Acute Coronary Syndrome (heart attack)

  1. What does STEMI stand for?
    ST-segment Elevation Myocardial Infarction
  2. What does NSTEMI stand for?
    Non-ST-segment Elevated Myocardial Infarction
  3. What are the types of acute coronary syndrome?
    • STEMI
    • NSTEMI
    • Unstable Angina (UA)
  4. Which type of ACS does not cause an increase in troponin?
  5. What are the characteristics of STEMI?
    • ST-segment elevation
    • new or presumably new left bundle branch block (obscuring ST-segment analysis)
    • Q wave present
    • elevated troponin levels
    • significant myocardial tissue death
    • persistent, significant occlusion
  6. What are the characteristics of UA/NSTEMI?
    • ST-T segment depression
    • T wave inversion
    • 25% chance of Q wave
    • ECG change may be absent
    • elevated troponin levels (NSTEMI)
    • persistent, moderate occlusion (NSTEMI)
    • moderate myocardial tissue death (NSTEMI)
    • possibly transient occlusion (UA)
    • minimal to no myocardial tissue death (UA)
  7. What are the characteristics of troponin?
    • elevated within 2-4h of MI onset (can be delayed 8-12h)
    • may remain elevated for up to 2wks
    • specific for myocardial necrosis
  8. What are the characteristics of CK-MB?
    • elevated 4-6h after MI onset
    • peaks at 24h and is normal in 48-72h
  9. How is MI ruled out?
    • measure troponin q 6h for 24h
    • no elevation after 24h means no MI occured
  10. What are the risk factors for ACS?
    • known CHD
    • PVD
    • cerebrovascular disease
    • diabetes
    • aneurysm
    • FR > 20%
  11. What are the complications of ACS?
    • restenosis or reocclusion, continued angina, progression to STEMI
    • hypotension
    • bradycardia
    • cardiogenic shock (both hypotension and bradycardia)
    • ventricular arrhythmias
    • thromboembolic disorder
    • left ventricle dysfunction
  12. What is the pre-hospital drug therapy for ACS?
    • chew aspirin
    • nitroglycerin (if previously prescribed)
    • fibrinolytics (select, eligible pts only - STEMI pts)
  13. What is the early hospital drug therapy for ACS?
    • Morphine
    • Oxygen
    • Nitro
    • Anti-platelet
    • DC COX2 inhibitors, NSAIDS and estrogen replacement therapy
  14. What is the hospital drug therapy for ACS?
    • Anti-ischemic tx:
    • nitro
    • morphine
    • BBL or CCB (non-DHP)
    • ACEI (or ARB) and aldosterone receptor blocker
    • Anti-thrombotic tx:
    • ASA
    • clopidogrel
    • prasugrel
    • eptifibitide
    • tirofiban
    • abciximab
    • UH
    • LMWH
    • fondaparinux
    • bivalirudin, argatroban, lepirudin, dabigatran
    • Other tx:
    • statin
    • hyperlipidemia control
    • glycemic control
    • Fibrinolytics (STEMI only):
  15. What is the drug therapy for UA/NSTEMI?
    • Anti-ischemic tx:
    • nitro
    • morphine IV
    • BBL or CCB (non DHP)
    • benzo (cocaine or stimulant abuse)
    • ACEI or ARB
    • Anti-thrombotic tx:
    • ASA
    • clopidogrel
    • prasugrel
    • eptifibitide (PCI or high risk only)
    • tirofiban (PCI or high risk only)
    • abciximab (PCI or high risk only)
    • UH
    • LMWH
    • bivalirudin
    • argatroban
    • lepirudin
    • dabigatran
    • fondaparinux
    • Other tx:
    • glycemic control
    • lipid control
  16. When is morphine used for ACS?
    • relieve sx, anxiety
    • comfort
    • mild venodilation
    • modest reductions in HR (increased vagal tone)
    • modest reductions in systolic BP
  17. What are the SE of morphine?
    • hypotension
    • bradycardia
    • respiratory depression
    • constipation
  18. What are the SE of clopidogrel and prasugrel?
    • bleeding
    • diarrhea (clopidogrel)
    • bruising (prasugrel)
  19. When are clopidogrel and/or prasugrel used for ACS?
    antiplatelet tx
  20. When are eptifibitide, abciximab, or tirofiban used for treatment of ACS?
    in high risk pts or pts scheduled for PCI (catheterization) ONLY
  21. What are the SE of eptifibitide, tirofiban, abciximab?
    • bleeding
    • profound thrombocytopenia (monitor platelet count 6h afterbolus dose, then daily)
  22. When are UH, LMWH, bivalirudin, argatroban, dabigatran used for treating ACS?
    All pts should be evaluated unless CI
  23. What are the SE of UH LMWH, bivalirudin, argatroban, dabigatran?
    • bleeding
    • HIT
    • mild elevations of hepatic transaminases
    • hyperkalemia
  24. What is the perferred reperfusion strategy for STEMI pts with sx onset fewer than 12h?
    PCI with antiplatelets and anticoagulants
  25. What is the national goal for door-to-balloon time?
    90 minutes
  26. What is the national goal for door-to-needle time?
    30 minutes
  27. When are fibrinolytics preferred over PCI?
    with early presentation (no more than 3h from sx onset and there will be a delay to PCI)
  28. What is the drug therapy for STEMI?
    • same as UA/NSTEMI except fibrinolytics:
    • reteplase
    • tenecteplase
  29. What are the SE of fibrinolytics?
    • bleeding (major and minor)
    • re-thrombosis
    • infusion-induced emboli
    • arrhythmia
  30. What are the absolute CI for fibrinolytics?
    • prior intracranial hemorrhage
    • known structural cerebral vascular lesion (e.g. arteriovenous malformation)
    • known malignant intracranial neoplasm
    • ischemic stroke within 3mo except acute ischemic stroke within 3h
    • suspected aortic dissection
    • active bleeding or bleeding diathesis (excluding menses)
    • significant closed head or facial trauma within 3mo
  31. Which fibrinolytics are preferred?
    alteplase, reteplase, tenecteplase (fibrin-specific)
  32. What is the drug therapy for pre-PCI?
    • ASA and clopidogrel
    • anticoagulant
    • eptifibitide or abciximab (unless clopidogrel administered 2-6 before)
  33. What is the drug therapy for post-PCI?
    • stop anticoagulant (avoid >48h use of UH)
    • eptifibitide for 18-24h or abciximab for total of 12h
  34. What is the drug therapy for stent placement?
    • ASA and clopidogrel or prasugrel for at least 1 yr, then ASA indefinitely (drug-eluting stents)
    • ASA and clopidogrel or prasugrel for at least 4 wks, optimally 1 yr, then ASA indefinitely (bare-metal stents)
  35. What is the drug therapy consideration for CABG after PCI?
    withhold clopidogrel or prasugrel for 5-7d before CABG
  36. What meds should be considered for ACS pt discharge?
    • BBL
    • ACE or ARB
    • antiplatelet
    • nitro prn
    • aldosterone receptor antagonist
    • statin
    • omega-3 fatty acid (at least 1g daily)
    • flu vaccine
    • smoking cessation
    • BP control
    • glycemic control
    • lipid control
    • physical activity
    • wt management
Card Set
Acute Coronary Syndrome (heart attack)
Acute Coronary Syndrome (heart attack)