Myocardial Infarction

imbalance between myocardial oxygen demand and supply

NSTEMI and UA (unstable angina)

presence of a new ECG ST elevation in 2 or more leads

• clinical presentation
• ECG
• cardiac biomarkers
• rule out differential diagnosis

• chest pain/discomfort
• shortness of breath/dyspnea
• diaphoresis
• nausea/vomiting
• dizziness or syncope
• fatigue/weakness

• CK-MB
• Troponin

CK-MB

7-14 days

• control chest pain
• restore coronary blood flow and min infart size
• rule out diff diagnosis
• prevent complications

• ventricular arrhythmias
• ventricular remodeling
• HF
• recurrent ischemia
• re-infarction
• cardiogenic shock
• stroke secondary to LV thrombus embolization

• venodilation (preload) and arterial vasodilation
• reduce myo O2 demand
• promote coronary blood flow

• sublingual: 4mg SL every 5min
• topical ointment: 0.5-2 inch q4-6h
• IV gtts: 5-10mcg/min

in STEMI if there is persistent ischemia, CHF, HTN

• hypotension
• flushing and HA
• reflex tachy/brady
• tolerance to nitrate therapy

ISIS-2 study

avoid use of NSAID like ibuprofen

beyond 6 hrs in STEMI pts with arterial oxygen desaturation or overt pulmonary congestion

COPD and CO2 retention

analgesic and venodilatory effects

• hypotension
• respiratory depression
• bradycardia

• 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

25-50 PO q6-12h and titrate to 200mg/day

6.25mg PO bid and titrate to 25mg PO BID

50mg PO and then titrate to 100mg/day

IND ONLY in pts who are hypertensive (at presentation) or have ongoing ischemia and with no contraindication to their use

5mg q5min x 3

5mg q5min x 2

• 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

• sign of acute decompensated HF
• low output state
• increased risk of cardiogenic shock
• second or thirddegree heart block
• active asthma/ reactive airways disease

goal of reperfusion is to restore myocardial perfusion in the infarct artery

• 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)

• 1. early presentation (less than 3 hrs)
• 2. invasive strategy is not an option
• 3. delay to invasive strategy

coronary angiography with either balloon angioplasty or placement of intracoronary stent within 90 min

planned PCI within a few hours after admin of a pharmacologic regimen intended to improve coronary patency before the procedure

PCI intervention after suspected failure of fibrinolytic therapy

• alteplase (tPA)
• reteplase (recombinant plasminogen activator)
• tenecteplase (TNKase)

Streptokinase (streptase)

• 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

adenosine diphosphate receptor inhibitor

• ticlpidine (ticlid)
• clopidogrel (plavix)
• prasugrel (effient)

• ticagrelor (brilinta)
• cangrelor

ticagrelor (brilinta)

it can interfere with clopidogrel metabolism by inhibiting 2c19

prasugrel (effient) is superior to plavix

• >=75
• <60kg

ticagrelor is has a better reduction from death vascular causes

100mg

• abiciximab (reopro)
• tirofiban (aggrastat)
• eptifibatide (integrelin)

inhibits platelets aggregation by reversibly/irreversibly antagonizing fibrinogen binding to the GP IIb/IIIA receptor

• 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

• thrombocytopenia
• bleeding

• sign of bleeding
• platelet
• CBC

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)

• 60 units/kg bolus (4000 u max)
• 12 units/kg/hr (mx initial rate 1000u/hr)

50-70 secs

• CBC
• platelet
• bleeding
• HIT

not used in the setting

no benefit with enoxaparin compared to UFH

• 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

if anticoagulation is need > 48hrs

• bleeding
• renal function
• platelet (less HIT compared to UFH)

not used alone bc of catheter thrombosis

• 2.5mg IV then 2.5mg SC daily
• contraindicated in CrCl < 30ml/min

it is an alt to UFH in pts with HIT pts and hig risk bleeding

no-lipid effect

• improvement in endothelial dysfunction
• antiinflm and antithrombotic properties
• matirx metalloproteinase activity

• CHD
• recurrent MI
• stroke
• need for coronary revascularization

it should be initiated and continued in all pts with STEMI w/out contraindications

lipitor 80

<100

<70 (pts with DM, ACS)

• LFTs
• CK

• fatal and nonfatal major CV events
• -decrese LV remodeling and ventricular dilitation

• in pts with:
• -anterior STEMI
• -ejection fraction <=40%
• -clinical sign of HF

• hypotension
• hyperkalemia
• renal failure
• cough

• potassium
• renal function

in pts with inc BP but cannot tolerate BB

pts with LV systolic dysfunction

in STEMI

hypotension and reflex tachy

• pt education
• smoking cessation
• DM
• life style modification