Cardio 24: NSTEMI and ACS Flashcards
Describe the events that leak to occlusion of coronary vessels
Plaque formation. Plaque gets larger and becomes less stable. Fibrous cap thins leading to rupture and thrombus formation !
Risk factors for ACS
HTN (>140/90) Age Men >45, women >55 Diabetes Dyslipidemia Family hx Smoking Sedentary lifestyle Chronic Kidney Disease (CKD)
Symptoms of ACS
Chest pain (Jaw, arm, back, shoulder) Shortness of breath Fatigue/weakness Nausea Diaphoresis lightheadedness
DDx for ACS
Pericarditis
Aortic dissection
Don’t miss and give anti-coagulants/platelets to.
Pneumothorax
Pulmonary embolism
Often presents similar to MI
GI causes
MusculoskeletalWhen will might you not see ST elevation with MI or UA ?
if collateral circulation has formed
Vasospams causing erosion
Coronary artery inflammation (youger patients )
Secondary Unstable Angina: Non-occlusive, come in with pneumonia can lead to decrease of blood supply/ oxygen leading to chest pain
Coronary artery dissection
What is the most common cause of UA/NSTEMI ?
Atherosclerotic CAD
What are the diagnostic tools used for ACS ?
H&P EKG CXR Biomarkers Cardiac imaging
What is the goal for placing an EKG ?
get it on in 10 minutes from presentation
Troponins are the biomarker of choice because
they are sensitive and specific .
Present at 2 hours after infarction
stay elevated for 14 days post infarction
What increases with a greater level of troponins in blood ?
Greater chance of death !
which biomarkers are useful to detect re-infarction >
CPK and CPK MB
Earliest biomarker to rise
myoglobin
BNP is not very important except for in assessment of …
Risk
Higher level = worse outcome
What will you look for on CXR to assess cardiac health ?
Mediastianal widening
CHF
Cardiomegaly
CT scans are useful in detecting
Aortic dissection
PE
Not very practical due to how long it takes
Echocardiogram is useful in assessing
LV size and systolic function
Very useful for Circumflex occlusion diagnosis.
Wall motion abnormalities
Mitral regurgitation
Pericardial effusionWhich patients are amenable to Stress testing ?
Low risk and stable patients
What is the “Gold Standard” for imaging ?
Cardiac catheterization
Diagnosis and treatment in same setting !
List the classes of Anti-platelet drugs
ASA
Thienopyridines
IIB/IIIA Inhibitors
Aspirin MOA
Cox-1 inhibitor (irreversible) prevents formation of thromboxane A2 (TxA2 platelet activation)
WIll a heart patient need to be on aspirin for life following ACS ?
Yes, 81-325 mg daily
MOA for Clopidogrel (plavix)
ADP receptor agonist
How long will a patient with a bare metal stent need to be on plavix (minimum)
One month
How long will a patient with a drug eluting stent need to be on plavix (minimum)
12 months
If you use ticlopidine instead of plavix what must be monitored ?
Complete blood count
Prasugrel has a shorter onset and can be given at the time of catheterization, making it a useful drug. What is a CI for this drug ?
Previous stroke, TIA or risk for intercranial hemorrhage.
What is a side effect of Ticagrelor ?
Chest tightness due to Adenosine release
Abciximab, Eptifibatide and Tirofiban are representative of what class of drugs ?
IIB/IIIA inhibitors
abciximab is a large molecule (binds irreversibly)
The other two are small molecule (bind reversibly)
Useful for HIGH RISK patients
If you do not plan to catheterize should you use Abciximab ?
nope
What class of drugs should be used in all patients suspected of ACS ?
Anti-coagulants
UFH inhibits Factor III leading to thrombin inactivation. The downside of this drug is…
Hard to control and must monitor
May actually activate platelets
Enoxaparin (LMWH) is good choice because it can be dosed subq and does not need…
to be monitored like UFH
Bivalrudin is a direct thrombin inhibitor. It does not require monitoring and has a reduced risk of bleeding. What is a downside ?
Expensive
Fondaparinux inhibits
Factor Xa
When is Fondaparinux considered the agent of choice ?
conservative treaments of individuals with increased bleeding risks !
Absolute Contraindication for Thrombolytics Include
Unstable Angina
NSTEMI
Previous Stroke Arteriovenous Malformation Cerebral malignancy Head Trauma within the past week Active bleeds
Anti-ischemics include
Bed rest O2 Doesn’t reduce risk unless hypoxic but still done regularly Β-blockers Nitrates Opiates Ace-I/ARB CA++ channel blockers
Advantages of Beta Blockers
Decrease HR, BP & contractility–> DECREASES MYOCARDIAL WORKLOAD (MVO2)
Decrease infarct size and reinfarction
Decreases Arrhythmias
Decreases mortality? (short vs. lon
When are BB’s contraindicated ?
Left sided heart failure
Hypotension –> shock
Severe asthma or COPD
How is metoprolol (a BB) administered
5mg IV q5’ X3 (HR 55-60 & BP>100) (Cautiously)
25-50mg PO BID w/i 24°
MOA for Nitrates
Coronary artery and venodilator
Decreases BP by decreasing preload
Decreased BP means decreased O2 demand
“Dilates coronary artery” actuallly just
decreases demand on the heart by decreasing
pre-load”
Should nitrate administeration preclude ACEi or BB therapy ?
NO !
NO survival benefit ever proven therefore should not preclude use of β-blocker or ACE-I
0.4mg SL q5’ X3
When should ACE-I be given within the first 24 hrs ?
EF <40%
Pulmonary congestion
ACEi should not be used if patient is….
hypotensive !
Or sensitive. In which case use an ARB
Non Dihydropyridine Ca+ channel blockers can be used if there is a contraindication for which class of drugs normally given to ACS patients ?
Beta Blockers
Non-DHP CCB’s
Under what conditions will you give Non-DHP CCB’s and BB’s together ?
Refractory ischemia
whens should you use caution with CCB’s and BB’s alike ?
Left ventricular dysfunction
Intra Aortic blood pump
Diastole it inflates backpush of blood leading to coronary perfusion
Systole colapses blood pumping
When should statins be administered to admitted ACS patients ?
as early as possible.
Has pleiotropic effects
TIMI Risk score
Important for assessing risk in invasive treatment of ACS
TIMI RISK-one point for each
Age >65
3 risk fx for CAD ( on the right)
Diabetes
Smoking
Men >45 Women >55
Low HDL
Fam Hx
ASA use in prior 7 days
Already feeling pain….
ST segment changes of ECG
Prior stenosis >50%
2 or more anginal events in prior 24°
\+ biomarkers
RIsk score is from 0-7 ( 4.7% - 40.9% risk of mortality)
PCI
Percutaneous coronary intervention (PCI)
Balloon angioplasty
Bare metal stents
Drug eluting stents
OtherCABG
Coronary artery bypass grafting (CABG)
Use of internal mammary artery important
Identify pts not considered high risk likely to benefit from invasive rx
Recurrent sx on appropriate med rx
High risk stress test
Long Term Treatments with Anti-platelet drugs
ASA
Thienopyridines
Varying length of time (maybe a month, maybe a year)
Lifetime use
Warfarin
Not really indicated. No benefit over aspirin. Needs to be monitored and higher risk of bleeding.
What is the goal of anti-ischemic and antihypertensive long term treatment
Goal BP <140/90 (130/80 w/ DM or CKD)
What is the goal of Lipid lowering therapy long term
Goal LDL <70 in high risk pts)
For diabetics, what is the goal HbA1c
< 7
Mandatory vaccinations for patients with ACS include
Influenza
Mandatory !!
Pneumovax
Why should patients with ACS avoid NSAIDs ?
Increases risk of heart disease and death.
Use nonselective only if absolutely necessary
Separate dose 4° from ASA
