IHD - ACS √ Flashcards
What are the diagnostic for STEMI
ST elevation
Biomarkers +
What are the diagnostic for NSTEMI
ST depression or T-wave inversion
Positive biomarkers
What are the Diagnostic for unstable Angina
ST depression or T wave inversion
Positive biomarkers
ACS clinical symptoms
Chest pain - that could radiate
Nausea
Sweating
Impending doom
Low grade fever
4th heart sounds
3rd heart sounds
What does BBB (brachial branch block )
1 or 2 mm raise in 2 or more leads (1-6 lead)
When do you take cardiac draws in the hospital
Every 6-8 for 3-4 draw bc some biomarkers are later in onset
What is the most important function of the heart ?
LV function and if you cant fix it you get a scar that can cause death if it ruptures
What does everyone get if they have STEMI or NSTEMI
Oxygenation only if < 90%
ECG leads monitoring
Glycemic control (<180 glucose)
Pain relief
Stool softeners
Vital Monitoring
Chest discomfort last ≥10mins flow chart (pic)
does it matter where in the hospital the patient is?
yes bc it helps give perspective
ED - Thrombolysis
Cath lab - PCI
ICU/Ward - Secondary prevention
STEM flow chart for treatment (pic)
Usually do fibrinolytic or primacy PCI, Happens in the ED
What is given to all STEMI patients
M- + or - morphine 1-5mg IV every 5-30mins (may or may not give due to chest pain relief being unknown wether it be nitro or morphine, usually 3 dose may or may not give M)
O - only give below 90%
N- Nitro .4mg every 5 mins for 3 dose (tachyphylaxis sign of nitrate intolerance, usually not in STEMI pts)
A - aspirin give 325 ( #1 drug to use )
Heparin (#2 drug to use)
+/- Metropolol, PY12 inhibitor, Statin
What anticoagulant is the drug of choice
Heparin
When would I use morphine but what do i risk as well
usually a patient that has high anxiety bc it raises heart rate but it can mask the pain of the chest and a DDI with clopidogrel
When would i consider giving O2
<90, HF or dyspnea
5 nitro contraindications
- SBP < 90
- 30 mmHg lower than baseline
- PDE-5i
- RV infarct
- hypertrophic heart
Limit: anginal pain, LV failure, severe hypertension
Heparin STEMI dosing for Fibrinolysis
Fibirnolysis
Bolus - 60 unit/kg/IV max 4000
Main - 12 unit/kg/IV max 1000 units
Heparin Stemi Primary PCI or medical management
PCI and medical management
Bolus - 60 unit/kg/IV max 5000
Main - 12 unit/kg/IV max 1000 units
Anti X and aPPT goal for Heparin STEMI/NSTEMI
Anti Xa - 0.3 - 0.6
aPPt - 50-70
In a STEMI when would I consider Beta Blockers
HR is in the 130 and ongoing STEMI
high O2 Demand
Hypertension
on going ischemia
When do we avoid BB in STEMI
Advance age 70+
Bradycardia < 60 bpm
Hypotensive pt SBP < 120
Prolonged PR interval >0.24 sec or 2nd/3rd degree Heart block
Active asthma or airway disease
Reperfusion flowchart for STEMI
Do we prefer PCI or thrombolytic in reperfusion
PCI because a much higher flow so much so that we withhold treatment with fibrinolytic for 30mins max
What is the fibrinolysis door to needle time
≤ 30 mins
If I can’t get to a cath lab when would I use Fibrinolysis
within 12 hours with elevation and can not be brought to the cath lab
What is the biggest risk of Fibrinolytics and which populations are more at risk?
ICH
75 +
Female
Cerebral vascular disease
elevated SBP/DBP
HTN
Which fibrinolytic have the lowest bleeding rate
Alteplase
Which fibrinolytic is recommended for STEMI
Tenecteplase because fast dosing ( iv over 5 seconds)
<60 kg 30 mg
60-69 35 mg
70-79 40 mg
80-89 45 mg
>90 50 mg
Alteplace dosing for STEMI
15 mg over 1 - 2 mins
0.75 kg/min over 30 mins
0.5 kg/min over 60 mins
What are the 3 criteria for successful fibrinolytic
- > 50% reduction in ST segments of the ECG
- Relief of chest pain
- Appearance of reperfusion arrhythmias
What are some options for antithrombotic during PCI
- Heparin as mono
- Heparin and cangrelor
- Stop heparin start Bivalirudin mono
- Stop heparin start Bivalirudin and cangrelor
- RARE use of glycoproteins IIb/IIIa add on to one above (salvage or bailout)
Why do most providers switch to Bivalirudin from heparin in PCI?
less bleeding and same outcome
Bivalirudin dosing
LD: 0.75mg per kg
Main: 1.75 mg per kg/hr
DC after cath lab
If cont 1.75 mg/kg/hr over 4 hours then 0.2 mg/kg/hr up to 20 hrs
How do we monitor bleeding time in the cath lab
ACT
Which PGy12i is preferred for fibrinolysis
Clopidogrel 600mg
Clopidogrel dosing
LD 300 - 600mg
MD 75 mg QD
Prasugrel Dosing
LD 60mg
MD 10mg if <60kg 5 mg QD
Ticagrelor dosing
LD 180 mg
MD 90 mg BID
Cangrelor dosing
LD 30 mcg/kg IV
MD 4 mcg/kg/min
Clopidogrel indications
NSTEMI, medical STEMI and Fibrinolytic STEMI, PAD
NO PCI
How many days do you need to stop Antiplatelet before surgery
5 days
What DDI do we need to worry about with clopidogrel
PPI inhibit 2C19 but Omeprazole and esomeprazole the worst and must change
Use pantoprazole
What do we worry about with Plavix
Clopidogrel
Genetic variation is a huge consideration why we only use for medical management and not primary PCI
Which has more bleeding prasugrel or Clopidogrel?
Prasugrel
What is Effient
Prasugrel
Prasugrel Indication
Primary PCI
which patient sub populations does prasugrel work better in?
male under the age of 65 who have daibetes
2 Benefits of Prasugrel
more potent
no genetic variablility
What important consideration do we take with Prasugrel
Effient
Elderly ≥ 75 have increase fatal bleeding events ( not a X contra but try to avoid but risk analysis with high risk pts)
Low body weight < 60kg lower to 5mg daily
What is an absolute contradiction for Prasugrel
history of TIA (transient ischemic attack) / stroke
How many days do we need to hold Effient for surgery
7 days
What is Ticagrelor
Brilinta
Brilinta DDI
CYP 3A4/5
Pgp
Aspirin
What previous bleeding contraindicates Ticagrelor
ICH
Ticagrelor indication
PCI or non invasie medical treatment
What do we do with Brilinta and Aspirin
They have to be on 81mg to be effective Antiplatelet
Okay to give the 325 upon admission and will not have an effect on Ticagrelor
What is the best pro of Ticagrelor
its speed
What sensation do pts feel on Ticagrelor
SOB but doesn’t actually affect their breathing intake
Antiplatelet oral comparison chart (PIC)
What is brand of Cangrelor
Kengreal
What is the wow factor of Cangrelor
100% inhibition within 2 mins
Full platelet recovery in 1 hour
Dosing for Kengreal
30 mcg/kg bolus
4 mcg/kg/min for at least 2 hours
Switching to outpt for pts on cangrelor
Brilinta 180mg any time
Effient 60mg and plavix 600 - Need to wait after infusion
What are the Glycoprotien IIb/IIa inhibitor
Tirofiban
Eptifibatide
Which glycoprotein IIa/IIIb cant be used for PCI STEMI
Tirofiban
Secondary therapy ACEi indication
HF
HTN
AMI (acute phase post infraction of left ventricle)
Nephropathy
Cardiovascular protection
When can i start after 24HRs for ACEi
HTN, LEVF ≥40%, DM, CKD
What is indication is important for ACEi to start
MUST USE WITHIN 24hrs
AMI - STEMI that has LVEF ≤40%
What is the one thing in treatment of NSTEMI that differs from STEMI
No use of fibrinolytic and risk stratify the pt
Risk cut offs for NSTEMI
Anticoagulation decisions between heparin, enoxaparin and fondaparinux
Usually heparin but if low risk not much to do after PCI easier for pt to switch to enoxaparin
What is the treatment for medical management
what is the treatment for CABG
When would i use CABG
multiple blocked vessels
