Acute Coronary Syndromes Flashcards
Patho phys
Takes decades
Begins with intimal thickening and xanthom fomration
Progression leads to dz extension into media and adeventitia
Stbale plaques
ACS after plaque ruptures and exposes necoritc ocre…then thrombotic event occurs
Pathophys of ACS
STEMI - complete coclusion
NSTE - partial…could be NSTEMI and unstable angina
LEads to pump dysfunction and electrical instability
Goal of tx
Interrupt platelet aggregation and thrombus formation
Prevent/minimize myocardial damage
Sx
Angina - pressurel ike, substernal chest discomfort
Radiates
Diaphoresis, dyspnea, nausau, lighthededness and syncope
Duration exceed 5-10 minutes and may have stuttering or waxing and waning course
Guidelines for eval
ECG within 10 minutes and repeat every 5-10
High sensitivity troponin
GRACE or TIMI score
Tx
Invasive - medical therapy, catheterization lab within 72 hours
Ischemia guide - medical tx…eval for ischemia despite medical therapy
When to give O2
If hypoxic - yes
If not hypoxic - probably
Aspirin
Everyone unless contraindication
30-50% reduction in risk of MI
Nitrates
Give SL…if still having pain, consider IV
No mortality benefit
Morphine
Do not give unless going to the cath lab
Heparin and enoxaparin
Hepatin - bolus and drip, higher bleeding rates, reversible, monitoring, control in cath lab
Enox - simple, give IV bolus, less bleeding, better if conservative approach
Bivalirudin - reserved for cath lab
P2Y12 inhibitor
Preferred - clopidogrel or ticagrelor
B blockers
Do NOT need to be given acutely but can be useful if HTN or tachy…can perpetuate shock as SE
Start oral dose in 24 hours unless contraindication
Fibrinolytics
Only given for STEMI
GLycoprotein 2b/3a inhibitors
Not routinely used
If used, check platelets…thrombocytopenia
Abciximab eptifibatide, tirofiban
Stress testing
No indicaiton for stress testing in someone with ACES and chest discomfort/ischemia
Can be performed AFTER stabiliation ofr risk stratificaiton in pts with conservative approach
Angiography
Probably a reasonable option
Mortality benefit in some high risk groups
STEMI management
PCI - preferred, esp if sx over 12 hours or shock…door to balloon time 90 minutes
Thrombolytics - if cannot get PCI within 2h ours…given with 30 minutes of walking into ER
Odd contraind tot thrombolytcis
High BP…always check BP!!!!!!!!!!
STEMI effect on ECG
Acute - ST elevation
Hours - ST elevation, dec R wave with Q wave beginning
1-2 days - T wave inverison and Q wave deepr
Days - ST normalizes, T wave inverted
Weeks later - ST and T noromal and Q wave persists
POst ACS event tx
Aspirin and high intesnity statin for life
P2Y12 inhibt and BEta block for 1 year…no B blocker if LVEF low or anginal
SL Nitroglyc
SMoking cessation and exercise
Risk factor reduction - diabetes, HTN, weight
Cocaine induced chest pain
Tx like regular ACS
Liberal use of benzos, nitrates and CCBs
Beta blockers are controversial
