Chapter 2: CVS Flashcards
Arrythmias
Irregular heartbeat (due to change in rate or rhythm control)
>Conditions like Atrial fibrillation and atrial flutter can be caused by arrythmias.
>Arrythmias can cause coagulation
>We tend to RX with anticoagulants (MI=>Arryth=>AF=>increase coagulation=>DOAC)
>Rhythm control: amiodarone, dronadarone, felcanide, soltalol, propafenone
>Rate control: Beta blockers (no soltalol), rate-limiting CCB contraindicated in HF (diltiazem, verapamil), then digoxin (for sedentary)
> Pill in the pocket approach (only take when needed): 2 drugs: flicanide, propafenone
Which of the following advice is the most appropriate and specifically related to Amiodarone regarding Mrs. R. who has recently been started on Amiodarone 200mg tablets for the treatment of atrial fibrillation?
A. This medicine can cause yellow vision.
B. This medicine may make you sleepy. If this happens, do not drive or use tools or machines. Do not drink alcohol.
C. Do not stop taking this medicine unless your doctor tells you to stop.
D. You may be dazzled by headlights especially at night.
E. Read the additional information given with this medicine.
D. You may be dazzled by headlights especially at night.
Blue-Grey Skin Tone
Amiodarone side effect, happens if patient goes under the sun or UV light exposure/photosensitivity
Ask patient to stop medication immediately and call 999, medical emergency
UPDATES
GTN Doses: 3-5 min for spray to take effect, after 1st and 2nd dose, no improvement, call 999
Stroke Management
3 types: heamorgagic stroke, TIA/minor ischeamic troke w/low risk of bleeding/no risk, ischemic stroke
>start statin as soon as able to swallow 80mg
Drugs: removed MR dipyridamole, added ticagrelor (TIA w/low risk of bleeding)
Blood Pressure:
Statins SE: can cause muscle breakdown (rhabdomylosis), can also cause myasthenia graves (infrequent)
Bromocriptine (Parkinson’s disease, Dopamine agonist can cause sudden onset of sleep, impulse control Disorders (gambling, sexual activity) : can cause CVS events
AMIODARONE
> Amiodarone has a very long half-life. Can stay in body for months even after last dose.
must continue to avoid direct sunlight, rx interactions, grapefruit juice at least 2 month after last dose
Amiodarone can be taken with or without food.
Amiodarone is photosensitive and can lead to a blue-gray tone.
Avoid grapefruit juice (inhibitor), more amiodarone
Corneal microdeposits (dazzling by headlights)
no red flags: book GP
red flags: visual impairment, discharge, blood, pain, send to A/E
Thyroid function (causes both)
Hepatotoxicity (jaundice, nausea, vomitting, fatigue)
Pulmonary toxicity, interstitial lung disease (statins also cause this)
Amiodarone Monitoring
Mneumonic: CHEST – L
>Thyroid function test (before treatment and then every 6 months)
>Liver function tests (before treatment and then every 6 months)
>Serum K+ (measured before treatment), can lead to hypokalaemia
>Chest x-ray (measured before treatment)
>IV use requires ECG (resuscitation facilities must be available)
DRUG INTERACTIONS – flecanaide, digoxin, warfarin, grapefruit juice
Soltalol
> (beta-blocker used to reduce heart rate in arrhythmias)
Sotalol is a water-soluble beta blocker.
Safety information
Sotalol can prolong the QT interval which can occasionally lead to life threatening ventricular arrhythmias
Soltalol Monitoring
Monitor Electrolytes
>ECG and measurement of corrected QT interval
>Serum electrolytes (K+ , Mg2+, Ca2+) (electrolyte disturbance i.e. hypokalaemia, hypomagnesaemia, should be corrected before starting sotalol.
DIGOXIN
> Digoxin is a cardiac glycoside that increases the force of myocardial contraction and reduces conductivity within the av node.
Different bioavailabilities depending on form: IV - 100%, Tablets 50-90%, Elixir 75%)
ANTI-DOTE: Digifab
Electrolyte imbalance leads to toxicity
Hypercalcaemia
Hypokalaemia (caused by diuretics, beta agonist, corticosteroids, theophylline, long term laxatives, insulin)
Hypomagnesaemia (caused by PPI)
hypoxia (low oxygen)
not IM route, only IV to prevent toxicity
Digoxin Toxicity
Advise patients to report to doctor immediately if presence of:
* Cardiac symptoms (arrhythmias and heart block)
* Neurological symptoms (weakness, lethargy, dizziness, headache, mental confusion and psychosis)
* Gastrointestinal symptoms (anorexia, nausea, vomiting, diarrhoea, abdominal pain; avoided by dividing larger doses)
* Visual symptoms (blurred and/yellow vision)
GIVE DIGIFAB
Digoxin Monitoring
> Serum electrolytes (K+ , Mg2+, Ca2+) (toxicity increased by electrolyte disturbance i.e., hypokalaemia, hypomagnesaemia, and hypercalcaemia)
Renal function (renal excretion of drug; reduce dose in renal impairment to reduce accumulation of metabolite)
Plasma-digoxin (mainly in renal impairment, blood should be taken at least 6 hours after dose) (NSAIDs, ACE/ARB, methotrexate increases digoxin toxicity)
Heart rate (should be maintained above 60 beats/min)
Renal impairment: Reduce dose, monitor plasma concentration in renal impairment
Digoxin Interactions (Drugs, Mode of Interaction, Effects, Solution)
> Amiodarone , quinine, dronaderone (increase conc. of digoxin in system leading to toxicity, reduce digoxin to 50%)
Diuretics (hypocalamia leads to toxicity, change drug)
Nsaids
ACE inhibitor
St Johns wort (enzyme inducer, reduces digoxin then patient at increased risk, stop st. johns)
HAS-BLED TOOL
What is the use of HAS-BLED TOOL? measure the risk of bleeding for patients on anticoagulants who have history of A.fib
>HAS-BLED SCORE uses the following in calculation
>Age Eg over 65
>Hypertension
>Liver/kidney Disease
>Alcohol use, Stroke
ORBIT TOOL NEW – gender, age over 74, bleeding history, Egfr less 60ml/min and treatment with antiplatelets
Total score is 7 . Below 2 is low , 3 to 4 medium , 5 to 7 high
Which statement is NOT TRUE about warfarin?
A. Warfarin can cause Calciphylaxis
B. Warfarin can cause purple toes.
C. Warfarin is easier to reverse compared to NOAC drugs.
D. Warfarin can interact with carbamazepine and lead to an increase in INR.
E. An INR of 2.5 is target for patients taking warfarin with conditions like Mitrial Stenosis
D. Warfarin can interact with carbamazepine and lead to an increase in INR. (leads to a decrease in INR)
When INR goes up, bleeding goes up. Low INR, reduced bleeding.
WARFARIN
> Antagonises the effect of vitamin K.
Anticoagulant effect takes 48 to 72 hours to fully develop
Target within 0.5 nits of target value is satisfactory
Anticoagulant treatment yellow booklets and alert cards should be issued to all patients
Take at the same time of day, once a day with a full glass of water, if a dose is missed DO NOT double the dose the next day
Careful with green leafy vegetable (spinach, kale, broccoli, Brussel sprouts, collard greens, pumpkin leaves). Patient should notify their anticoagulation clinic of any changes to medication, lifestyle or diet
Brown tablets = 1mg Blue tablets = 3mg Pink tablets = 5mg white = 0.5mg
Ensure warfarin dose is expressed in milligrams and not the number of tablets
purple toes – bilateral, painful lesions on toes/feet that blanch with pressure.
INR TARGETS
INR 2.5 for:
>treatment of deep-vein thrombosis or pulmonary embolism (including those associated with antiphospholipid syndrome or for recurrence in patients no longer receiving warfarin sodium)
>atrial fibrillation
>cardioversion—target INR should be achieved at least 3 weeks before cardioversion and anticoagulation should continue for at least 4 weeks after the procedure (higher target values, such as an INR of 3, can be used for up to 4 weeks before the procedure to avoid cancellations due to low INR)
>dilated cardiomyopathy
>mitral stenosis or regurgitation in patients with either atrial fibrillation, a history of systemic embolism, a left atrial thrombus, or an enlarged left atrium
>bioprosthetic heart valves in the mitral position (treat for 3 months), or in patients with a history of systemic embolism (treat for at least 3 months), or with a left atrial thrombus at surgery (treat until clot resolves), or with other risk factors (e.g. atrial fibrillation or a low ventricular ejection fraction) [note: NICE guideline NG208 (Heart valve disease presenting in adults: investigation and management, November 2021) does not recommend anticoagulation after surgical biological heart valve replacement unless there is another indication for anticoagulation.]
>acute arterial embolism requiring embolectomy (consider long-term treatment)
>myocardial infarction
INR 3.5 for:
>recurrent deep-vein thrombosis or pulmonary embolism in patients currently receiving anticoagulation and with an INR above 2;
>Mechanical prosthetic heart valves:
the recommended target INR depends on the type and location of the valve, and patient-related risk factors
consider increasing the INR target or adding an antiplatelet drug, if an embolic event occurs whilst anticoagulated at the target INR.
***learn 3.5 conditions
Manage INR
High INR and Bleeding
>give vitamin K by injection/IV
> Major bleeding—stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injection; give dried prothrombin complex (factors II, VII, IX, and X); if dried prothrombin complex unavailable, fresh frozen plasma can be given but is less effective; recombinant factor VIIa is not recommended for emergency anticoagulation reversal
INR >8.0, minor bleeding—stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injection; repeat dose of phytomenadione if INR still too high after 24 hours; restart warfarin sodium when INR <5.0
INR >8.0, no bleeding—stop warfarin sodium; give phytomenadione (vitamin K1) by mouth using the intravenous preparation orally [unlicensed use]; repeat dose of phytomenadione if INR still too high after 24 hours; restart warfarin when INR <5.0
INR 5.0–8.0, minor bleeding—stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injection; restart warfarin sodium when INR <5.0
INR 5.0–8.0, no bleeding—withhold 1 or 2 doses of warfarin sodium and reduce subsequent maintenance dose
Unexpected bleeding at therapeutic levels—always investigate possibility of underlying cause e.g. unsuspected renal or gastro-intestinal tract pathology
ADVICE FOR PATIENTS ON WARFARIN
> They should always take their anticoagulant treatment booklet (‘Yellow book’) when they go to the warfarin clinic to have their INR checked.
They should take their warfarin at the same time each day.
They should not miss doses or take additional doses, without advice from a healthcare professional.
They must inform anticoagulant clinic staff if they think they have taken too much warfarin or have missed any doses.
If a dose is accidentally missed, they should continue with the regimen as prescribed, and never take a double dose (unless specifically advised).
Seek medical advice before undertaking any major changes in diet, especially if their diet is rich in vitamin K (such as broccoli, kale, or spinach) — this can potentially affect control of anticoagulation.
Limit alcohol intake to a maximum of one or two drinks a day, and never binge drink. (excessive alcohol leads to increase risk of bleeding)
Inform the anticoagulant clinic staff and other healthcare professional (their GP, dentist, pharmacist, and/or medical or nursing staff) of changes to their lifestyle, for example if they start, stop, or change the dose of other medicines.
Spontaneous bleeding occurs whilst on warfarin and the bleeding does not stop, or recurs. This includes bruising, bleeding gums, nosebleeds, prolonged bleeding from cuts, blood in the urine or stools, coughing up blood, a subconjunctival haemorrhage, and vaginal bleeding in a postmenopausal woman.
They get sudden severe back pain (which may indicate spontaneous retroperitoneal bleeding).
They experience difficulty breathing, increased breathing rate, or chest pain (which could be symptoms of pulmonary embolism).
Warfarin Interactions
> In pregnancy: No, causes congenital malfunctions, LMWH as alternative (must be given by brand: enoxaparin=clexin)***doesnt cross placenta
Travelling patients: wear compression stockings, increase mobility
Surgery: stop taking warfarin 5 days before elective (planned) surgery
INTERACTIONS
>Azoles (for thrush)– fluconazole, miconazole, clotrimazole (increase risk of INR, increases bleeding)
>Cranberry juice, pomegranate (both enzyme inhibitors, increases warfarin)
>Diet – green leafy veg
>SSRIs (GI irritation and GI bleeding)
>Metronidazole (can take 5-7 days max if INR is stable)
>NSAIDs (increase risk of bleeding)
>St John’s wort (reduces warfarin, increases clotting)
Scenario: Warfarin |Management | Anticoagulation - oral | CKS | NICE
DIRECT ORAL ANTICOAGULANTS (DOACS)
Mneumonic: READ, see an O (once a day: rivaroxaban, edoxaban)
> Direct-acting oral anticoagulants (DOACs) include apixaban, dabigatran etexilate, edoxaban, and rivaroxaban. Dabigatran etexilate is a reversible inhibitor of free thrombin, fibrin-bound thrombin, and thrombin-induced platelet aggregation. Apixaban, edoxaban, and rivaroxaban are reversible inhibitors of activated factor X (factor Xa) which prevents thrombin generation and thrombus development
> Types of DOAC:
rivaroxaban (brand names include Xarelto)
dabigatran (brand names include Pradaxa)
apixaban (brand names include Eliquis)
Edoxaban (brand names include Lixiana)
DOAC eGFR
REA: 15, D: 30 (dabigatran is different)
MHRA/CHM advice: Direct-acting oral anticoagulants (DOACs): reminder of dose adjustments in patients with renal impairment
(May 2023)
>Dabigatran – avoid if eGFR less than 30 ml/min/1.73 m² (risk of bleeding)
>Apixaban – avoid if eGFR less than 15 ml/min/1.73 m² (risk of bleeding)
>Rivaroxaban – avoid if eGFR less than 15 ml/min/1.73 m² (risk of bleeding)
>Edoxaban – avoid if eGFR less than 15 ml/min/1.73 m² (risk of bleeding)
CRITERIA – APIXABAN / EDOXABAN
> Antidote is Andexanet Alfa. Risk of bleeding, nose bleeds (stop taking medicine, seek medical attention) e.t.c
WHEN TO GIVE 2.5mg BD or 5mg BD dose ?? 2 of first 3 criteria to be on higher strength
AGE – LESS than 80 years
BODY WEIGHT – over 60kg
SERUM CREATININE–less than 133micromol/litre
creatinine clearance - 15–29 mL/minute.
Interactions – Nsaids, SSRIs, clarithromycin, st. johns’ wort, lopinavir
EDOXABAN (no antidote)
61kg or more – for 60mg Edoxaban
Interactions
ciclosporin , erythromycin , ketoconazole, dronaderone, amiodarone
CRITERIA – DABIGATRAN / RIVAROXABAN
> DABIGATRAN IS DIFFERENT
Dabigatran Antidote is idaricuzimab >Risk of bleeding , nose bleeds e.t.c
do not include in a dossette box (hygroscopic, attracts water)
avoid if eGFR less than 30 ml/min/1.73 m² (risk of bleeding)
Mode of action: direct thrombin inhibitor
Most expensive on annual basis
Rivaroxaban (factor Xa inhibitor)
which strengths to take with food? 15, 20 mg absorbed better
**DOAC summary
DIFFERENCES BETWEEN WARFARIN AND NOACS
> Cost: doac more expensive
Convenience /MONITORING: doac more convenient, no monitoring of INR
Duration of action: 12 (BD)-24(OD), Warfarin: 72 hrs
Diet: green leafy vegetables dont interact
Drug interactions: SSRI (increases bleeding), NSAIDs (increase bleeding), Aspirin/Antiplatelets (increase bleeding), amiodarone (increase conc. of doacs)
A 55-year-old man has just suffered from transient ischaemic stroke with low bleeding risk. His daughter calls 999 and paramedics arrived in an ambulance shortly after. The man has not been given any medication and there are no signs or symptoms of haemorrhage. NKDA
Which medication would you expect the patient to be administered when he initially presents in hospital?
A. Ticagrelor 90mg
B. Aspirin 300mg
C. Alteplase 900mcg
D. Aspirin 300mg plus clopidogrel 300mg
E. Clopidogrel 75mg
D. Aspirin 300mg plus clopidogrel 300mg (day 1), then reduce Aspirin 75mg and clopidogrel 75mg for 21 days
ASPIRIN
> Antiplatelet drug
Caution – anaemia, asthma, ulcer, uncontrolled hypertension
Contraindicated – bleeding disorders, severe cardiac failure, haemophaelia
Causes reyes syndrome in patients under 16yrs (except for Kawasaki disease)
Can pregnant women take aspirin? Yes, pre-eclampsia in 2nd and 3rd trimester (75/150mg OD dependent on BMI), OTC only if prescribed (check SCR)
Toxicity symptoms include – tinnitus, deafness, sweating , vasodilation , coma.
Antidote: sodium bicarbonate
CVD PREVENTION – PRIMARY VS SECONDARY
Drug interactions – warfarin, anti-platelet drugs, asthmatic patients
Aspirin | Drugs | BNF | NICE see link for doses of Aspirin in stroke
STROKE
WHAT ARE THE SYMPTOMS OF STROKE??? ACT FAST
face drooping, slurred speech, paralysis, numbness, confusion
>There are three types of strokes: TIA, Ischceamic stroke, haemorrhagic
>Initial management and long-term treatment
>Haemorrhagic stroke (deadly)
>Control blood pressure if high. Might need scan and medical procedures
>No statins, No aspirin or anticoagulant unless risk of DVT or PE
>Transient Ischaemic attack
>Immediately give Aspirin. Plus PPI if necessary
>Ischaemic stroke (70%)
>Give Alteplase within 4.5 hours of symptoms of acute ischaemic stroke. Not in intracranial haemorrhage. Give Aspirin within 24 hours if no haemorrhage . No warfarin in acute phase.
Stroke
> Transient ischaemic attack and minor ischaemic stroke
Patients suspected of having a transient ischaemic attack should immediately receive aspirin, unless contraindicated. Patients with aspirin hypersensitivity, or those intolerant of aspirin despite the addition of a proton pump inhibitor, should receive a suitable alternative antiplatelet.
Patients presenting within 24 hours of transient ischaemic attack or minor stroke who have a low risk of bleeding, should be considered for dual antiplatelet therapy with clopidogrel plus aspirin followed by clopidogrel monotherapy. Ticagrelor [unlicensed use] plus aspirin dual antiplatelet therapy followed by either ticagrelor [unlicensed use] or clopidogrel [unlicensed use] monotherapy is also an option. For patients who are not appropriate for dual antiplatelet therapy, clopidogrel monotherapy [unlicensed use] should be given.
A proton pump inhibitor should be considered for patients with a history of dyspepsia associated with aspirin, or for concurrent use with dual antiplatelet therapy to reduce the risk of gastrointestinal haemorrhage.
ISCHAEMIC STROKE
> Initial management
**rule out any intracranial bleeding
Alteplase or tenecteplase [unlicensed use] are recommended in the treatment of acute ischaemic stroke if it can be administered within 4.5 hours of symptom onset and if intracranial haemorrhage has been excluded by appropriate imaging techniques. It should be given by medical staff experienced in the administration of thrombolytics and the treatment of acute stroke, within a specialist stroke centre. Some patients may also be eligible for surgical management. Provided that intracranial haemorrhage has been excluded, patients who received thrombolysis should be started on an antiplatelet after 24 hours, unless contraindicated.
Patients with disabling acute ischaemic stroke should be started on aspirin (unless contraindicated) as soon as possible within 24 hours and continued for 2 weeks after stroke onset, when long-term antithrombotic treatment should be started. Patients being transferred to care at home before 2 weeks should be started on long-term antithrombotic treatment earlier.
Anticoagulants are not recommended as an alternative to antiplatelet drugs in acute ischaemic stroke in patients who are in sinus rhythm (only in DVT/Pulmonary Embolism). However, anticoagulants may be indicated in patients with ischaemic stroke and symptomatic deep vein thrombosis or pulmonary embolism. Patients with immobility after acute stroke should not be routinely given low molecular weight heparin or graduated compression stockings for the prevention of deep vein thrombosis. Warfarin sodium should not be given in the acute phase of an ischaemic stroke. Patients already receiving anticoagulation for a prosthetic heart valve who experience a disabling ischaemic stroke and are at significant risk of haemorrhagic transformation, should have their anticoagulant treatment stopped for 7 days and substituted with aspirin.
Treatment of hypertension in the acute phase of ischaemic stroke can result in reduced cerebral perfusion, and should therefore only be instituted in the event of a hypertensive emergency, or in those patients considered for thrombolysis.
HEMORRHAGIC STROKE
Avoid aspirin, antiplatelets, statins
>Surgical intervention may be required following intracerebral haemorrhage to remove the haematoma and relieve intracranial pressure.
>Rapid blood pressure lowering treatment should not be given to patients who have an underlying structural cause, have a score on the Glasgow Coma Scale of below 6, are going to have early neurosurgery to evacuate the haematoma, or who have a very large haematoma with a poor expected prognosis.
>Consider rapid blood pressure lowering for patients who present within 6 hours of symptom onset with a systolic blood pressure between 150 and 220 mmHg and who do not fit any exclusion criteria. Aim for a systolic blood pressure target of 130 to 139 mmHg within 1 hour and sustained for at least 7 days, ensuring that the magnitude drop does not exceed 60 mmHg within 1 hour of starting treatment. Rapid blood pressure lowering should also be considered on a case-by-case basis for patients who present beyond 6 hours of symptom onset or who have a systolic blood pressure greater than 220 mmHg and who do not fit any exclusion criteria. Seek specialist paediatric advice if considering blood pressure lowering in patients aged 16 or 17 years who do not fit any exclusion criteria.
>Patients taking anticoagulants should have this treatment stopped and reversed. Anticoagulant therapy has, however, been used in patients with intracerebral haemorrhage who are symptomatic of deep vein thrombosis or pulmonary embolism; placement of a caval filter is an alternative in this situation.
>Patients with immobility after acute stroke should not be routinely given low molecular weight heparin or graduated compression stockings for the prevention of deep vein thrombosis.
LONG-TERM TREATMENT
Blood Pressure and Cholesterol
> Specialist advice should be sought for patients with atrial fibrillation and those at a high risk of ischaemic stroke or cardiac ischaemic events, as aspirin and anticoagulant therapy are not normally recommended following an intracerebral haemorrhage.
Blood pressure should be measured and treatment initiated where appropriate, taking care to avoid hypoperfusion. For guidance on blood pressure lowering therapy and treatment targets, see Hypertension.
After a stroke, don’t start beta blocker treatment for hypertension.
> Statins should be avoided following intracerebral haemorrhage, however they can be used with caution when the risk of a vascular event outweighs the risk of further haemorrhage. Patients should be assessed for lipid-lowering therapy on the basis of their overall cardiovascular risk and the underlying cause of the haemorrhage. For further information, see Cardiovascular disease risk assessment and prevention.
Put on Atorvastatin 80mg as soon as they can swallow
LONG-TERM PREVENTION OF STROKE
> Bloods - clopidogrel, ticagrelor , aspirin
BP control 130/80 - Anti-hypertensives but not beta-blockers
Cholesterol control – High intensity Statins
Give lifestyle advice such as stop smoking , physical activity , alcohol reduction, diet, weight loss
CHADS-VASC SCORE - STROKE
likelihood of patient developing a stroke
CONGESTIVE HEART FAILURE 1
HYPERTENSION 1
AGE 75 OR MORE 2
DIABETES 1
STROKE 2
-VASCULAR DISEASE 1
AGE 65 TO 74 1
SC SEX CATEGORY 1
Statin for primary prevention: Atorvastatin 20mg and BP
Higher the score, higher the risk.
Following admission to hospital a 68-year-old patient has their QRISK-3 score calculated. This score is taken into account before initiating suitable treatment.
What purpose does the QRISK-3 tool serve?
A. Calculates the likelihood of a patient having a major cardiovascular event over the following ten years.
B. Determines a patient’s probability of having a deep vein thrombosis.
C. Estimates the risk of bleeding in patients with atrial fibrillation who are being offered anticoagulation.
D. Estimates the risk of bleeding in patients with heart failure who are taking immunosuppressants.
E. Estimates the risk of stroke for a patient with non-valvular atrial fibrillation.
A. Calculates the likelihood of a patient having a major cardiovascular event over the following ten years.
Start, Stop criteria for elderly.
MYOCARDIAL INFARCTION (HEART ATTACK)
> Myocardial infarction or M is a serious medical emergency in which the supply of blood to the heart is suddenly blocked or reduced usually by atherosclerosis or blood clot.
STEMI
A STEMI or ST-elevation myocardial infarction is caused by a sudden complete (100 percent) blockage of a heart artery (coronary artery).
NSTEMI
A non-STEMI is usually caused by a severely narrowed artery but the artery is usually not completely blocked. The diagnosis is initially made by an electrocardiogram (ECG or EKG).
ACUTE CORONARY SYNDROME
Unstable Angina: rupture or artery causes chest pain, GTN
STEMI: complete blockage
NSTEMI: plaque narrows
ECG
QT interval
ST segment: if elevated (STEMI), if stays as is – or dips (NSTEMI)
TREATMENT
DRUG TREATMENT NSTEMI – MONA HB
Morphine, oxygen, Nitrates, Aspirin, Betablockers, heparin (low molecular weight)
DRUG TREATMENT STEMI – OBAMA SN
Morphine, Oxygen , Nitrates, Betablockers, Aspirin, Ace-inhibitors, statins.
