Acute Coronary Syndromes (STEMI, NSTE-ACS) Flashcards
Unstable angina
Normal cardiac biomarkers
May have nonspecific ECG changes, ST-segment depression, or T-wave inversion
NSTEMI
ST-segment elevation of ≥1 mm in ≥2 contiguous limb or chest leads, although ST-segment elevation in leads V2 and V3 must be ≥2 mm in men and ≥1.5 mm in women
ST-elevation equivalents include new LBBB or posterior MI (tall R waves and ST depressions in V1-V4)
Immediate indications for angiography in unstable angina/NSTEMI
hemodynamic instability
HF
recurrent rest angina despite therapy
new or worsening MR murmur
sustained VT
ST-segment elevation causes
acute pericarditis, LV aneurysm, stress (takotsubo) cardiomyopathy, coronary vasospasm, acute stroke, or normal variant
Key concepts
if ischemic symptoms less than 12 hours, PCI should be performed to improve survival.
Key concepts
If cardiogenic shock or hemodynamic instability, PCI or CABG (when PCI is not feasible) is indicated to improve survival, irrespective of the time from MI onset.
key concepts
PCI should be performed as soon as possible, with first medical contact to PCI time ≤90 minutes in a PCI-capable hospital and ≤120 minutes if transferred from a non–PCI-capable hospital to a PCI-capable hospital.
Other indications for PCI
failure of thrombolytic therapy
new HF or cardiogenic shock
Aspirin indications
ASAP for all patients with ACS
Continue indefinitely as secondary prevention
P2Y12 inhibitor indications (clopidogrel, ticagrelor, or prasugrel in patients with ACS treated with PCI)
ASAP for all patients with ACS
Prasugrel contraindicated in patients age ≥75 years or history of CVA/TIA
Continue for at least 1 year following MI in most patients
β-Blockers indications (metoprolol, carvedilol)
Administer for ACS within 24 hours
Continue indefinitely as secondary prevention
Anticoagulant indications (UFH, LMWH, fondaparinux)
ASAP for definite or likely ACS. Choice depends on reperfusion strategy. Any can be used with thrombolytic therapy. UFH is preferred for PCI, and fondaparinux should be avoided.
ACE inhibitors indications
Administer within 24 hours
Continue indefinitely in patients with reduced LVEF or clinical HF, diabetes, hypertension, or CKD
ARB indications
Administer if intolerant of ACE inhibitor
Nitroglycerin indications
Administer in presence of ongoing chest pain or HF
Statin indications
Administer high-intensity statin early, even in patients with low LDL levels
Continue indefinitely as secondary prevention
Eplerenone indications
Administer 3 to 14 days after MI if LVEF ≤40% and clinical HF or diabetes
Recommendations for temporary pacing acute MI
symptomatic bradycardia (including complete heart block)
alternating LBBB and RBBB
new or indeterminate-age bifascicular block with first-degree AV block
Right ventricular infarction
may present with hypotension or may develop hypotension following the administration of nitroglycerin or morphine. Look for JVD with clear lungs, hypotension, and tachycardia. The most predictive ECG finding is ST-segment elevation on right-sided ECG lead V4R. Treat with IV fluids.
Mechanical complications (VSD, papillary muscle rupture, and LV free wall rupture)
may occur 2 to 7 days after an MI. Emergency echocardiography -initial diagnostic test.
VSD or papillary muscle rupture -> abrupt pulmonary edema or hypotension and a loud holosystolic murmur and thrill.
LV free wall rupture causes sudden hypotension or cardiac death associated with pulseless electrical activity.
Patients with papillary muscle rupture and VSD should be stabilized with an intra-aortic balloon pump, afterload reduction with sodium nitroprusside, and diuretics followed by emergency surgical intervention.
Cardiogenic shock
Emergency revascularization supported by intra-aortic balloon pump and LVAD may be necessary.
Postinfarction angina
Cardiac catheterization is indicated.
ICDs indications in post-MI patients
> 40 days since MI or >3 months since PCI or CABG
LVEF ≤35% and NYHA functional class II or III or LVEF ≤30% and NYHA functional class I
