones are best?
enoxaparin or UFH (followed by fondaparinux)
NSTEMI- conservatively, this anticoagulant is preferred in patients who have an increased risk of bleeding
fondaparinux
NSTEMI-invasively, these two anticoagulants have the strongest support
enoxaparin and UFH (followed by bivalirudin and fondaparinux)
do not use this drug as the sole anticoagulant to support PCI
fondaparinux
Usually UFH and LMWH are interchangeable UNLESS
over 75 receiving thrombolytic therapy or have significant renal dysfunction
this class limits myocardial damage and mortality when used for acute STEMI and reduce reinfarction and mortality when used chronically post-STEMI
BB
cautions to this class: HR<50 bpm, heart block, hypotension, moderate/severe LV dysfunction, COPD, asthma, signs of peripheral hypo perfusion
BB
this class decreases progression to CHF, reinfarction, and mortality. It limits post infarction LV remodeling and preserves ventricular pump functions
ACEI
T or F: an IV ACE inhibitor should be given to patients within the first 24 hours with anterior infarction, pulmonary congestion, or LVEF <40
FALSE. only oral
this class has no beneficial effect on death or nonfatal MI. It may increase mortality in some patients (LV dysfunction or pulmonary edema)
CCB
NSTEMI- these CCBs should be given to pts with continuing or recurring ischemia and in whom BB are contraindicated
non-dyhydropyridines (verapamil or diltiazem)
NSTEMI- these CCB should not be administered to patients with NSTEMI/UA in the absence of a bb
dihydropyridines
STEMI- these drugs should not be given to pts with STEMI and associated systolic LV dysfunction and CHF
verapamil or diltiazem (reasonable in pts who BB are ineffective in the absence of CHF, LV dysfunction, or AV block)
Overall, EVERY PATIENT with NSTEMI/UA and STEMI should get:
ASA
NTG
BB
ACEI
long term prevention of CAD: STEMI
ASA indefinitely plus
- 1-12 months of clopidrogel if metal or no stent
- at least 12 months of clopidrogel if drug eluding stent
- THROMBOLYTIC for at least 14 days
long term prevention of CAD: NSTEMI/UA
ASA indefinitely plus
- 1-12 months of clopidrogel if metal or no stent
- at least 12 months of clopidrogel if drug eluding stent
Long term prevention drugs for all patients
NTG (SL)
BB (unless contraindicated)
ACEI or ARB
this class decreases CV mortality and all cause mortality in pts with a variety of cholesterol concentrations. They are good for primary and secondary prevention of MI- long term prevention
HMG-CoA reductase inhibitors (statins)
this class can be used for long term prevention when BBs are not successful, contraindicated
CCB (verapamil and diltiazem- NOT dihydropyridine CCB)
can be used in pts with paroxysmal or chronic atrial fib or flutter and in post MI patients
warfarin
INR goal
2.0-3.0
