ST-Elevation Myocardial Infarction (STEMI) Flashcards
Koenen
What are some tx strategies for STEMI?
PCI within 90 minutes at facility w cath lab (GOLD standard)
Cath lab within 120 minutes for patients transferred from non-PCI capable facility
Fibrinolytic agent for patients unable to transfer to PCI capable hospital within 120 min
What are some early interventions for STEMI?
MONA
Morphine
Oxygen
Nitrates
Aspirin
What is morphine used for in STEMI patients?
pain, anxiety, pulmonary edema
What is the dosing for morphine?
4-8 mg IV, then 2-8 mg IV q 5-15 minutes PRN
Which types of patients should we be careful with use of morphine?
Hypotensive and bradycardic patients and patients w renal failure
Morphine can cause histamine release which can lead to downstream effects of HoTN and bradycardia
Morphine can accumulate in patients w poor renal function
Why has morphine been controversial in the past couple years?
Does not reduce mortality, only sx benefit
May decrease P2Y12
Falling out of favor
When should oxygen be used?
In hypoxemic patients w SpO2 < 90%
No benefit in patients without hypoxemia
only for sx relief of Shortness of breath
If oxygen is used, what is the recommended dose to use?
2-4 L/min nasal cannula, then titrate up to get them > 90% SpO2
What are nitrates used for in STEMI patients?
chest pain and HTN
Used for symptomatic relief by reducing LV preload and increased coronary blood flow
What dose of nitrate should be used?
Nitroglycerin: 0.4 mg SL q 5 min PRN x 3 doses
Which types of patients should we be careful with use of nitrates?
Caution in HoTN, bradycardia and tachycardia
Contraindicated in RV infarction and PDE5 inhibitor use within 24-48 hours
What is the dose for aspirin use in STEMI tx?
162-325 mg loading dose prior to PCI
Chew non-enteric coated
Rectal suppository if oral route not available
What are some options for P2Y12 inhibitors and the doses?
Clopidogrel 600 mg
- Commonly used in patients w high bleed risk
- Often cheapest option
Prasugrel 60 mg
- Increased bleed risk
- CI in patients w hx of stroke or TIA or active bleed
Ticagrelor 180 mg
- Similar rates of major bleeding compared to clopidogrel
- Twice daily dosing is a downside
- Expensive
which P2Y12 inhibitor are preferred?
Ticagrelor and prasugrel preferred over clopidogrel
What literatures explore P2Y12 inhibitors to help with choosing which to choose?
TRITON-TIMI trial showed lower rate of primary composite outcome and lower rate of stent thrombosis in prasugrel vs clopidogrel
PLATO trial favored use of ticagrelor over clopidogrel in terms of stent thrombosis and death
What is Cangrelor? dose?
IV P2Y12 inhibitor
30 mcg/kg bolus followed by 4 mcg/kg/min infusion
Run for 2 hours or until PCI complete
how do you go from IV to oral p2y12?
Stop infusion → administer oral loading dose immediately after dc of drip
Why are antiplatelets necessary prior to PCI?
Prevent platelet adhesion and aggregation in early stages of MI
Reduce myocardial damage
When should anticoagulation start for STEMI?
Start immediately after dx
What are the options for anticoagulation for PCI candidates in STEMI?
heparin and bivalirudin (Heparin drip is preferred)
Dose for Heparin?
70-100 unit/kg bolus
Titrate drip based on hospital nomogram
Dose for Bivalirudin?
0.75 mg/kg IV bolus
1.75 mg/kg/hr infusion
1 mg/kg/hr infusion for CrCl < 30
What is the duration for anticoagulation in STEMI tx?
Bivalirudin continued for 4 hours following PCI
Heparin can be stopped immediately after PCI
What are some maintenance meds following PCI?
dual antiplatelet therapy (DAPT)
Beta blocker
ACEi
Statin
Doses for DAPT?
Aspirin 81 mg indefinitely PLUS P2Y12 inhibitor x 1 year
Clopidogrel 75 mg daily
Prasugrel 10 mg daily
Ticagrelor 90 mg BID
DAFT After PCI: reduce risk of stent thrombosis, prevent subsequent cardiac adverse effects
What are some contraindications for beta blockers?
decompensated HF, low output state, cardiogenic shock, bradycardia, AV block
Continually reassess if Beta blocker can be started
Which beta blockers are recommended in the guidelines for STEMI management?
Oral preferred
Start short acting inpatient
Transition to long-acting on discharge
Metoprolol
IR (T): 25-50 mg q 6-12 hours
ER (S): 25-200 mg daily: Titrale to 200 mg as tolerated
Carvedilol
6.25 mg BID
Titrate to 25 mg BID as tolerated
Who should be recommended ACEI for STEMI management?
Recommended for all patients w LVEF < 40%
Can be routinely given any patient post-MI unless CI
Doses for ACEi in STEMI?
ACEi, starting dose, target dose
Lisinopril
2.5-5 mg daily
10mg daily or higher
Captopril
6.25-12.5 mg TID daily
25-50 mg TID daily
Ramipril
2.5 mg BID
5 mg BID
Trandolapril
0.5 mg daily
4 mg daily
What are some contraindications for ACEi?
HoTN, hyperkalemia, renal failure
Which statin is indicated for STEMI and what dose?
High intensity statin indicated
Atorvastatin 80 mg recommended by guidelines
Atorvastatin 40-80 mg and rosuvastatin 20-40 mg also reasonable
