Myocardial Infarction

  1. what causes ACS
    imbalance between myocardial oxygen demand and supply
  2. NSTE ACS consists of
    NSTEMI and UA (unstable angina)
  3. STEMI is defined as
    presence of a new ECG ST elevation in 2 or more leads
  4. steps to diagnose MI
    • clinical presentation
    • ECG
    • cardiac biomarkers
    • rule out differential diagnosis
  5. clinical presentations
    • chest pain/discomfort
    • shortness of breath/dyspnea
    • diaphoresis
    • nausea/vomiting
    • dizziness or syncope
    • fatigue/weakness
  6. the different cardiac biomarkers
    • CK-MB
    • Troponin
  7. cardiac biomarker better for diagnosis re-infarction
  8. how many days does troponin stay elevated
    7-14 days
  9. 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
  10. complications of STEMI
    • ventricular arrhythmias
    • ventricular remodeling
    • HF
    • recurrent ischemia
    • re-infarction
    • cardiogenic shock
    • stroke secondary to LV thrombus embolization
  11. effects of NTG
    • venodilation (preload) and arterial vasodilation
    • reduce myo O2 demand
    • promote coronary blood flow
  12. NTG Routes and dosing
    • sublingual: 4mg SL every 5min
    • topical ointment: 0.5-2 inch q4-6h
    • IV gtts: 5-10mcg/min
  13. when is IV NTG usually used
    in STEMI if there is persistent ischemia, CHF, HTN
  14. what to watch out for when taking NTG
    • hypotension
    • flushing and HA
    • reflex tachy/brady
    • tolerance to nitrate therapy
  15. what study shows aspirin to decrease mortality in MI pts
    ISIS-2 study
  16. what to avoid when giving aspirin therapy
    avoid use of NSAID like ibuprofen
  17. 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
  18. what is the caution with given oxygen in STEMI pts
    COPD and CO2 retention
  19. effects of morphine
    analgesic and venodilatory effects
  20. AE of Morphine
    • hypotension
    • respiratory depression
    • bradycardia
  21. 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
  22. metoprolol dosing range
    25-50 PO q6-12h and titrate to 200mg/day
  23. Carvedilol dosing range
    6.25mg PO bid and titrate to 25mg PO BID
  24. Atenolol dosing range
    50mg PO and then titrate to 100mg/day
  25. 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
  26. IV metoprolol dosing
    5mg q5min x 3
  27. IV atenolol dosing
    5mg q5min x 2
  28. 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
  29. 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
  30. what is the goal of reperfusion
    goal of reperfusion is to restore myocardial perfusion in the infarct artery
  31. 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)
  32. when is fibrinolysis generally preferred
    • 1. early presentation (less than 3 hrs)
    • 2. invasive strategy is not an option
    • 3. delay to invasive strategy
  33. what is primary PCI
    coronary angiography with either balloon angioplasty or placement of intracoronary stent within 90 min
  34. what is facilitated PCI
    planned PCI within a few hours after admin of a pharmacologic regimen intended to improve coronary patency before the procedure
  35. rescue PCI
    PCI intervention after suspected failure of fibrinolytic therapy
  36. fibrin-specific therapy
    • alteplase (tPA)
    • reteplase (recombinant plasminogen activator)
    • tenecteplase (TNKase)
  37. Non-fibrin specific
    Streptokinase (streptase)
  38. 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
  39. P2Y12 antagonists are also known as
    adenosine diphosphate receptor inhibitor
  40. thienopyridine P2Y12 antagonists
    • ticlpidine (ticlid)
    • clopidogrel (plavix)
    • prasugrel (effient)
  41. direct acting P2Y12 antagonists
    • ticagrelor (brilinta)
    • cangrelor
  42. which P2Y12 antagonist is not a pro drug
    ticagrelor (brilinta)
  43. how does PPI affect plavix
    it can interfere with clopidogrel metabolism by inhibiting 2c19
  44. TRITON-TIMI 38 study
    prasugrel (effient) is superior to plavix
  45. prasugrel is shown to be inefficient in which pts
    • >=75
    • <60kg
  46. PLATO study
    ticagrelor is has a better reduction from death vascular causes
  47. what is the maximum dose of ASA that can be given to a pt on ticagrelor (brilinta)
  48. what are the glycoprotein IIb/IIIA inhibitors
    • abiciximab (reopro)
    • tirofiban (aggrastat)
    • eptifibatide (integrelin)
  49. MOA of glycoprotein IIb/IIIA inhibitors
    inhibits platelets aggregation by reversibly/irreversibly antagonizing fibrinogen binding to the GP IIb/IIIA receptor
  50. 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
  51. AEs of glycoprotein IIb/IIIA inhibitors
    • thrombocytopenia
    • bleeding
  52. monitoring for glycoprotein IIb/IIIA inhibitors
    • sign of bleeding
    • platelet
    • CBC
  53. 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)
  54. UFH bolus + dosing range
    • 60 units/kg bolus (4000 u max)
    • 12 units/kg/hr (mx initial rate 1000u/hr)
  55. what do you adjust the aPTT in STEMI pts
    50-70 secs
  56. monitoring for UFH
    • CBC
    • platelet
    • bleeding
    • HIT
  57. enoxaparin in PCI
    not used in the setting
  58. ATOLL study
    no benefit with enoxaparin compared to UFH
  59. 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
  60. when is enoxaparin preferred over UFH
    if anticoagulation is need > 48hrs
  61. monitoring for enoxaparin
    • bleeding
    • renal function
    • platelet (less HIT compared to UFH)
  62. Fondaparinux with PCI
    not used alone bc of catheter thrombosis
  63. fondaparinux with fibrinolytic
    • 2.5mg IV then 2.5mg SC daily
    • contraindicated in CrCl < 30ml/min
  64. bivalirudin with PCI/Fibrinolytic
    it is an alt to UFH in pts with HIT pts and hig risk bleeding
  65. lipid effect of statins in treating STEMI pts
    no-lipid effect
  66. what activity improvements do statins have in lipid mgmt
    • improvement in endothelial dysfunction
    • antiinflm and antithrombotic properties
    • matirx metalloproteinase activity
  67. lipid management decreases the risk of what in MI pts
    • CHD
    • recurrent MI
    • stroke
    • need for coronary revascularization
  68. when should statin therapy be used
    it should be initiated and continued in all pts with STEMI w/out contraindications
  69. which statin drug/dose is shown to reduce ischemic events among pts with ACS
    lipitor 80
  70. LDL goal for STEMI pts
  71. LDL goal in very high risk pts
    <70 (pts with DM, ACS)
  72. statin monitoring
    • LFTs
    • CK
  73. what have ACEI shown to reduce in pts with STEMI
    • fatal and nonfatal major CV events
    • -decrese LV remodeling and ventricular dilitation
  74. when should ACEI be added within 24 hrs
    • in pts with:
    • -anterior STEMI
    • -ejection fraction <=40%
    • -clinical sign of HF
  75. SE of ACEI
    • hypotension
    • hyperkalemia
    • renal failure
    • cough
  76. monitoring for ACEI
    • potassium
    • renal function
  77. when can CCB be used
    in pts with inc BP but cannot tolerate BB
  78. use verapamil and diltiazem with caution in
    pts with LV systolic dysfunction
  79. when is dihydropyridine (nifedipine) contraindicated
    in STEMI
  80. what does dihydropyridine cause
    hypotension and reflex tachy
  81. other secondary prevention measures
    • pt education
    • smoking cessation
    • DM
    • life style modification
Card Set
Myocardial Infarction
PT II Exam