Exam 1: ACS (Rogers) Flashcards
Signs and Symptoms of ACS
- nausea or vomiting
- diaphoresis (sweating)
- shortness of breath
Atypical Symptoms
- epigastric pain
- indigestion
- stabbing or pleuritic pain
- increasing dyspnea in the absence of chest pain
Diagnosing ACS
all patients with acute chest pain should have an ECG and troponin measured within 10 minutes of arrival at an emergency facility
STEMI on ECG
- persistent ST elevation
- Q wave not present on initial ECG, but develops over hours to days
NSTEMI/UA on ECG
- may have normal ECG
- ST depression, transient ST elevation, or new T-wave inversion
- Q wave changes unlikely
- no ST elevation
high sensitivity troponin unit
ng/L (preferred)
conventional troponin unit
ng/mL
high sensitivity troponin normal value
< 14 ng/L
conventional troponin normal value
< 0.05 ng/mL
need to check troponin trends
3 levels over 12 hours
Unstable Angina Signs
- chest pain may occur at rest, while sleeping, or with little physical exertion
- is more severe and lasts longer than stable angina (>30 min)
- comes as a suprise
- less ischemia
- does not lead to detectable quantities of troponin
NSTEMI
- troponin is elevated
- not a full occlusion of the vessel
- chest pain
- no ST elevation
STEMI
- chest pain
- troponin is elevated
- persistent ST elevation on ECG
Ventricular Remodeling
changes in the size, shape and function of the left ventricle after an ACS
leads to heart failure
If initial ECG is not diagnostic but the patient remains symptomatic and there is a high clinical suspicion for ACS
serial ECGs should be performed every 15-30 minutes for the first hour
serial troponin levels
levels should be obtained at presentation and 3-6 hours after symptom onset
MONA: M
Morphine
4-8 mg IV, followed by 2-8 mg IV q5-15 min
Side Effects: Morphine
- sedation
- respiratory depression
- nausea/vomiting
MONA: O
oxygen
maintain oxygen saturation > 90%
MONA: N
Nitroglycerin
0.3-0.4 mg q5min x 3 for ischemic pain
IV for persistent ischemia: start at 10 mcg/min and titrate by 5 mcg/min q5min (max 200mcg/min)
Side Effects: NTG
- headache
- hypotension
MONA: A
Aspirin
162-325 mg chewable x 1 dose
coronary angiography
catheter is inserted into the radial and femoral artery and fed up the heart to show blocked artery
stent will be placed if needed
percutaneous coronary intervention (PCI)
small balloon is used to reopen a blocked artery to increase blood flow
fibrinolytic mechanism of action
promotes the conversion from plasminogen to plasmin to increase rate of fibrin degradation
tenecteplase (TNK-tPA) dosing
weight based
reteplase (rPA) dosing
10 units x 2 doses (30 minutes apart)
alteplase (tPA)
15 mg bolus, then weight based dosing
Steptokinase (SK)
- first fibrinolytic
- less expensive
- less specific for fibrin
- not often used in the US
absolute contraindications for Fibrinolytics
- history of intracranial hemorrhage
- ischemic stroke within the past 3 months
- aortic bleeding or dissection
- significant closed-head or facial trauma within the past 3 months
Reperfusion in STEMI
should be administered to all eligible STEMI patients whose symptoms began in the past 12 hours
Is PCI or use of fibrinolytic preferred
PCI: lower rates of death, recurrent ischemia or infarction, intracranial hemorrhage
door to needle time: stemi
within 30 minutes of hospital arrival
door-to-balloon time: stemi
within 90 minutes of hospital arrival
fibrinolytic use in therapy
recommended for stemi patients at non-PCI capable hospital or when ≥120 minutes away from PCI-capable hospital
not recommended for NSTEMI/UA
Early Invasive: NSTEMI
coronary angiography +/- revascularization
preferred for patients with high-risk featurs
Ischemia Guided: NSTEMI
treatment with evidence-based medications
no heart cath unless patient has recurrent ischemic symptoms or becomes hemodynamically unstable
P2Y12 inhibitors in ACS
DAPT recommended for 12 months in STEMI/NSTEMI/UA
DAPT is always ASA+P2Y12
Cangrelor in ACS
IV option used during PCI when patient does not receive loading dose
Cangrelor Dosing
30 mcg/kg followed by 4 mcg/kg/min x 2hours
When to use 300 mg Plavix loading dose
fibrinolytic + ≤75 yoa
when to not use a loading dose of plavix
fibrinolytic + > 75 yoa
Prasugrel not recommended in
ischemia guided strategy (ticagrelor/clopidogrel) preferred
Contraindication: Prasugrel
history of TIA/stroke
not recommended in patients ≥ 75, <60kg, or high bleeding risk
P2Y12 in NSTEMI/UA: Ischemia Guided Therapy
clopidogrel and ticagrelor preferred
P2Y12 in NSTEMI/UA: PCI
any could be used, preference for ticagrelor or prasugrel
P2Y12 in STEMI: Fibrinolytic
clopidogrel preferred
P2Y12 in STEMI: PCI
ticagrelor or prasugrel preferred
Patient Counseling: Aspirin
- bleeding
- take with food
- take lifelong
Patient: P2Y12 inhibitors
- bleeding
- take with aspirin for 1 year
- Take ticagrelor 12 hours apart and let Dr. know of SOB
GP IIb/IIIa Inhibitors place in therapy
potent IV anti-platelets given in addition to ASA and P2Y12 inhibitor
given at the time of PCI
Considering GP IIb/IIIa inhibitors in NSTEMI
highrisk features such as positive troponin
inadequate P2Y12 inhibitor loading
bail out
Considering GP IIb/IIIa inhibitors in STEMI
large thrombus burden
inadequate P2Y12 inhibitor loading
bail out
Abciximab (Reopro) bolus dose
0.25 mg/kg IV
Abciximab (Reopro) maintenance dose
0.125 mcg/kg/min
continue up to 12 hours
Eptifibatide (Integrilin) bolus dose
180 mcg/kg IV x 2 (10 minute apart)
Eptifibatide (Integrilin) : maintenance dose
2 mcg/kg/min
continue up to 18 hours
Eptifibatide (Integrilin) : Renal adjustment
CrCl<50 mL/min
1 mcg/kg/min
Tirofiban (Aggrastat): bolus dose
25 mcg/kg IV
Tirofiban (Aggrastat): maintenance dose
0.15 mcg/kg/min
continue up to 18 hours
Tirofiban (Aggrastat): renal dosing
CrCl < 60 mL/min
0.075 mcg/kg/min
Anticoagulation place in ACS
recommended in addition to anti-platelet therapy to improve vessel patency and prevent reocclusion
Unfractionated Heparin (UFH) MOA
Anti-Xa and anti-IIa activity
Risk of UFH Therapy
HIT: drop in platelet count and increased thrombosis
Enoxaparin MOA
Anti Xa and anti IIa activity (higher ratio than UFH)
accumulates in renal impairment (avoid)
Bivalirudin MOA
direct thrombin inhibitor
Bivalirudin in ACS
may not be effective for MACE and stent thrombosis
may have lower bleeding risk
not used together with GPIIb/IIIa inhibitors except for bail out
Fondaparinux MOA
Factor Xa inhibitor
Fondaparinux in ACS
do not use alone for PCI (high risk of thrombosis)
if already giving fondaprinux and patient needs a PCI, need to give unfractionated heparin or bivalirudin
Fondaparinux Renal Impairment
contraindicated for CrCl < 30 mL/min
UFH Bolus Dose
60 units/kg iv (max 4000 units)
50-100 units/kg during PCI
UFA maintenance dose
12 units/kg/hr infusion titrated to aPPT target
no maintenance dose during PCI
Enoxaparin bolus dose
30 mg IV
Enoxaparin maintenance dose
1 mg/kg sc q12h (first dose 15 min after bolus)
≥75 years reduce to 0.75 mg sc q12h
Enoxaparin Renal Adjustment
CrCl < 30 mL/min
1 mg/kg q24
Bivalirudin Bolus Dose
0.75 mg/kg IV
Bivalirudin maintenance dose
1.75 mg/kg/hr infusion
Bivalirudin renal dosing
CrCl < 30 mL/min
1 mg/kg/hr
dialysis
0.25 mg/kg/hr
Fondaparinux bolus dose
2.5 mg IV
fondaparinux maintenance dose
2.5 mg sc q24h
UFA: NSTEMI Ischemia Guided Strategy
Yes: 48 hours
UFA: NSTEMI Early Invasive Strategy
Yes (until PCI)
UFA: STEMI Fibrinoltyic
yes: 48 hours
UFA: STEMI PCI
yes: until pci
Bivalirduin: UA/NSTEMI Ischemia Guided Strategy
NO
Bivalirduin: UA/NSTEMI early invasive
Yes (until PCI)
Bivalirudin: STEMI fibrinolytic
NO
consider using for HIT
Bivalirudin: STEMI PIC
yes until PCI (preferred for high bleeding risk)
Enoxaparin: UA/NSTEMI ischemia guided
yes (LOS up to 8 days)
Enoxaparin: UA/NSTEMI early invasive
yes until pci
Enoxaparin: STEMI fibrinoltyic
Yes (LOS up to 8 days)
Enoxaparin: STEMI PCI
no
Fondaparinux: UA/NSTEMI ischemia guided
Yes (LOS up to 8 days)
Fondaparinux: UA/NSTEMI PCI
not ideal, do not use alone for pci
Fondaparinux: STEMI fibrinolytic
yes (LOS up to 8 days)
Fondaparinux: STEMI pci
no
Beta Blockers place in ACS
initiate within the first 24 hours of ACS
reasons not to start a beta blocker
- bradycardia
- HF or other low-output state
- risk for cardiogenic shock
- PR interval > 0.24s
- second or third degree heart block
- active asthma or reactive airway disease
Metoprolol target dose
tartrate: 100 mg BID
succinate: 200 mg daily
carvedilol starting dose
6.25 mg bid
carvedilol target dose
25 mg bid
propranolol starting dose
40 mg BID/TId
propranolol maintenance dose
80 mg qid
atenolol starting dose
25-50 mg daily
atenolol target dose
100 mg daily
beta blockers without beta 2 activity
atenolol, metoprolol, bisoprolol, nebivolol
Calcium Channel Blockers place in ACS
administer nonDHP to patients with recurrent ischemia and contraindications to beta blockers
do not use CCBs in patients with
-LV dysfunction
- increased risk for cardiogenic shock
- PR interval > 0.24s
- second or third degree AV block without a cardiac pacemaker
Statins in ACS
- initiate or continue high intensity statin
- obtain lipid profile
High intensity statins
atorvastatin 40-80 mg
rosuvastatin 20-40 mg
ACE inhibitor/ARB place in ACS
recommended in all patients
use cautiously in the first 24 horus of AMI, initiate after 24 hours
captopril starting dose
6.25-12.5 mg tid
captopril target dose
25-50 mg tid
lisinopril starting dose
2.5-5mg daily
lisinopril target dose
≥10 mg daily
ramipril starting dose
2.5 mg bid
ramipril target dose
5 mg bid
valsartan starting dose
20 mg bid
valsartan target dose
160 mg bid
when not to use ACE inhibitor
- hypotension/shock
- bilateral renal artery stenosis
- acute renal failure
-drug allergy/angioedma
monitoring ACEis
- serum creatinine
- potassium (increases)
- decreased blood pressure
- angioedema
maintenance dual antiplatelet
ASA 81 mg
P2Y12 inhibitor x 12 months
Triple Antithrombotic Therapy
- some patients require oral anticoagulation in addition to DAPT
- AFib
- STEMI and asymptomatic LV mural thrombi
- STEMI and anterior apical kinesis or dyskineases
