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Therapeutics > Lecture 4 > Flashcards

Lecture 4 Flashcards

1
Q

WHat is ACS

A

acute myocardial ischemia resulting from an imbalance between myocardial O2 supply and demand

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2
Q

What are the spectrum of conditions? Which ones are acute coronary syndromes

A

Silent ischemia
SIHD
UA
NSTEMI
STEMI

LAst 3 are coronary sydnromes

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3
Q

WHat happens in acute coronary syndromes

A

There is the rupture of atherosclerotic plaques, blood clot forms around the rupture, blocking the artery

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4
Q

Classification of MI

A

Type 1- spontaneous MI ( atherosclerotic rupture)
Type 2 - MI secondary to ischemic balance

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5
Q

MOst common ACS?

A

NSTEMI (70% of cases)

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6
Q

PErcipitating factors that could cause ACS

A

recent exercise
weather (warm or cold)
diet (large meal)
Emotion (fright or anger)
coitus
walking against wind
smoking

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7
Q

signs and symptoms of ACS

A

Retrosternal chest pain (may radiate to shoulder down to the left arm)
Nausea and vomiting
SOB
sweating dizziness

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8
Q

atypical symptoms of ACS more likely in

A

Females, elderly , diabeics, impaired renal function

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9
Q

atypical sx of ACS

A

Epigastric pain
indigestion
stabbing pain
increased dyspnea and absence of chest pain

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10
Q

all patients with acute chest pain should have

A

an ECG within 10 minutes of arrival to ER

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11
Q

describe P wave

A

atria contracting (upper chamber)

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12
Q

describe QRS wave

A

ventricle contracting

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13
Q

Describe T wave

A

ventricle relaxing

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14
Q

ECG reading of STEMI

A

persistent ST elevation

Q qave changes may not be present on initial ECG, but develops over hours/days and remains permanently

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15
Q

ECG changes in UA/NSTEMI

A

May have normal ECG
NO ST elevation
ST depression or T wave inversion are possible
Q wave changes unlikely

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16
Q

WHat do we do after ECG

A

Draw troponin levels

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17
Q

WHat is troponin

A

Troponin is a damage marker that is released from the heart when damage is present

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18
Q

Two different troponin tests

A

HIgh sensitivity troponin (preferred)
Conventional troponin

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19
Q

difference between sensitivity and specificity

A

sensitivity is likelihood of detecting a disease when it exists
soecificity is likelihood of not detecting a disease when it does not exist

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20
Q

normal value of high sensitivity troponin test

A

<14

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21
Q

Normal value of conventional troponin test

A

<0.05

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22
Q

how often to check troponin trend

A

3 levels over 12 hrs

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23
Q

stable vs unstable angina

A

stable- chest pain occurs during physical exertion
unstable- chets pain may occur at rest (while sleeping or little physical exertion)

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24
Q

compare stable and unstable angina

A

Stable- predictable
relieved by rest
lasts <5 min

unstable- comes as a surprise
is more severe
>30 mins

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25
Compare UA (unstable angina) and NSTEMI
closely related and tx is the same UA- less ischemia, no detectable troponin NSTEMI- troponin elevated
26
Compare NSTEMI vs STEMI
NSTEMI- chest pain troponin elevated no ST elevation on ECG (main difference) May instead have ST depression of T wave inversion STEMI- Chest pain troponin is elevated PErsistent ST elevation
27
Is troponin detected in Ua? NSTEMI? STEMI?
Not detected in UA, detected in STEMI and NSTEMI
28
ECG findings in UA? NSTEMI? STEMI?
no ECG findings in UA ST depression in NSTEMI ST elevation in STEMI
29
WHAT IS TIMI score? How is it ranked?
Thrombolysis in myocardial infarction Risk of experiencing either death, MI or urgent need for revascularization within 14 days low risk- 0-2 points medium- 3-4 points High- 5-7 points
30
ACS could lead to
HF, bradycardia, arrythmia, pericarditis, stroke
31
What is ventricular remodelling? What does it lead to?
Changes in the size and shape and function of left ventricle after ACS Leads to HF preventing ventricular remodelling is important
32
What is MACE
Major adverse cardiac events Stroke MI CV death
33
ECG recommendation for patient that arrived to hospital
ECG should be done within 10 mins of arrival to hospital. If initial ECG is not diagnostic and patient remains symptomatic, serial ECG should be performed every 15-30 mins for 1st hr
34
How to treat UA/NSTEMI
- MONA (morphine, O2, NTG, ASA) - Reperfusion (early invasive strategy no fibrinolytic vs Ischemia guided strategy) - Antiplatelets .DAPT= ASA+P2Y12 inhibitors 12 month duration Ticagrelor or prasgurel preferred with or without GPIIBIIIA inhibitor - Anticoag with LMWH or UFH - BB - ACE or ARB - statin -NTG PRN
35
Explain MONA
morphone O2 NTG ASA
36
Morphine use? side effects? what to avoid?
relieve chest pain. could cause sedation, respiratory depression, N/V. Avoid NSAIDs due to Na and H20 retention
37
Morphine doses
Used to relieve chest pain 4-8 mg IV, followed by 2-8 mg IV Q 5-15 mins
38
goals with MONA (oxygen)
keep saturation >90%
39
NTG use in MONA
increases blood flow to heart
40
NTG dosing in MONA
sublingual NTG- 0.3-0.4 mg Q 5 min x 3 for ischemic pain
41
What is IV NTG used for?
for persistent ischemia, HF or HTN
42
dosing IV NTG
start at 10 mcg/min titrate by 5 mcg/min q 5 min MAX=200 mcg/min
43
side effects of NTG
headache/hypotension
44
why is transdermal NTG not recommended in ACS
onset of action=15-60 mins
45
what is a contraindication of NTG
PDE5 inhibitors
46
Aspirin dose in MONA
162-325 mg aspirin x 1 dose
47
can enteric coated ASA be used?
Yes, it has to be chewed though
48
What if a patient takes baby aspirin everyday and they already took their dose that morning would you still give a loading dose of aspirin
Yes! give 3 additional 81 mg tabs
49
how often to check ECG and troponin levels in pt remains symptomatic
Check ECG every 15-30 mins for 1 hr check high sensitivity troponin every 3-6 hours for 1st 12 hou
50
summarize MONA
Morphine- 4-8 mg IV then 2-8 mg IV Q 5-15 mins Oxygen- Maintain O2 saturation>90% NTG_0.3-0.4 mg Sl Q 5 mins x 3, then 10 mcg/min IV if needed ASA- 162-325 mg
51
STEMI tx guideline
- MONA - Reperfusion (PCI vs fibrinolytic) - antiplatelets DAPT- ASA+P2Y12 inhibitors, 12 month duration fibrinolytic- clopidogrel preferred PCI- ticagrelor or prasgurel - Anticoag UFH or bivalirudin -BB -ACE or ARB -Statin -NTG PRN
52
for UA/NSTEMI tx, what P2y12 are preferred
Ticagrelor or prasgurel
53
ANticoag for NSTEMI/UA management
LMWH or UFH
54
P2Y12 drugs preferred in STEMI
fibrinolytic- clopidogrel preferred PCI- ticagrelor or prasgurel preferred
55
Anti coag preferred in STEMI management
UFH or bivalirudin
56
Reperfusion strategies in STEMI
PCI Fibrinolytic
57
Reperfusion strategies in NSTEMI
early invasive strategy ischemic guided strategy
58
What is a coronary angiography(heart cath)
shows which arteries have blockages
59
how is a coronary angiograohy (heart cath) performed
Catheter is inserted into the radial abd femoral artery and fed up to heart Dye is injected into coronary artery X-ray picture is taken and shows blocked artery Stent is placed on blocked artery if needed
60
PCI procedure
Uses a small balloon to reopen a blocked artery to increase blood flow A stent is placed if needed to keep artery open long term
61
What is CABG
coronary artery bypass graft open heart surgery a vein or artery is removed from leg and reattached to blocked artery
62
What do fibrinolytics do?
breakdown plasminogen to plasmin plasmin breaks down fibrin in the body
63
name fibrinolytic agents
Tenecteplase(TNK-tPa) Reteplase(rPa) Alteplase(tpa)
64
Tenecteplase dosing
<60 Kg- 30 Mg 60-69- 35 mg 70-79- 40 mg 80-89- 45 mg >or = 90- 50 mg
65
Reteplase dosing
10 units x 2 doses (30 mins apart)
66
Alteplase dosing
15 mg bolus then 0.75 mg/kg over 30 mins (max- 50 mg), then 0.5 mg/kg (max 35) over 60 mins (max total 100 mg)
67
Absolute contraindications for fibrinolytics
history of cranial hemorrhage ischemic stroke within past 3 months active bleeding aortic dissection
68
Reperfussion therapy in STEMI? which one is preferred
PCI vs fibrinolytic (PCI preferred)
69
Reperfusion therapy should be administered for ALL STEMI pts who_______
symptoms began in the last 12 hours
70
Door to needle time vs DOor to balloon time
Door to needle- time fibrinolytic needs to be administered (within 30 mins of hospital arival) Door to balloon time- 90 mins within hospital arrival if PCI or stent taken
71
when is fibrinolytic therapy used in STEMI pts
at non-PCI capable hospitals and when >120 min away from PCI capable hospital
72
Reperfusion therapy in NSTEMI/UA
Early invasive vs ischemic guided Fibrinolytics NOT recommended
73
when to use early invasive revascularization in NSTEMI
Early invasive- preferred for patients within high risk features
74
High risk features that need early invasive revascularization
refractory angina new onset HF Rising troponin New ST segment depression
75

Therapeutics (38 decks)

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