case managment/ AUC etc Flashcards
what is the dose of IV epi for severe analylaxis
What is pre med dosages
do you need to treat for shellfish allerg
IV 1:10K over 5-15 min
prod 50 x 3 over 24 hours planned for emergent pred 50 IV x 1 or hydrocort 200 mg daily
dont need to
what are the treaments for severe reactions.?
Laryengeal edema SQ 1:1000, benadyl, hydrochort 200 mg
Hypotension
- IVF
- 1:10K IVP
IV enox dose for PCI if have been given a dose
0.3 mg/kg
SOHD when can you revasc
a. for sx -
b. for px - LM, LAD , 2VD or 3VD, LV dysfunction with ischemia or FFR < 0.80 for any lad
a. Stenosis > 50% with limiting anging
- sten > 50% with dyspnea or CHF and > 10% LV ischemia
- no limiting sx on OMT
b. for px
- LM > 50%
- any LAD > 50% with documented ischemia or FFR < 0.80
- 2VD or 3VD , LV dysfuntion with ischemia or FFR < 0.80
- large are of ischemia,
- )dont do pci for 1 VD not lad and no ischemia doc
SIHD important class three for PCI
no ischemia documented non LAD vessel with single vessel dz
PCI vs. CABG Guidelines
Can do CABG for all lesional varietes except 1vd/ 2vd no prox lad. (when should do PCI.
Should not do pci Class III 3VD syntax > 22 and ful revasc not possible.
LM + 2VD or 3VD with syntax >= 33
synatx need to now for AUC (2)
> 22 and 3vd/2vd and full revasc not possilbe
>= 33 and LM + 2v or 3vd
How do the guidelines consider PCI
reduces incidence of angina, may increase risk of short term MI and doesnt lower the long term risk of MI
5 year syntax
no differnce in mort but higher mace due to higher revasc.
-<=22 no difference also lm.
22-32 3V subgroup does diverge but LM doesnt
dm pci vs cabg
maace higher with pci 46b vs 29 p 0.0002
freedom 1900 18.7 vs 26.6 exception of stroke
Syntax 2 interesting finding
women did better with cabg than pci
CABG for survival
LM >50%
3VD
CABG or PCI VT due to ischemia mediated VT
lima to pLAD (single vessel dz)
Syntax II what factors lowered syntax for CABG
female, younger, LVEF reduced
LM PCI two major studyies
Nobel included repeat pci at 5 years no mor difference, older stent types.
Excel (xience) –> awaiting 5 year
Syntax LM no difference TVR high PCI and stroke higher for cabg (same theme)
general theme of all PCI vs. CABG studies
no diff in mort, higher macce driven by TLR, higher stroe with cabg
What did stitches show?
improved survival at ten years post CABG compared to medical therapy alone. EF < 35% no need for viability
Drachmans 7 px reason for revasc with PCI - first four aare antaomic
- LM
- pLAD
- multivessel dz
- LV dysfunction
- large ischemic burden
- ischemic VT/cardiac arrest
- acs CV shoc
Guidleine genral concepts: Revasc vs. med therapy for SIHD
for those with silent ischemia or mild sx only revasc if adverse events –> VT, EF drop, MI
When need a cath after noninvasive testing 4
resting or exercise induced lv dysfucntion, stress echo +
duke treadmill score greater than negative 11
LV dilitation or lung uptae with perfusion imaging
CAC >400 agaston
CAC score in which recommend revasc?
> 400 agaston units
revasc is most beneficial with what degree of ischmia?
> 10% per GL (not really in AUC interesting), in one study really was 20% (death 7% vs. 2%)
courage trial basic facts
when did it end?
2004
inclusion angina or + NST and CAD on cath
2287 (1149 PCI + OMT and 1138 OMT)
follow up median 4.6 years
Biggest issue with courage
crossover of 32%
also pci was not ischemia driven
PCI success 93%
BARI 2 D study
inclusion
results
inclusion - DM and 50% >= stnnosis without prior intervention 2x2 factial
did not compare PCI to cabg, CABG vs. OMT and PCI and OMT
reduction of advers events with CABG revasc.
revasc did reduce angina
fame 1005 patients FFR
FFR guided approach reduction in MACE (driven by revasc)
Fame II
FFR PCI + OMT vs. OMT in stable CAD
fame II 5 year
reduced death or mi at 5 years
NSTEMI early invasive how early
2 hours if ongoing angina, hemodynamic stability, ischemia at rest or VT
24 hours otherwise–> in general iia
