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Cardio Therapeutics > IHD/ACS II > Flashcards

IHD/ACS II Flashcards

1
Q

Overview: Diagnosis

A
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2
Q

ACS: Sx/Signs

A

-Chest pain: dull, 15-30 min, radiates to jaw/arm/back
-Dyspnea
-Nausea
-Diaphoresis
-Palpitations
-Pallor
-Anxiety

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3
Q

Desired Outcomes of ACS Treatment

A

Short-term
-Restoration of blood flow
-Prevent death/complications
-Prevent coronary artery reocclusion
-Relief chest pain

Long-term
-Control CV risks
-Prevent CV events
-Improve QOL

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4
Q

General Treatment Measures

A
  1. Admit to ICU
  2. Oxygenation
  3. ECG monitoring
  4. Glycemic control
  5. Vitals monitoring
  6. Pain relief
  7. Stool softeners
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5
Q

STEMI TX: 1 = MONA

A

MONA

  1. Morphine: 1-5 mg IV bolus PRN
    -Avoid in lethargy, hypotension, bradycardia
    -Caution: CLOP + MORPH = DDI
  2. Oxygen: 2-4 lpm nasally
    -If O2 < 90, HF, dyspnea
  3. NTG SL
    -0.4 mg every 5 min x 3 doses
    -Do not use if SBP < 90 or < 30 below baseline
  4. ASA/Clop
    -325 mg
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6
Q

STEMI TX = 2 AC

A

Heparin
-Could use LMWH or fondaparinux for STEMI but for primary PCI we clinically only use UFH

FIBRINOLYSIS
= 60 u/k bolus (max 4,000)
= 12 u/k IV (max 1000 u/hr)

PRIMARY PCI
= 60 u/k IV bolus (max 5,000)
= 12 u/k IV (max 1000 u/hr)

MED MAN
= 60 u/k IV bolus (max 5,000)
= 12 u/k IV (max 1000 u/hr)

BB: Metoprolol Tartrate
-within 12 hr
-5 mg IV q 5 min (up to 3 doses)
-Avoid in: 70+, brady < 60, SBP < 120, PR > 0.24, heart block 2-3, asthma

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7
Q

Heparin Nomogram for ACS at UCSDH

A

Goal aPTT 50-70 seconds or anti-Xa 0.3-0.6 IU/mL

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8
Q

Reversing Heparin

A

protamine dose = 1 mg for every 100 units of circulating heparin (t 1⁄2 = 60-120 min)

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9
Q

Reperfusion Therapy

A

Goal: TIMI-3 flow = normal epicardial and myocardial
perfusion

Time Windows:
– Door-2-Balloon: 90 minutes (primary PCI)
– Door-2-Needle: 30 minutes (thrombolysis)

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10
Q

Fibrinolysis Indications

A

Key goal would be to achieve TIMI-3 flow

  1. Sx of ACS with an onset within 12hours of first medical contact
  2. ST-segment elevation of at least 1mm in height in 2 or more contiguous leads, or new or presumed new left bundle branch block
  3. Anticipated that primary PCI cannot be performed within 120 minutes of first medical contact
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11
Q

Characteristics of patients w/ increased risk of ICH

A

Intracranial hemorrhage (ICH) remain biggest concern w/ fibrinolytics

– female gender
– age >75 years old
– known cerebral vascular disease
– elevated DBP and/or SBP
– HTN

Same CI as other fibrinolytic card: VCAT BIHH

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12
Q

Tenecteplase dosing

A

Single IV bolus over 5 seconds

  • <60 kg: 30mg
  • 60-69 kg: 35 mg
  • 70-79 kg: 40 mg
  • 80-89 kg: 45 mg
  • > 90kg: 50mg
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13
Q

Fibrinolysis Monitoring + successful tx def

A

– Blood pressure
– Bleeding (hematocrit, hemoglobin, hematuria, hematemesis, etc)
– Mental status (r/o ICH)
– Allergic reactions

Consider fibrinolysis successful if:
1. > 50% reduction in ST segments of the ECG
2. relief of chest pain
3. appearance of reperfusion arrhythmias

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14
Q

Primary PCI - Cath Lab

A
  1. Heparin already started
  2. Angiogram
  3. Anti-thrombotics (BCBCHH)
    -Continue heparin as monotherapy
    -Continue heparin and add Cangrelor
    -Stop heparin, start Bivalirudin
    -Stop heparin, start Bivalirudin and Cangrelor
    -Salvage: Glycoprotein IIb/IIa (rare)
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15
Q

Bivalirudin dosing in Primary PCI

A
  • Loading dose: 0.75 mg/kg IV bolus
  • Maintenance dose: 1.75 mg/kg/hr IV

Caution: reduce dose with significant renal disease

-Discontinue at the end of PCI or may continue at 1.75 mg/kg/hr x 4 hours and then 0.2 mg/kg/hr (up to 20 hours post PCI)

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16
Q

ADP Receptor Blockers: Primary PCI

A

– Thienopyridines
– P2Y12 receptor inhibitors
– ED or Cath lab

= Clopidogrel, Prasugrel, Ticagrelor, Cangrelor

Clop = LD 300 mg for fibrinolysis, LD 300-600 otherwise

17
Q

Clopidogrel (Plavix®)

A

For MED MAN ACS (no pcis)

DDI:
-Avoid omeprazole or esomeprazole (PPIs),use pantoprazole or H2RAs
-Use PPIs only if high risk of GI bleed

Genetics:
-CYP2C192 allele and lesser extent CYP2C193 allele

Requires 2 step activation by CYP enzymes

Less bleeding compared to others

18
Q

Platelet reactivity units (PRU) of ____ is the suggested “target” or “goal” to reduce ischemic risk

A

< 230

19
Q

Prasugrel (Effient®)

A

*indicated for ACS being managed with PCI

At risk pts for use of Prasugrel:
- age 75+
- <60 kg body weight
- stroke/TIA hx (CONTRA)*

Higher rates of bleeding, hold drug 7 days prior to CABG, no DDIs/genetics

20
Q

Ticagrelor (Brilinta®)

A

*indicated for ACS (PCI or non-invasive medical management)

DDI:
-CYP 3A4/5, PGP, aspirin

CI:
-ICH hx
(Nonintracranial fatal bleeding profile favors ticagrelor, Intracranial fatal bleeding profile favors clopidogrel)
-Caution in LD/COPD

AE:
-dyspnea

LDIC

21
Q

Comparison of ORAL thienopyridines in “at risk” populations

A
  1. MI/Diabetes/CYP PM: PT
  2. 75+/Stoke/TIA: CT
  3. A/COPD/LD/ADH: CP
  4. DDI: P
22
Q

Cangrelor (Kengreal®)

A

-Adjunct to PCI to reduce periprocedural MI, repeat coronary revasc and stent thrombosis (who have not been treated with a P2Y12 or GP IIb/IIIa inhibitor)

-Dose: 30 mcg/kg IV bolus

-AE: bleeding

23
Q

Cangrelor – Transitioning to oral P2Y12

A
  • Ticagrelor 180 mg at any time during cangrelor infusion or immediately after
  • Prasugrel 60 mg immediately after discontinuation of cangrelor
  • Clopidogrel 600 mg immediately after discontinuation of cangrelor
24
Q

Tirofiban, Eptifibatide (Glycoprotein IIb/lla inhibitors)

A

AE: bleeding, thrombocytopenia

25
Q

Indications for ACE Inhibitors: ICU

A
  • AMI
    – use within first 24 hours of a suspected anterior wall MI or STEMI associated with clinical heart failure and those with an LVEF ≤ 40% in patients with no contraindications
    – use after first 24 hours for hypertension, LVEF ≥ 40%, DM, CKD
26
Q

NSTE-ACS: TX

A

NSTE-ACS = unstable angina or NSTEMI

Early pharmacotherapy for NSTE-ACS is similar to STEMI except:
– Don’t use fibrinolytics
– MONA, heparin (BB, P2Y12i, statin)

27
Q

NSTE-ACS: ED TX

A
  1. Heparin
    -Early invasive, ischemia
    = 60 u/k IV bolus (max 5,000)
    = 12 u/k IV (max 1000 u/hr)
  2. Enoxaparin
    -Ischemia
    = 1 mg/kg SQ
    -Avoid in < 20 CRCL
  3. Fondaparinux
    -Ischemia
    = 2.5 mg SC daily (up to 8 days)
    -Avoid in < 30 CRCL
28
Q

Other Early Pharm TX for NSTE-ACS

A
  1. Antiplatelets
    = PCI = CTPC
    = Med Man = CT only
  2. CCB
    = sub for BB
    = diltiazem more useful
    = don’t use in LV dys or pulm edema
  3. Glycoprotein IIb/IIa
    = consider if high TIMI score, ongoing chest pain and medium score
    = caution, bleeding af
29
Q

Secondary Prevention after MI

A

RAR C BAS

  1. Control modifiable risk factors
    * Smoking, BP, lipids, diabetes, physical activity, weight management, diet, stress
  2. Aspirin 81-162 mg QD
    -Use < 100 if in combo with ticagrelor
  3. Rivaroxaban 2.5 mg BID
    -wait until DAPT complete then add to aspirin if needed
  4. Clop, Pras, Tica
  5. BB (give for at least 1 year for all pts, indefinitely in LV < 40%
    -Metoprolol, carvedilol
  6. ACEI/ARB
    = all pts with LVEF < 40%, CKD, DIA, HTN, anterior wall MI
    = avoid in hypotension, RF, hyperkalemia
  7. Spironolactone, Eplernone
    = first 2 weeks post MI in patients already receiving an ACEI with EF ≤ 40% and HF sx and diabetes
    = 25 mg PO QD

Cardio Therapeutics (31 decks)

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