Lab 1 - STEMI, NSTEMI, Cardiogenic shock Flashcards
Nitroglycerin - Dose and route
0,5 mg sublingually
Nitroglycerin - Adverse effects
Headache
Hypotension and reflex tachycardia
Dizziness
Euphoria
Nitroglycerin - Contraindications
Phosphodiesterase type 5 inhibitors (sildenafil) because it potentiates the hypotensive effects
Hypotension, HF, methemoglobinemia (high doses), anemia
Nitroglycerin - MoA
Release NO in vascular smooth muscle cells and cause dilation
Metoprolol - MoA
Selective B1 adrenoceptor antagonist
Metoprolol - Dose and route
25 mg orally every 6 hours (4 times per 24 hour)
IV in patients with severe ischemia
Metoprolol - Adverse effects
Dizziness, fatigue, bradycardia, nausea
High doses: hypoglycemia, bronchoconstriction, peripheral vasoconstriction –> cold hands/feet
Metoprolol - Contraindications
Acute/severe heart failure Low cardiac output Hypotension AV block Bronchospasm Diabetes Asthma COPD Vasospastic disease
Aspirin - MoA
Inhibition of prostaglandin synthesis by inhibiting COX
Aspirin - Dose and route
325 mg initially, then 75/100 mg/d orally
Aspirin - Adverse effects
GI bleeding, peptic ulcers Increased risk of bleeding Hyperkalemia Hypersensitivity reactions Tinnitus
Aspirin - Contraindications
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
Clopidogrel - MoA
Adenosine diphosphate inhibitor (P2Y12 rec ant.). Inhibit glycoprotein IIb/IIIa
Clopidogrel - Dose and route
300 mg intially, then 75mg/d orally
Clopidogrel - Adverse effects
Bleeding
Neutropenia
Clopidogrel - Contraindications
Hemorrhagic stroke Active internal bleeding Intracranial neoplasm Hypertension Recent trauma/surgery PUD Severe HTN
Enoxaparin - MoA
Anticoagulant. Inactivate factor X
Enoxaparin - Dose and route
1 mg/kg every 12 hours subcutaneously
Enoxaparin - Adverse effects
Bleeding caused by excessive anticoagulation
Thrombocytopenia
Morphine - MoA + Which drugs do you usually combine it with?
Opiod. Mu receptor agonist
Metoclopromide (D2 rec. ant) - 10 mg IV
Morphine - Dose and route
5-10 mg IV.
Morphine - Adverse effects
Itching Nausea and vomiting Constipation Drowsiness Dry mouth Respiratory depretion
Morphine - Contraindications
Closed-head injury
Respiratory depression when appropriate equipment is not available
Nitroglycerin - Interactions
PDE- 5 inhibitors (Sildenafil)
Alcohol, antihypertensive, B-blockers, antideppressive can lead to syncope
Metoprolol - Interactions
Increased risk of cardiac depression with Diltiazem and Verapamil
Hypotensive effect is decreased with NSAIDs
Aspirin - Interactions
Potassium sparing diuretics --> Hyperkalemia Antidiabetic drugs (sulfonylurea) --> Decreased hypoglycemic effect
Clopidogrel - Interactions
CYP3a4 inhibitors (atorvastatin, erythromycin, omeprazol) –> decreased metabolic activation of the drug
Thrombolysis - Drugs + Doses
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
MI - Diagnosis
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.
NSTEMI - treatment after MONA
High risk: Coronary angiography –> PCI or CABG
Low risk: 2nd troponin measurement –> Positive –> Coronary angiography –> PCI/CABG
Negative –> Stress test, coronary angiography
STEMI - treatment after MONA
> 90 min: Thrombolysis
<90 min: Primary PCI (coronary angioplasty, stenting)
Cardiogenic shock- Treatment
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
Cardiogenic shock- Diagnosis
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.
MI- Differential Diagnosis
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
