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what causes ACS
imbalance between myocardial oxygen demand and supply
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NSTE ACS consists of
NSTEMI and UA (unstable angina)
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STEMI is defined as
presence of a new ECG ST elevation in 2 or more leads
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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
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the different cardiac biomarkers
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cardiac biomarker better for diagnosis re-infarction
CK-MB
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how many days does troponin stay elevated
7-14 days
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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
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NTG Routes and dosing
- sublingual: 4mg SL every 5min
- topical ointment: 0.5-2 inch q4-6h
- IV gtts: 5-10mcg/min
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when is IV NTG usually used
in STEMI if there is persistent ischemia, CHF, HTN
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what to watch out for when taking NTG
- hypotension
- flushing and HA
- reflex tachy/brady
- tolerance to nitrate therapy
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what study shows aspirin to decrease mortality in MI pts
ISIS-2 study
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what to avoid when giving aspirin therapy
avoid use of NSAID like ibuprofen
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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
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what is the caution with given oxygen in STEMI pts
COPD and CO2 retention
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effects of morphine
analgesic and venodilatory effects
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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
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metoprolol dosing range
25-50 PO q6-12h and titrate to 200mg/day
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Carvedilol dosing range
6.25mg PO bid and titrate to 25mg PO BID
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Atenolol dosing range
50mg PO and then titrate to 100mg/day
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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
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IV metoprolol dosing
5mg q5min x 3
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IV atenolol dosing
5mg q5min x 2
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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
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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
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what is the goal of reperfusion
goal of reperfusion is to restore myocardial perfusion in the infarct artery
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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)
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when is fibrinolysis generally preferred
- 1. early presentation (less than 3 hrs)
- 2. invasive strategy is not an option
- 3. delay to invasive strategy
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what is primary PCI
coronary angiography with either balloon angioplasty or placement of intracoronary stent within 90 min
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what is facilitated PCI
planned PCI within a few hours after admin of a pharmacologic regimen intended to improve coronary patency before the procedure
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rescue PCI
PCI intervention after suspected failure of fibrinolytic therapy
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fibrin-specific therapy
- alteplase (tPA)
- reteplase (recombinant plasminogen activator)
- tenecteplase (TNKase)
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Non-fibrin specific
Streptokinase (streptase)
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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
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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
-
PLATO study
ticagrelor is has a better reduction from death vascular causes
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what is the maximum dose of ASA that can be given to a pt on ticagrelor (brilinta)
100mg
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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
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AEs of glycoprotein IIb/IIIA inhibitors
-
monitoring for glycoprotein IIb/IIIA inhibitors
- sign of bleeding
- platelet
- CBC
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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
-
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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
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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
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which statin drug/dose is shown to reduce ischemic events among pts with ACS
lipitor 80
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LDL goal for STEMI pts
<100
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LDL goal in very high risk pts
<70 (pts with DM, ACS)
-
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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
-
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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
in STEMI
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what does dihydropyridine cause
hypotension and reflex tachy
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other secondary prevention measures
- pt education
- smoking cessation
- DM
- life style modification
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