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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
Q

Compare UA (unstable angina) and NSTEMI

A

closely related and tx is the same

UA- less ischemia, no detectable troponin

NSTEMI- troponin elevated

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26
Q

Compare NSTEMI vs STEMI

A

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

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27
Q

Is troponin detected in Ua? NSTEMI? STEMI?

A

Not detected in UA, detected in STEMI and NSTEMI

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28
Q

ECG findings in UA? NSTEMI? STEMI?

A

no ECG findings in UA
ST depression in NSTEMI
ST elevation in STEMI

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29
Q

WHAT IS TIMI score? How is it ranked?

A

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

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30
Q

ACS could lead to

A

HF, bradycardia, arrythmia, pericarditis, stroke

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31
Q

What is ventricular remodelling? What does it lead to?

A

Changes in the size and shape and function of left ventricle after ACS
Leads to HF
preventing ventricular remodelling is important

32
Q

What is MACE

A

Major adverse cardiac events

Stroke
MI
CV death

33
Q

ECG recommendation for patient that arrived to hospital

A

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
Q

How to treat UA/NSTEMI

A
  • 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
Q

Explain MONA

A

morphone
O2
NTG
ASA

36
Q

Morphine use? side effects? what to avoid?

A

relieve chest pain. could cause sedation, respiratory depression, N/V. Avoid NSAIDs due to Na and H20 retention

37
Q

Morphine doses

A

Used to relieve chest pain
4-8 mg IV, followed by
2-8 mg IV Q 5-15 mins

38
Q

goals with MONA (oxygen)

A

keep saturation >90%

39
Q

NTG use in MONA

A

increases blood flow to heart

40
Q

NTG dosing in MONA

A

sublingual NTG- 0.3-0.4 mg
Q 5 min x 3 for ischemic pain

41
Q

What is IV NTG used for?

A

for persistent ischemia, HF or HTN

42
Q

dosing IV NTG

A

start at 10 mcg/min
titrate by 5 mcg/min q 5 min
MAX=200 mcg/min

43
Q

side effects of NTG

A

headache/hypotension

44
Q

why is transdermal NTG not recommended in ACS

A

onset of action=15-60 mins

45
Q

what is a contraindication of NTG

A

PDE5 inhibitors

46
Q

Aspirin dose in MONA

A

162-325 mg aspirin x 1 dose

47
Q

can enteric coated ASA be used?

A

Yes, it has to be chewed though

48
Q

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

A

Yes! give 3 additional 81 mg tabs

49
Q

how often to check ECG and troponin levels in pt remains symptomatic

A

Check ECG every 15-30 mins for 1 hr
check high sensitivity troponin every 3-6 hours for 1st 12 hou

50
Q

summarize MONA

A

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
Q

STEMI tx guideline

A
  • 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
Q

for UA/NSTEMI tx, what P2y12 are preferred

A

Ticagrelor or prasgurel

53
Q

ANticoag for NSTEMI/UA management

A

LMWH or UFH

54
Q

P2Y12 drugs preferred in STEMI

A

fibrinolytic- clopidogrel preferred
PCI- ticagrelor or prasgurel preferred

55
Q

Anti coag preferred in STEMI management

A

UFH or bivalirudin

56
Q

Reperfusion strategies in STEMI

A

PCI
Fibrinolytic

57
Q

Reperfusion strategies in NSTEMI

A

early invasive strategy
ischemic guided strategy

58
Q

What is a coronary angiography(heart cath)

A

shows which arteries have blockages

59
Q

how is a coronary angiograohy (heart cath) performed

A

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
Q

PCI procedure

A

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
Q

What is CABG

A

coronary artery bypass graft
open heart surgery
a vein or artery is removed from leg and reattached to blocked artery

62
Q

What do fibrinolytics do?

A

breakdown plasminogen to plasmin

plasmin breaks down fibrin in the body

63
Q

name fibrinolytic agents

A

Tenecteplase(TNK-tPa)
Reteplase(rPa)
Alteplase(tpa)

64
Q

Tenecteplase dosing

A

<60 Kg- 30 Mg
60-69- 35 mg
70-79- 40 mg
80-89- 45 mg
>or = 90- 50 mg

65
Q

Reteplase dosing

A

10 units x 2 doses (30 mins apart)

66
Q

Alteplase dosing

A

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
Q

Absolute contraindications for fibrinolytics

A

history of cranial hemorrhage
ischemic stroke within past 3 months
active bleeding
aortic dissection

68
Q

Reperfussion therapy in STEMI? which one is preferred

A

PCI vs fibrinolytic (PCI preferred)

69
Q

Reperfusion therapy should be administered for ALL STEMI pts who_______

A

symptoms began in the last 12 hours

70
Q

Door to needle time vs DOor to balloon time

A

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
Q

when is fibrinolytic therapy used in STEMI pts

A

at non-PCI capable hospitals and when >120 min away from PCI capable hospital

72
Q

Reperfusion therapy in NSTEMI/UA

A

Early invasive vs ischemic guided

Fibrinolytics NOT recommended

73
Q

when to use early invasive revascularization in NSTEMI

A

Early invasive- preferred for patients within high risk features

74
Q

High risk features that need early invasive revascularization

A

refractory angina
new onset HF
Rising troponin
New ST segment depression

75
Q
A

Therapeutics (38 decks)

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