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What does STEMI stand for?
ST-segment Elevation Myocardial Infarction
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What does NSTEMI stand for?
Non-ST-segment Elevated Myocardial Infarction
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What are the types of acute coronary syndrome?
- STEMI
- NSTEMI
- Unstable Angina (UA)
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Which type of ACS does not cause an increase in troponin?
UA
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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
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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)
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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
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What are the characteristics of CK-MB?
- elevated 4-6h after MI onset
- peaks at 24h and is normal in 48-72h
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How is MI ruled out?
- measure troponin q 6h for 24h
- no elevation after 24h means no MI occured
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What are the risk factors for ACS?
- known CHD
- PVD
- cerebrovascular disease
- diabetes
- aneurysm
- FR > 20%
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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
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What is the pre-hospital drug therapy for ACS?
- chew aspirin
- nitroglycerin (if previously prescribed)
- fibrinolytics (select, eligible pts only - STEMI pts)
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What is the early hospital drug therapy for ACS?
- Morphine
- Oxygen
- Nitro
- Anti-platelet
- DC COX2 inhibitors, NSAIDS and estrogen replacement therapy
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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):
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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
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When is morphine used for ACS?
- relieve sx, anxiety
- comfort
- mild venodilation
- modest reductions in HR (increased vagal tone)
- modest reductions in systolic BP
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What are the SE of morphine?
- hypotension
- bradycardia
- respiratory depression
- constipation
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What are the SE of clopidogrel and prasugrel?
- bleeding
- diarrhea (clopidogrel)
- bruising (prasugrel)
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When are clopidogrel and/or prasugrel used for ACS?
antiplatelet tx
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When are eptifibitide, abciximab, or tirofiban used for treatment of ACS?
in high risk pts or pts scheduled for PCI (catheterization) ONLY
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What are the SE of eptifibitide, tirofiban, abciximab?
- bleeding
- profound thrombocytopenia (monitor platelet count 6h afterbolus dose, then daily)
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When are UH, LMWH, bivalirudin, argatroban, dabigatran used for treating ACS?
All pts should be evaluated unless CI
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What are the SE of UH LMWH, bivalirudin, argatroban, dabigatran?
- bleeding
- HIT
- mild elevations of hepatic transaminases
- hyperkalemia
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What is the perferred reperfusion strategy for STEMI pts with sx onset fewer than 12h?
PCI with antiplatelets and anticoagulants
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What is the national goal for door-to-balloon time?
90 minutes
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What is the national goal for door-to-needle time?
30 minutes
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When are fibrinolytics preferred over PCI?
with early presentation (no more than 3h from sx onset and there will be a delay to PCI)
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What is the drug therapy for STEMI?
- same as UA/NSTEMI except fibrinolytics:
- reteplase
- tenecteplase
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What are the SE of fibrinolytics?
- bleeding (major and minor)
- re-thrombosis
- infusion-induced emboli
- arrhythmia
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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
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Which fibrinolytics are preferred?
alteplase, reteplase, tenecteplase (fibrin-specific)
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What is the drug therapy for pre-PCI?
- ASA and clopidogrel
- anticoagulant
- eptifibitide or abciximab (unless clopidogrel administered 2-6 before)
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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
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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)
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What is the drug therapy consideration for CABG after PCI?
withhold clopidogrel or prasugrel for 5-7d before CABG
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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
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