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PR3154 > AMI > Flashcards

AMI Flashcards

1
Q

coronary heart disease /

IHD

A
  • stable angina
  • ACS
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2
Q

types of ACS

A

STEMI

NSTE-ACS
= NSTEMI (+ve enzyme rise)

= unstable angina (-ve enzyme rise)

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3
Q

cardiac enzymes to monitor

A

CK (rhabdo)

troponin (cardiac muscle death)

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4
Q

angiogram

A

x-ray with contrast dye to see where blockage is located and extent of blockage

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5
Q

CT scan vs MRI scan vs US

A

CT: uses x-ray. 5-15mins. sometimes contrast needed

MRI: magnetic field, radio freq waves. 45mins-2hrs. sometime contrast needed

US; see gross structure (EF, preg, GI)

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6
Q

coronary angioplasty

A

catheter with inflated balloon to compress plaque, achieve reperfusion of blood vessel

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7
Q

reperfusion

A

1) primary PCI (aspirin + P2Y12i, UFH, eptifibatide)
- usually radial approach > femoral

2) fibrinolytics

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8
Q

MI pt steps

A

1) load aspirin
2) PCI = load P2Y12i // thrombolytics

3) anticoagulants (UFH, eptifibatide)

4) PCI

5) DAPT

6) add high intensity statins if no CI
atorvastatin 40-80mg OD
rosu 20-40mg OD

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9
Q

UFH Intravenous (ACT)

A
  • 2000-5000 units (no more than 50-70 units/kg)

to achieve ACT of 250 – 300 seconds

  • repeat bolus (max 10 000 units) as needed to maintain ACT throughout PCI.

if ACT > 2000 secs, not to bolus

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10
Q

UFH and Eptifibatide // previous LMWH use

A
  1. If GPIIb/IIIa inhibitor used (e.g. eptifibatide) used, repeat bolus of up to max 7000 units as needed to maintain ACT throughout PCI.
  2. previous LMWH use: Check ACT prior to bolus
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11
Q

duration of UFH

A

until PCI complete/ 48hrs

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12
Q

LMWH enoxaparin based on when PCI is

A

Last SQ LMWH 8-12h before PCI: 0.3mg/kg bolus

Last SQ LMWH >12h before PCI: Use UFH

Last SQ LMWH <8h before PCI: Nil need for further LMWH

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13
Q

MI with previous thrombolytics

A

Start SQ Enox between 15min before and 30 min after fibrinolytic.

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14
Q

NSTEMI and STEMI PCI dose

LMWH

A

NSTEMI: 1 mg/kg every 12 hours

STEMI: 15before and 30min after fibrinolytic

  • < 75yo, bolus IV 30mg followed by SQ 1mg/kg Q12H
  • if ≥75yo, omit bolus, followed by SQ 0.75mg/kg Q12H
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15
Q

duration of LMWH

A

duration of 48h and up to 8d or until revascularisation.

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16
Q

eptifibatide dose

(anticoag, glycoprotein 2b3a)

A

Double bolus of 180ug/kg iv
(10min interval)

Follow: infusion 2.0ug/kg/min for 72h

  • short t1/2, need infusion.
17
Q

feature of eptifibatide

A
  • Renal dose adj CrCl < 50 ml.min
    Not for ESRD = Cock-gault eqn
  • Short t1.2, Infused for 72h
  • use in pPCI before potent antiPLT
18
Q

FU plans

A
  • duration of antiplt (DAPT)
  • monitor and FU (bleeding risk, SE)
  • counsel
    (DAPT duration and lifelong aspirin: stent is thrombogenic)
    (invasive procedure when to stop DAPT?)
19
Q

monitor labs

A

bleeding
FBC
dyspnea (ticagrelor)

20
Q

stents

  • stent platform
  • polymer coating/ embedded drug
A

bare metal stent (high thrombogenicity)

1st gen –> 3rd gen drug eluting stents
(polymer free, bioresorbable stent,

biolimus drug w/ high lipo)

21
Q

immunosuppressant + DAPT limus from stent

A

prevent overproliferation, stent recognised as foreign body –> clot on stent –> MI

  • in-stent thrombosis
  • or in-stent restenosis
22
Q

12mn (usual) SAPT for

A

prevent recurrence of ASCVD

stop at 3mnth if high bleeding risk

23
Q

bleeding risk assessment at time of PCI

A

precise-DAPT score > 25

major, minor criteria ARC-HBR
HIGH RISK: 1 major risk or 2 minor risk

24
Q

major bleed risk ARC-HBR

to shorten duration

A
  • anticipated use of LT OAC
  • end stage CKD
  • Hb <11g/dL
  • spontaneous bleed (hosp/ transfusion: <6mn)
  • mod-severe thrombocytopenia (PLT)
  • chronic bleeding diathesis
  • liver cirrhosis, protal HTN
  • active malignancy (<12mn)
  • previous spontanous ICH (<12mn)
  • nodeferrable major surgery on DAPT
  • recent major surgery/ trauma within 30d before PCI
25
Q

minor risk ARC-HBR

A

age =/> 75yo

moderate CKD
Hb 11-12.9g/dL
spontaneous bleeding (12mn)

LT use of NSAID/ steroids
ischemic stroke at any time

26
Q

choice of P2Y12i

A
  • ACS (tica)
  • stable CAD (clopid) –> undergoing coronary stent implantation
  • STEMI pt undergoing thrombolysis (clop + aspirin)
27
Q

duration of DAPT

A

CCS, ticag (12mn)

ACS, clopi (6mnth)

28
Q

duration of DAPT (p2y12i) based on bleeding risk

A

HIGH = 3 - 6 mnths
NORMAL = 12 mnths
EXTENDED = >12mnth (risk of ischemic events)

29
Q

criteria for extended DAPT

A

high thrombotic risk: complex CAD + 1 criterion

  • DM
  • hx of recurrent MI
  • multivessel CAD
  • polyvascular disease (CAD + PAD)
  • premature (<45yo) or accelerated CAD (within 2yrs)
  • systemic inflamm disease (HIV, SLE, arthritis)
  • CKD 15-59ml/min
30
Q

technical high thrombotic risk factors

A
  • at least 3 stents implanted
  • at least 3 lesions treated
  • total stent legnth > 60mm
  • hx of complex revascularisation
  • hx of stent thrombosis on antiplt tx
31
Q

moderate thrombotic risk: non-complex CAD + 1 criterion

A

DM
hx of recurrent MI
polyvascular disease (CAD, PAD)
CKD (15-59 ml/min)

32
Q

aspirin dose

A

LD: 300mg (unless alr on aspirin)

75-100mg OD

33
Q

clopidogrel dose

A

Clopidogrel: 600mg (LD),

75mg OM (up to 30mnths)

34
Q

clopi concerns

A

CYP2C19 LOF (23)
incr risk fo CV, CB events (MACCE)
as less clopido effect to protect

35
Q

ticagrelor dose

A

Ticagrelor: 180mg (LD)
For ACS w/ or w/o stent : 90mg BD (12-36mnths)

Extended therapy: 60mg BD
Not funded, expensive

36
Q

ticagrelor concerns

A

Higher bleeding risk
dyspnea , bradycardia (adenosine effect)

37
Q

CVS risk factors to control

A

cholesterol ** add on high intensity statins
HBP
physical activity
LT aspirin use
T2DM
diet
tobacco

PR3154 (11 decks)

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