Lab 1 - STEMI, NSTEMI, Cardiogenic shock

Question 1

Nitroglycerin - Dose and route

Answer 1

0,5 mg sublingually

Question 2

Nitroglycerin - Adverse effects

Answer 2

Headache
Hypotension and reflex tachycardia
Dizziness
Euphoria

Question 3

Nitroglycerin - Contraindications

Answer 3

Phosphodiesterase type 5 inhibitors (sildenafil) because it potentiates the hypotensive effects
Hypotension, HF, methemoglobinemia (high doses), anemia

Question 4

Nitroglycerin - MoA

Answer 4

Release NO in vascular smooth muscle cells and cause dilation

Question 5

Metoprolol - MoA

Answer 5

Selective B1 adrenoceptor antagonist

Question 6

Metoprolol - Dose and route

Answer 6

25 mg orally every 6 hours (4 times per 24 hour)

IV in patients with severe ischemia

Question 7

Metoprolol - Adverse effects

Answer 7

Dizziness, fatigue, bradycardia, nausea

High doses: hypoglycemia, bronchoconstriction, peripheral vasoconstriction –> cold hands/feet

Question 8

Metoprolol - Contraindications

Answer 8

Acute/severe heart failure
Low cardiac output
Hypotension
AV block
Bronchospasm
Diabetes 
Asthma
COPD
Vasospastic disease

Question 9

Aspirin - MoA

Answer 9

Inhibition of prostaglandin synthesis by inhibiting COX

Question 10

Aspirin - Dose and route

Answer 10

325 mg initially, then 75/100 mg/d orally

Question 11

Aspirin - Adverse effects

Answer 11

GI bleeding, peptic ulcers
Increased risk of bleeding
Hyperkalemia
Hypersensitivity reactions
Tinnitus

Question 12

Aspirin - Contraindications

Answer 12

Children –> Reye syndrome
Hypersensitivity to aspirin og another salicylate
Kidney disease
Gout (inhibit excretion of uric acid)
Lithium therapy (inhibit excretion of lithium)
Potassium-sparing diuretics

Question 13

Clopidogrel - MoA

Answer 13

Adenosine diphosphate inhibitor (P2Y12 rec ant.). Inhibit glycoprotein IIb/IIIa

Question 14

Clopidogrel - Dose and route

Answer 14

300 mg intially, then 75mg/d orally

Question 15

Clopidogrel - Adverse effects

Answer 15

Bleeding

Neutropenia

Question 16

Clopidogrel - Contraindications

Answer 16

Hemorrhagic stroke
Active internal bleeding
Intracranial neoplasm
Hypertension
Recent trauma/surgery
PUD
Severe HTN

Question 17

Enoxaparin - MoA

Answer 17

Anticoagulant. Inactivate factor X

Question 18

Enoxaparin - Dose and route

Answer 18

1 mg/kg every 12 hours subcutaneously

Question 19

Enoxaparin - Adverse effects

Answer 19

Bleeding caused by excessive anticoagulation

Thrombocytopenia

Question 20

Morphine - MoA + Which drugs do you usually combine it with?

Answer 20

Opiod. Mu receptor agonist

Metoclopromide (D2 rec. ant) - 10 mg IV

Question 21

Morphine - Dose and route

Answer 21

5-10 mg IV.

Question 22

Morphine - Adverse effects

Answer 22

Itching
Nausea and vomiting
Constipation
Drowsiness
Dry mouth 
Respiratory depretion

Question 23

Morphine - Contraindications

Answer 23

Closed-head injury

Respiratory depression when appropriate equipment is not available

Question 24

Nitroglycerin - Interactions

Answer 24

PDE- 5 inhibitors (Sildenafil)

Alcohol, antihypertensive, B-blockers, antideppressive can lead to syncope

Question 25

Metoprolol - Interactions

Answer 25

Increased risk of cardiac depression with Diltiazem and Verapamil
Hypotensive effect is decreased with NSAIDs

Question 26

Aspirin - Interactions

Answer 26

Potassium sparing diuretics --> Hyperkalemia
Antidiabetic drugs (sulfonylurea) --> Decreased hypoglycemic effect

Question 27

Clopidogrel - Interactions

Answer 27

CYP3a4 inhibitors (atorvastatin, erythromycin, omeprazol) –> decreased metabolic activation of the drug

Question 28

Thrombolysis - Drugs + Doses

Answer 28

Tenecteplase (tissue plasminogen activator) - max dose 50 mg + Enoxaparin - 30 mg IV initially, 1 mg/kg Subc after 15 min.
Increased risk for reocclusion if only Tenecteplase is used

Question 29

MI - Diagnosis

Answer 29

ECG - NSTEMI: ST- depression, T wave inversion
ECG- STEMI: ST- elevation, T wave inversion (initially high), Q wave development
Echo (doppler): infarct- associated wall motion abnormalities. Doppler detects ventricular septal detect and mitral regurgitation.
MRI: indiated regions of infarct
Cardiac- specific troponin (cTn I, T): elevated in 7 days. Small troponin elevations may also occur in pts with CHF, myocarditis, pulmonary embolism and after exercise.
CK-MB: Elevated in 3 days. May be elevated after disease or trauma.
Polymorphonuclear leukocytosis: appear within few hours after onset of pain, persists 3-7 days.

Question 30

NSTEMI - treatment after MONA

Answer 30

High risk: Coronary angiography –> PCI or CABG
Low risk: 2nd troponin measurement –> Positive –> Coronary angiography –> PCI/CABG
Negative –> Stress test, coronary angiography

Question 31

STEMI - treatment after MONA

Answer 31

> 90 min: Thrombolysis

<90 min: Primary PCI (coronary angioplasty, stenting)

Question 32

Cardiogenic shock- Treatment

Answer 32

O2
Morphine for pain and anxiety
Nitroglycerin
Correct abnormalities: fluid resuscitation, arrhythmia, electrolyte, acid-base
Optimize filling pressure: Underfilled (IV fluid infusion) Overfilled (dobutamine)
PCI or CABG –> TOC (decreases myocardial workload and improved end-organ perfusion
Inadequate tissue perfusion and adequate intravascular V: Dobutamine 2, mcg/kg/min IV infusion

Question 33

Cardiogenic shock- Diagnosis

Answer 33

Lab: WBC, CRP, hepatic transaminase
ABG
Cardiac markers
ECG
XRAY- pulmonary vascular congestion/pulmonary edema
Echo: cause and damage in heart
Swan-Ganz catheterization: exclude other types of shock.

Question 34

MI- Differential Diagnosis

Answer 34

Cardiac troponins: elevated in CHF, myocarditis, PE, exercise
CK-MB: elevated after electroconversion, trauma, disease
ECG:
-ST depression: also in hypokalemia, digoxin
-ST elevation: pericarditis (more than 1 zone)

STEMI: Tacotsubo cardiomyopathy

Stable angina, GERD, Acute aortic dissection, anxiety, asthma, musculoskeletal chest pain