imbalance between myocardial oxygen demand and supply
NSTE ACS consists of
NSTEMI and UA (unstable angina)
STEMI is defined as
presence of a new ECG ST elevation in 2 or more leads
steps to diagnose MI
clinical presentation
ECG
cardiac biomarkers
rule out differential diagnosis
clinical presentations
chest pain/discomfort
shortness of breath/dyspnea
diaphoresis
nausea/vomiting
dizziness or syncope
fatigue/weakness
the different cardiac biomarkers
CK-MB
Troponin
cardiac biomarker better for diagnosis re-infarction
CK-MB
how many days does troponin stay elevated
7-14 days
what are the treatment goals for MI pts
control chest pain
restore coronary blood flow and min infart size
rule out diff diagnosis
prevent complications
complications of STEMI
ventricular arrhythmias
ventricular remodeling
HF
recurrent ischemia
re-infarction
cardiogenic shock
stroke secondary to LV thrombus embolization
effects of NTG
venodilation (preload) and arterial vasodilation
reduce myo O2 demand
promote coronary blood flow
NTG Routes and dosing
sublingual: 4mg SL every 5min
topical ointment: 0.5-2 inch q4-6h
IV gtts: 5-10mcg/min
when is IV NTG usually used
in STEMI if there is persistent ischemia, CHF, HTN
what to watch out for when taking NTG
hypotension
flushing and HA
reflex tachy/brady
tolerance to nitrate therapy
what study shows aspirin to decrease mortality in MI pts
ISIS-2 study
what to avoid when giving aspirin therapy
avoid use of NSAID like ibuprofen
how long should oxygen therapy be continued in pts with STEMI
beyond 6 hrs in STEMI pts with arterial oxygen desaturation or overt pulmonary congestion
what is the caution with given oxygen in STEMI pts
COPD and CO2 retention
effects of morphine
analgesic and venodilatory effects
AE of Morphine
hypotension
respiratory depression
bradycardia
guideline recommendations for oral B-blockers
1. should be initiated in the first 24 hrs in pts with STEMI without any contraindications
2. should be continued during and after hospitalization for all pts with STEMI
3. pts with initial contraindications to the use of beta-blockers in the first 24hrs after STEMI should be reevaluated to determine their subsequent eligibility
metoprolol dosing range
25-50 PO q6-12h and titrate to 200mg/day
Carvedilol dosing range
6.25mg PO bid and titrate to 25mg PO BID
Atenolol dosing range
50mg PO and then titrate to 100mg/day
guidelines on IV B-blockers
IND ONLY in pts who are hypertensive (at presentation) or have ongoing ischemia and with no contraindication to their use
IV metoprolol dosing
5mg q5min x 3
IV atenolol dosing
5mg q5min x 2
COMMIT/CCS-2 trial
1. examined efficacy and safety of the early routine use of IV beta blockers in MI
2. use early IV beta-blocker then high-dose PO beta-blocker
3. there were lower rates of recurrent MI and VF in the group treated with beta-blocker
contraindications to using B-blockers during STEMI
sign of acute decompensated HF
low output state
increased risk of cardiogenic shock
second or thirddegree heart block
active asthma/ reactive airways disease
what is the goal of reperfusion
goal of reperfusion is to restore myocardial perfusion in the infarct artery
when is an invasive strategy generally preferred
1. door to balloon is less than 90 min
2. door to ballon-door to needle less than hr
3. if pt is high risk for STEMI
-cardiogenic shock
-killip class is greater than or equal to 3
4. contraindications to finrinolysis
5. late presentation (greater than 3 hrs)
when is fibrinolysis generally preferred
1. early presentation (less than 3 hrs)
2. invasive strategy is not an option
3. delay to invasive strategy
what is primary PCI
coronary angiography with either balloon angioplasty or placement of intracoronary stent within 90 min
what is facilitated PCI
planned PCI within a few hours after admin of a pharmacologic regimen intended to improve coronary patency before the procedure
rescue PCI
PCI intervention after suspected failure of fibrinolytic therapy
fibrin-specific therapy
alteplase (tPA)
reteplase (recombinant plasminogen activator)
tenecteplase (TNKase)
Non-fibrin specific
Streptokinase (streptase)
absolute contraindications of fibrinolytic agents
1. any prior ICH
2. known structural cerebral vascular lesion
3. known malignant intracranial neoplasm
4. ischemic stroke within 3 mo
-except acute ischemic stroke w/in 4.5hrs
5. suspected aortic dissection
6. active bleeding or bleeding diathesis
-excluding menses
7. significant closed-head or facial trauma within 3 mo
8. intracranial or intraspinal surgery within 2 mths
9. severe uncontrolled hypertension (unresponsive to emergency therapy)
10. for streptokinase, prior treatment within the previous 6 months
P2Y12 antagonists are also known as
adenosine diphosphate receptor inhibitor
thienopyridine P2Y12 antagonists
ticlpidine (ticlid)
clopidogrel (plavix)
prasugrel (effient)
direct acting P2Y12 antagonists
ticagrelor (brilinta)
cangrelor
which P2Y12 antagonist is not a pro drug
ticagrelor (brilinta)
how does PPI affect plavix
it can interfere with clopidogrel metabolism by inhibiting 2c19
TRITON-TIMI 38 study
prasugrel (effient) is superior to plavix
prasugrel is shown to be inefficient in which pts
>=75
<60kg
PLATO study
ticagrelor is has a better reduction from death vascular causes
what is the maximum dose of ASA that can be given to a pt on ticagrelor (brilinta)
100mg
what are the glycoprotein IIb/IIIA inhibitors
abiciximab (reopro)
tirofiban (aggrastat)
eptifibatide (integrelin)
MOA of glycoprotein IIb/IIIA inhibitors
inhibits platelets aggregation by reversibly/irreversibly antagonizing fibrinogen binding to the GP IIb/IIIA receptor
recommendations for glycoprotein IIb/IIIA Inhibitors
1. it is reasonable to begin tx with an IV treatment such as abiciximab, high-bolus-dose tirofiban, or double-bolus eptifibatide at the time of primary PCI in selected pts with STEMI who are recieving UFH
2. reasonable to administer IV antagonist in the pre-catherization laboratory setting to pts with STEMI for whom primary PCI is intended
AEs of glycoprotein IIb/IIIA inhibitors
thrombocytopenia
bleeding
monitoring for glycoprotein IIb/IIIA inhibitors
sign of bleeding
platelet
CBC
how should STEMI pts be treated with anticoagulants
if the pts with STEMI undergoing reperfusion with fibrinolytic therapy should receive anticoagulant therapy for a minimum of 48 hrs or hospital LOS (up to 8 days)
UFH bolus + dosing range
60 units/kg bolus (4000 u max)
12 units/kg/hr (mx initial rate 1000u/hr)
what do you adjust the aPTT in STEMI pts
50-70 secs
monitoring for UFH
CBC
platelet
bleeding
HIT
enoxaparin in PCI
not used in the setting
ATOLL study
no benefit with enoxaparin compared to UFH
enoxaparin with fibrinolytic
can be used as alternative to UFH in pts < 75
-Scr must ne <2.5 and <2.0 in men, women
-30mg IV bolus then 1mg/kg SC q12h
-1mg/kg daily if CrCl < 30ml/min
when is enoxaparin preferred over UFH
if anticoagulation is need > 48hrs
monitoring for enoxaparin
bleeding
renal function
platelet (less HIT compared to UFH)
Fondaparinux with PCI
not used alone bc of catheter thrombosis
fondaparinux with fibrinolytic
2.5mg IV then 2.5mg SC daily
contraindicated in CrCl < 30ml/min
bivalirudin with PCI/Fibrinolytic
it is an alt to UFH in pts with HIT pts and hig risk bleeding
lipid effect of statins in treating STEMI pts
no-lipid effect
what activity improvements do statins have in lipid mgmt
improvement in endothelial dysfunction
antiinflm and antithrombotic properties
matirx metalloproteinase activity
lipid management decreases the risk of what in MI pts
CHD
recurrent MI
stroke
need for coronary revascularization
when should statin therapy be used
it should be initiated and continued in all pts with STEMI w/out contraindications
which statin drug/dose is shown to reduce ischemic events among pts with ACS
lipitor 80
LDL goal for STEMI pts
<100
LDL goal in very high risk pts
<70 (pts with DM, ACS)
statin monitoring
LFTs
CK
what have ACEI shown to reduce in pts with STEMI
fatal and nonfatal major CV events
-decrese LV remodeling and ventricular dilitation
when should ACEI be added within 24 hrs
in pts with:
-anterior STEMI
-ejection fraction <=40%
-clinical sign of HF
SE of ACEI
hypotension
hyperkalemia
renal failure
cough
monitoring for ACEI
potassium
renal function
when can CCB be used
in pts with inc BP but cannot tolerate BB
use verapamil and diltiazem with caution in
pts with LV systolic dysfunction
when is dihydropyridine (nifedipine) contraindicated