Acute Coronary Syndrome Flashcards
What is the difference between UA and AMI?
AMI has necrosis of cardiac muscle
In UA, is vessel completely occluded?
Nope
What causes a Type I MI?
ASCAD plaque rupture, clot formation, coronary thrombosis; SUPPLY problem
What causes a Type 2 MI?
Increased O2 demand or decrease O2 supply (coronary artery spasm, embolism, anemia, arrhythmias, hypertension, hypotension)
How long does it take for full necrosis to occur?
6 hours
What is ventricular remodeling?
Scarring in heart after MI–doesn’t function as well
What agent can reduce scarring post-MI?
ACE Inhibitor!
What are the symptoms of ACS?
Chest pain at rest for more than 20 minutes
Feels like angina
Also: N/V, diaphoresis, SOB, impending doom
How long do you have to do ECG after MI/
Within 10 minutes of presentation
In STEMI, ST is ____ and ___ wave appears
ST is elevated; Q wave appears
What are the cardiac enzymes that indicate MI?
Troponin T and Troponin I–elevation corresponds with size of MI
When should Cardiac Troponin be measured?
In ED and 3-6 hours after symptoms (and maybe later)
What are the TIMI Risk factors?
Age > 65 3 or more risk factors Known CAD >2 episodes of chest discomfort within 24 hours >0.5 mm ST-segment depression \+ biochemical marker
What does the TIMI score mean?
0-2: Low
3-4: Medium
5-7: High
What is the difference between Unstable angina, NSTEMI, and STEMI?
UA: maybe relieved by NTG; No ECG unusualy; negative cardiac markers
NSTEMI: Not usually relieved by NTG; no STE, rarely Q waves; POSITIVE cardiac markers
STEMI: Not usually relieved by NTG; STE; Q waves present; POSITIVE cardiac markers
How are all ACS’s treated initially?
MONA! Morphine Oxygen Nitrates Aspirin
Dosing for Morphine in ACS?
2-4 mg IV q5-30 minutes
When do you give oxygen?
if O2 sat <90%
When do you NOT use nitrates?
- SBP:
- ___ change from baseline
- HR between __ and __
- Use of ___ within 24-48 hours
- SBP <90
- 30 mmHg change from baseline
- HR between 50-100 bpm
- Use of PDEIs within 24-48 hours
How often to monitor BP and HR when using nitrates?
q2h
Dose of IV nitrates during ACS?
5-10 mcg/min titrated to 75-100 mcg/min (for symptom relief or limiting side effects)
Which class of meds should NOT be used for pain management during MI?
NSAIDs!!! (APAP, morphine sulfate, NTGs a-okay!)
What drug classes are used to treat STEMI w/PCI (after MONA therapy)?
- Antiplatelets (P2Y12 inhibitors or GPIIb/IIIa)
- Anticoagulants
Which antiplatelets are used for STEMI w/PCI?
Clopidogrel, Prasugrel, or ticagrelor
Prasugrel or ticagrelor preferred
When is prasugrel contraindicated??
History of TIA/stroke
When are all P2Y12 inhibitors contraindicated?
History of hemorrhagic stroke
Concurrent use of anticoagulants
Moderate-severe liver disease
When is prasugrel used w/extreme caution?
Pts under 60 kg
Pts older than 75 years
How long are P2Y12 inhibitors used after STEMI w/PCI?
12 months
How long before elective CABG should prasugrel b d/ced?
7 days
How long before elective CABG should clopidogrel and ticagrelor be d/ced?
5 days
What are the GPIIb/IIIa inhibitors?
Eptifibitide
Abciximab
Tirofiban
What are Contraindications to GPIIb/IIIa Inhibitors?
-Internal bleeding, major surgery, stroke w/in 30 days
-Hx of hemorrhagic stroke
-Intracranial neoplasm, AV malformation
Acute pericarditis
Uncontrolled HTN
THROMBOCYTOPENIA
Which of the anticoags is administered as a bolus only?
Enoxaparin
What anticoags are used for STEMi w/PCI?
Bivalirudin
Enoxaparin
Heparin
When are fibrinolytics used for medical reperfusion?
When patients can’t be transferred and treated within 120 minutes (PCI)
How does fibrinolytic therapy work (MoA)?
It activates plasminogen to plasmin, which dissolves fibrin clots
What is the dosing for reteplase?
10 units IV then 10 units IV 30 minutes later
What is the dosing for alteplase?
15 mg bolus, then 0.75 mg/kg over 30 minutes, then 0.5 mg/kg over 1 hour
What is the dosing for tenecteplase?
<60 kg: 30 mg IV 60-69.9 kg: 35 mg IV 70-79.9 kg: 40 mg IV 80-89.9 kg: 45 mg IV >90 kg: 50 mg IV
What are the contraindications to fibrinolytics?
- Malignant IC neoplasm
- Active bleeding
- Severe uncontrolled HTN
- TIA w/in 3 months
- Facial trauma or head trauma w/in 3 months
- Aortic dissection
- Cerebral vascular lesion
- Hemorrhagic stroke
- SK: not used within 6 months, or previous allergy
What are MPs for fibrinolytics?
- Evidence for reperfusion (symptoms relief, ECG normalizing, Reperfusion arrhythmia possible)
- Signs of bleeding
- Baseline CBC, platelet count, INR/aPTT
- Mental status changes q2h
What antiplatelets are used for STEMI w/out PCI?
ASA & clopidogrel (300 mg LD on day 1)
How long to administer DAPT after STEMI w/out PCI?
14 days to 1 year
What anticoags are used for STEMI w/out PCI?
Heparin
LMWH (enoxaparin)
fondaparinux
How long should anticoag therapy last for STEMi w/out PCI?
2-8 days
What is the maximum dose for heparin?
Bolus: 4000 units
Infusion: 1000 units/hr
What is the rate of infusion for heparin dose?
12 units/kg /hr
What is the bolus dose of heparin?
60 units/kg
How is enoxaparin dosed?
30 mg IV bolus
1 mg/kg SC q12h
How long should Beta-blockers be used?
3 years
How long should beta-blockers be used if LEF <40%?
still 3 years?
How does Beta blocker help after MI/
Limits myocardial damage and mortality; reduces risk of reinfarction, makes it harder to develop V fib
When should IV Beta-blocker not be used?
Unstable blood pressure (low)
When should IV beta-blocker be used?
High blood pressure
Which patients benefit the most from ACEI therapy post-MI/
Pts with DM, CKD, LVEF <40
Should ACEI be given IV or oral?
ORAL - not IV within 24 hours
How long is ACEI used if LVEF <40%?
forever
What patients may benefit from aldosterone antagonists?
LVEF <40% w/HF symptoms or diabetes
When is aldosterone antagonist contraindicated?
Cr >2.5 in men or >2 in women
K >5 mEq/L
Which antiplatelets are used for UA/NSTEMI?
Clopidogrel or ticagrelor
Which anticoags are used for UA/NSTEMI with PCI?
Heparin
Bivalirudin
LMWH
Fondaparinux
Which anticoags are used for UA/NSTEMI w/out pCI?
Heparin
LMWH
fondaparinux
When should fondaparinux be avoided?
CrCl <30mL/min
