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Clinical 2.0 > Acute Coronary Syndrome > Flashcards

Acute Coronary Syndrome Flashcards

1
Q

describe the difference between plaques between non stemi and stemi

A

nonstemi still some blood flow mostly made of platelets

stemi theres complete occlusion and lots of fibrin

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2
Q

troponin or st elevation in the following?

  1. unstable angina
  2. nstemi
  3. stemi
A
  1. none
  2. troponin
  3. troponin and st elevation
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3
Q

what are the 3 types of acute coronary syndrome

A

unstable angina
non-st-segment elevation MI
ST-segment elevation MI

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4
Q

what causes stemi

A

complete occlusion of a coronary artery by clot - rupture of atherosclerotic plaque

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5
Q

what is the diagnosis of acs based on

A

signs and symptoms
ECGs
cardiac biomarkers - CK-MB, TnT

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6
Q

what are some classic symptoms

A

radiating chest apin
SOB
NV
diaphoresis

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7
Q

who is more liekly to have silent type without chest pain and other classical symptoms

A

elderly, diabetic, women

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8
Q

signs

A

syncope
arrythmia
elevated or low BP
diffuse rales, wheezing, resp distress

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9
Q

what does jugular venous distention indicate

A

right atrial hypertension usually from RV infraction or elevated LV filling pressure

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10
Q

what enzymes are released into circulation when cardiac cells are damaged

A

creatinine kinase

troponins

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11
Q

describe the timing of ck-mb enzyme

A

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

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12
Q

which is the perferred biomarker for assessment of myocardial damage

A

troponins because of high sensitivity

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13
Q

describe timing of troponins

A

appears in serum within 4-12 hr after MI onset
peaks 12-48 hours
stays elevated for 7-10 days

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14
Q

when should biomarker essays be done

A

stat on presentation then repeated every 4-6 hours for the first 12-24 hrs then periodically

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15
Q

what biomarker results are needed for diagnosis

A

at least 2 elevated ck-mb or 1 tnt exceeding the upper reference range

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16
Q

when should a 12 lead ecg be done

A

within 10 min on presentation

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17
Q

what does an ecg tell you

A

distinguishes from stemi and nstemi
informs location of myocardial damage
affects decision pathway and management

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18
Q

ecg diagnostic criteria for st elevation

A

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

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19
Q

what acg abnormalities might be observed for nstemi

A

st depression

t wave inversion

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20
Q

initial management of acs in emergency

A

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

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21
Q

what does mona stand for

A 
initial management 
morphine
oxygen 
nitrates 
asa
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22
Q

why is it important to treat the pain right away

A

pain raises sympathetic activation so increase the myocardial demand

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23
Q

time is what in stemi

A

muscle

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24
Q

priority to reestablish blood flow to occulded artery as wuickly as possible what are the two types of perfusion strategies in stemi

A

primary percutaneous coronary intervention

fibrinolytics

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25
Q

what does the choice of reperfusion strategy depend on

A

location availablity of pci capable facilities

onset of symptoms

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26
Q

reperfusion goals of therapy

A

decrease mortality and complications
reduce or contain infarct size
salvage functioning myocardium and prevent remodelling
reestablish patency of the infarct related artery

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27
Q

whats the recommended method of reperusion

A

primary pci when it can be preformed in a timely fashion

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28
Q

ideal door to balloon time for primary pci and for stemi in non pci capable hospital

A

under 90 min

if transferred should be considered if <120min can be acheived

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29
Q

when fibrinolyic therapy is chose when should it be administered

A

within 30min of hospital arrival

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30
Q

when should reperfusion therapy occur within

A

12 hours

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31
Q

if the fibrinolytic is administered at a non pci capable hospital what happens after

A

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

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32
Q

describe primary pci process

A

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

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33
Q

define timi grade flow

A

adopted scoring system from 0-3 referring to level of cornary blood flow assessed during PCI
3 = complete perfusion

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34
Q

whats a drug eluting stent

A

antiproliferative drugs coating released slowly over time to prevent restenosis

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35
Q

patients who recieved a des will require what

A

dual antiplatelet therapy for a min of 1 year

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36
Q

why is fibrinolytics not administered to nstemi and ua patients

A

clot is not fibrin made mostly of platelets

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37
Q

fibrinolytic agents

A

tenecteplase
reteplase
alteplase
streptokinase - non fibrin specific

38
Q

tenecteplase fibrinolytic of choice whats the dose

A

5 second single bolus

39
Q

absolute contraindications to fibrinolytics due to bleeding risk

A

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

40
Q

what should patients be given before undergoing primary pci

A

asa 162-325
loading dose of a p2y12 receptor inhibitor as early as possible
usually low molecular weight heparin

41
Q

dose before primary pci and examples of p2y12 receptor inhibitor

A

clopidogrel 600
prasugrel 60
ticagrelor 180

42
Q

what should patients be on after primary pci

A

asa 81-162 daily for life plus a p2y12 receptor inhibtor at maintenance dose for min 1 year

43
Q

maintenance dose of p2y12 receptor inhibitors

A

clopidogrel 75
prasugrel 10
ticagrelor 90 bid

44
Q

what should be given for stemi patients recieving fibrinolytics

A

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

45
Q

enoxaparin in stemi in patients < 75

A

give 30mg iv bolus before tnk
continue 1mg/kg sc q12h after tnk
max 140mg

46
Q

enoxaparin in stemi in patients over 75

A

dont give enoxaparin iv bolus
.75mg/kg sc q12h after tnk
max 100mg

47
Q

who should not use prasugrel

A

patients with history of stroke or TIA due to higher rates of major bleeding

48
Q

patients who undergo pci should receive dual antiplatelet therapy for

A

1 year

49
Q

what is the maintenence dose of asa

A

81 same amount of antiplatelet action but less risk of bleeding

50
Q

stemi patients treated with fibrinolytics should be on dapt for how long

A

not warranted just asa daily undefinately but most go on to have a pci

51
Q

triple therapy of dapt and warfarin indicated in who

A

stemi patients with low ejection fraction of has concurrent heart failure

52
Q

what should you monitor for efficacy after reperfusion

A

signs and symptoms of ongoign chest pain
no new ecg changes
serial monitoring of biomarkers
stent thrombosis
complications: arrhythmias, HF, pericarditis

53
Q

what should you monitor for safety after reperfusion

A

major and minor bleeding complications

signs of bleeding: bloody stool, melena, hematuria, bruising, oozing from puncture sites

54
Q

what are some stemi complications

A

heart failure
cardiogenic shock
arrhythmias
pericarditis

55
Q

why might heart failure occur after stemi and what is the therapy

A

LV myocardium may become ischemic, stunned, or injured after mi
echocardiography to assess lv ejection fraction
diuretics, vasodilators, and inotropic may be needed

56
Q

what is cardiogenic shock after stemi and what is the result

A

decreased cardiac output and evidence of tissue hypoxia in precence of adequate intravascular volume often due to extensive lv infraction
high rate of mortality

57
Q

why do arrhythmias happen post mi

A

due to ischemia and severe HF

58
Q

who is an impantable cardioverter defibrillator indicated in

A

before discharge in patients who develop sustained VF more than 48 hours after stemi

59
Q

treatment of pericarditis after stemi

A

asa 650 qid or nsaids

resolves in 3-4 days

60
Q

goals of adjunct therapy after stemi

A

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

61
Q

how do beta blockers help post stemi

A

increase myocardial salvage in the infarct area
prevent extension of infraction by reducing oxygen demand
decrease mortality and nonfatal mi

62
Q

when should beta blockers be initiated after mi

A

within 24 hours after onset of mi

63
Q

start beta blockers at a low dose post mi and titrate to maintain a resting hr of what

A

55-60bpm

64
Q

contraindications to beta blockers

A 
hypotension 
bradycardia
acute heart failure 
cardiogenic shock 
asthma 
2nd or 3rd degree av block
65
Q

dosing of metoprolol post mi

A

start 25mg bid

titrate to max 100bid

66
Q

dosing of atenolol

A

12.5-25 daily up to 100 daily

67
Q

dosing of carvediol

A

3.125 bid

titrate to 25 bid

68
Q

how do acei help post mi

A

min ventricular remodelling
reduce oxygen demand and myocardial wall stress by reducing afterload and preload
reduce cv mortality

69
Q

who is the benefit of acei the greatest

A

anterior infraction
HF
diabetes
CKD

70
Q

when should acei be intiated after mi

A

24 hour of mi once bp has been stabilized

71
Q

who should you use acei with caution in

A

renal impairment

hyperkalemia

72
Q

acei monitoring

A

scr
electrolytes
watch for hyperkalemia

73
Q

ramipril dosing

A

1.25-2.5 daily

target 10mg

74
Q

enalapril dosing

A

2.5 bid

target 10-20bid

75
Q

lisinopril dosing

A

2.5-5 daily

target 40 daily

76
Q

captopril dosing

A

6.25 tid

target 25-50 tid

77
Q

candesartan dosing

A

4mg daily

target 32

78
Q

telmisartan dosing

A

40mg daily

target 80

79
Q

valsartan dosing

A

20mg bid

target 160 bid

80
Q

what should you monitor for statins

A

lipid panel
LFT
CK
symptoms of myopathy

81
Q

dosing for atorvastatin, fluvastatin
lovastatin
simvastatin

A

20-80 mg daily

82
Q

dosing for pravastatin

A

20-40 daily

83
Q

rosuvastatin dosing

A

5-40mg daily

84
Q

what does evolocumab do

A

monoclonal antibody that inhibits PCSK9 - lowers LDL

85
Q

should you use evolocumab

A

not much risk reduction and very costly

86
Q

who should aldosterone antagonists be considered in

A

patients with sig LV dysfunction

87
Q

who should you caution the use of aldosterone antagonists in

A

crcl<30 and potassium >5

88
Q

monitoring for aldosterone antagonist

A

check potassium baseline and wihtin 1 week of initiation

89
Q

spironolactone dosing

A

12.5 daily

titrate to 25mg

90
Q

eplerenone dosing

A

25mg daily

titrate to 50

91
Q

non pharm therapies

A 
cardiac rehab program 
weight maagement 
physical exercise 
ICD assessment for patients with ongoing lv dysfunction 
psychosocial issues
92
Q

risk factor modification

A 
smoking cessation 
hypertension 
dyslipidemia 
obesity 
sedentary 
stress

Clinical 2.0 (24 decks)

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