Acute Coronary Syndrome Flashcards
describe the difference between plaques between non stemi and stemi
nonstemi still some blood flow mostly made of platelets
stemi theres complete occlusion and lots of fibrin
troponin or st elevation in the following?
- unstable angina
- nstemi
- stemi
- none
- troponin
- troponin and st elevation
what are the 3 types of acute coronary syndrome
unstable angina
non-st-segment elevation MI
ST-segment elevation MI
what causes stemi
complete occlusion of a coronary artery by clot - rupture of atherosclerotic plaque
what is the diagnosis of acs based on
signs and symptoms
ECGs
cardiac biomarkers - CK-MB, TnT
what are some classic symptoms
radiating chest apin
SOB
NV
diaphoresis
who is more liekly to have silent type without chest pain and other classical symptoms
elderly, diabetic, women
signs
syncope
arrythmia
elevated or low BP
diffuse rales, wheezing, resp distress
what does jugular venous distention indicate
right atrial hypertension usually from RV infraction or elevated LV filling pressure
what enzymes are released into circulation when cardiac cells are damaged
creatinine kinase
troponins
describe the timing of ck-mb enzyme
detectable in serum within 3-6 hr post MI
peaks in 12-24 hr
stays elevated for 2-3 days
*can be elevated in other conditions
which is the perferred biomarker for assessment of myocardial damage
troponins because of high sensitivity
describe timing of troponins
appears in serum within 4-12 hr after MI onset
peaks 12-48 hours
stays elevated for 7-10 days
when should biomarker essays be done
stat on presentation then repeated every 4-6 hours for the first 12-24 hrs then periodically
what biomarker results are needed for diagnosis
at least 2 elevated ck-mb or 1 tnt exceeding the upper reference range
when should a 12 lead ecg be done
within 10 min on presentation
what does an ecg tell you
distinguishes from stemi and nstemi
informs location of myocardial damage
affects decision pathway and management
ecg diagnostic criteria for st elevation
st segment elevation in >2 contiguous leads exceeding .2mV in leads v1, v2, v3 or .1mV or greater in other leads or new left bundle branch block
what acg abnormalities might be observed for nstemi
st depression
t wave inversion
initial management of acs in emergency
oxygen 4L/min by nasal prong
asa 162-325
nitroglycerin SL or IV
morphine 2-5mg IV q5-30min prn if pain not relieved by nitro
what does mona stand for
initial management morphine oxygen nitrates asa
why is it important to treat the pain right away
pain raises sympathetic activation so increase the myocardial demand
time is what in stemi
muscle
priority to reestablish blood flow to occulded artery as wuickly as possible what are the two types of perfusion strategies in stemi
primary percutaneous coronary intervention
fibrinolytics
what does the choice of reperfusion strategy depend on
location availablity of pci capable facilities
onset of symptoms
reperfusion goals of therapy
decrease mortality and complications
reduce or contain infarct size
salvage functioning myocardium and prevent remodelling
reestablish patency of the infarct related artery
whats the recommended method of reperusion
primary pci when it can be preformed in a timely fashion
ideal door to balloon time for primary pci and for stemi in non pci capable hospital
under 90 min
if transferred should be considered if <120min can be acheived
when fibrinolyic therapy is chose when should it be administered
within 30min of hospital arrival
when should reperfusion therapy occur within
12 hours
if the fibrinolytic is administered at a non pci capable hospital what happens after
urgent transfer for pci in patients with failed reperfusion or reocclusion OR
transfer for angiography and revascularization within 3-24hr for other patients as part of an invasive strategy
describe primary pci process
catheter placed through femoral artery to the aorta and coronary arteries
contrast dye injected
xrays taken to determine location of occlusion
balloon catheter with or without stent goes to site and inflates to open the coronary
stents left inplace to keep vessel open
repeat xrays
define timi grade flow
adopted scoring system from 0-3 referring to level of cornary blood flow assessed during PCI
3 = complete perfusion
whats a drug eluting stent
antiproliferative drugs coating released slowly over time to prevent restenosis
patients who recieved a des will require what
dual antiplatelet therapy for a min of 1 year
why is fibrinolytics not administered to nstemi and ua patients
clot is not fibrin made mostly of platelets
fibrinolytic agents
tenecteplase
reteplase
alteplase
streptokinase - non fibrin specific
tenecteplase fibrinolytic of choice whats the dose
5 second single bolus
absolute contraindications to fibrinolytics due to bleeding risk
prior ICH
known structural cerebral vascular lesion
malignant intracranial neoplasm
ischemic stroke within 3 mon except acute witin 4.5hr
suspected aortic dissection
active bleeding
sig head trauma within 3 mon
intracranial/spinal surgery within 3 mon
severe uncontrolled hypertension
what should patients be given before undergoing primary pci
asa 162-325
loading dose of a p2y12 receptor inhibitor as early as possible
usually low molecular weight heparin
dose before primary pci and examples of p2y12 receptor inhibitor
clopidogrel 600
prasugrel 60
ticagrelor 180
what should patients be on after primary pci
asa 81-162 daily for life plus a p2y12 receptor inhibtor at maintenance dose for min 1 year
maintenance dose of p2y12 receptor inhibitors
clopidogrel 75
prasugrel 10
ticagrelor 90 bid
what should be given for stemi patients recieving fibrinolytics
asa 162-325 on presentation then for life
clopidogrel 300 loading dose then continue 75mg daily for 14 days
LMWH/UFH initiated at time of fibrinolytics and continued for 48hr-8days
enoxaparin in stemi in patients < 75
give 30mg iv bolus before tnk
continue 1mg/kg sc q12h after tnk
max 140mg
enoxaparin in stemi in patients over 75
dont give enoxaparin iv bolus
.75mg/kg sc q12h after tnk
max 100mg
who should not use prasugrel
patients with history of stroke or TIA due to higher rates of major bleeding
patients who undergo pci should receive dual antiplatelet therapy for
1 year
what is the maintenence dose of asa
81 same amount of antiplatelet action but less risk of bleeding
stemi patients treated with fibrinolytics should be on dapt for how long
not warranted just asa daily undefinately but most go on to have a pci
triple therapy of dapt and warfarin indicated in who
stemi patients with low ejection fraction of has concurrent heart failure
what should you monitor for efficacy after reperfusion
signs and symptoms of ongoign chest pain
no new ecg changes
serial monitoring of biomarkers
stent thrombosis
complications: arrhythmias, HF, pericarditis
what should you monitor for safety after reperfusion
major and minor bleeding complications
signs of bleeding: bloody stool, melena, hematuria, bruising, oozing from puncture sites
what are some stemi complications
heart failure
cardiogenic shock
arrhythmias
pericarditis
why might heart failure occur after stemi and what is the therapy
LV myocardium may become ischemic, stunned, or injured after mi
echocardiography to assess lv ejection fraction
diuretics, vasodilators, and inotropic may be needed
what is cardiogenic shock after stemi and what is the result
decreased cardiac output and evidence of tissue hypoxia in precence of adequate intravascular volume often due to extensive lv infraction
high rate of mortality
why do arrhythmias happen post mi
due to ischemia and severe HF
who is an impantable cardioverter defibrillator indicated in
before discharge in patients who develop sustained VF more than 48 hours after stemi
treatment of pericarditis after stemi
asa 650 qid or nsaids
resolves in 3-4 days
goals of adjunct therapy after stemi
reduce the risk of short term and long term complications with stemi
slow progression of chd and minimize the future cardiovascular events and other morbidities
improve mortality and restore quality of life
how do beta blockers help post stemi
increase myocardial salvage in the infarct area
prevent extension of infraction by reducing oxygen demand
decrease mortality and nonfatal mi
when should beta blockers be initiated after mi
within 24 hours after onset of mi
start beta blockers at a low dose post mi and titrate to maintain a resting hr of what
55-60bpm
contraindications to beta blockers
hypotension bradycardia acute heart failure cardiogenic shock asthma 2nd or 3rd degree av block
dosing of metoprolol post mi
start 25mg bid
titrate to max 100bid
dosing of atenolol
12.5-25 daily up to 100 daily
dosing of carvediol
3.125 bid
titrate to 25 bid
how do acei help post mi
min ventricular remodelling
reduce oxygen demand and myocardial wall stress by reducing afterload and preload
reduce cv mortality
who is the benefit of acei the greatest
anterior infraction
HF
diabetes
CKD
when should acei be intiated after mi
24 hour of mi once bp has been stabilized
who should you use acei with caution in
renal impairment
hyperkalemia
acei monitoring
scr
electrolytes
watch for hyperkalemia
ramipril dosing
1.25-2.5 daily
target 10mg
enalapril dosing
2.5 bid
target 10-20bid
lisinopril dosing
2.5-5 daily
target 40 daily
captopril dosing
6.25 tid
target 25-50 tid
candesartan dosing
4mg daily
target 32
telmisartan dosing
40mg daily
target 80
valsartan dosing
20mg bid
target 160 bid
what should you monitor for statins
lipid panel
LFT
CK
symptoms of myopathy
dosing for atorvastatin, fluvastatin
lovastatin
simvastatin
20-80 mg daily
dosing for pravastatin
20-40 daily
rosuvastatin dosing
5-40mg daily
what does evolocumab do
monoclonal antibody that inhibits PCSK9 - lowers LDL
should you use evolocumab
not much risk reduction and very costly
who should aldosterone antagonists be considered in
patients with sig LV dysfunction
who should you caution the use of aldosterone antagonists in
crcl<30 and potassium >5
monitoring for aldosterone antagonist
check potassium baseline and wihtin 1 week of initiation
spironolactone dosing
12.5 daily
titrate to 25mg
eplerenone dosing
25mg daily
titrate to 50
non pharm therapies
cardiac rehab program weight maagement physical exercise ICD assessment for patients with ongoing lv dysfunction psychosocial issues
risk factor modification
smoking cessation hypertension dyslipidemia obesity sedentary stress
