4 - ACS Part 1 Flashcards
1
Q
What are the 3 types of ACS?
A
1) unstable angina
2) Non ST segment elevation MI (NSTEMI)
3) ST segment elevation MI (STEMI)
2
Q
What type is the most serious and why?
A
STEMI bc the vessel is completely occluded (lots of fibrin)
3
Q
What tests are used to differentiate between the 3 types of ACS?
A
- if troponin is elevated, it rules out UA (troponin is released when cardiac cells die)
- if ST is elevated = STEMI, if not = NSTEMI
4
Q
What is a STEMI caused by?
A
complete occlusion of a coronary after by clot (rupture of atherosclerotic plaque)
5
Q
Along with troponin T (TnT) what is another test/maker of cardiac death?
A
CK-MB (the most specific CK isoenzymes for myocardium)
6
Q
What are some classic symptoms that appear in all ACS?
A
- chest pain typically radiating to shoulder down left arm
- shortness of breath
- nausea or vomiting
- diaphoresis (sweating)
7
Q
1/3 of all MIs are _____ type
A
silent
8
Q
What groups of people are less likely to have classic symptoms?
A
-elderly, diabetic, and women
9
Q
What are some signs that they are actually experiencing ACS?
A
- syncope
- bradycardia, tachycardia or other arrhythmias
- high or low BP
- diffuse rales, wheezing or respiratory distress usually indicate pulmonary deem and CHF
- jugular venous distension indicates right atrial hypertension, usually from RV infarction or elevated LV filling pressure
10
Q
When is CK-MB detectable in serum?
A
within 3-6 hours after MI, peaks in 12-24 hours, and stays elevated for 2-3 days
11
Q
When is TnT detectable in serum?
A
4-12 hours after MI onset, peaks in 12-48 hours, and stays elevated for 7-10 days
12
Q
When should biomarker essays be done?
A
STAT on presentation, then repeated Q4-6H for the first 12-24 hours, then periodically
13
Q
What is needed for diagnosis of STEMI or NSTEMI?
A
At least 2 elevated CK-MB or 1 TnT exceeding the upper reference range
14
Q
When should a 12-lead ECG be done ?
A
within 10 min of presentation to Emergency Department
15
Q
What is an ECG used for?
A
distinguishing between STEMI and NSTEMI
16
Q
What other types of ECG abnormalities may be observed for NSTEMI
A
- ST depression
- T wave inversion
17
Q
What is the initial management?
A
- oxygen at 4L/min by nasal prong to maintain O2 saturation > 90%
- ASA 162 - 325 mg PO chew/shallow (if not already given by EMS)
- nitroglycerin SL or IV
- morphine 2 - 5 mg IV q5-30 min prn
MONA
- morphine
- oxygen
- nitrates
- ASA
18
Q
Why is morphine given as part of initial management?
A
- bc pain increases sympathetic NS which increases oxygen demand
- so treating pain will bring oxygen demand back down
19
Q
STEMI: time = _____
A
muscle
20
Q
What are the 2 types of repercussion strategies in STEMI?
A
1) PCI - primary percutaneous coronary intervention
2) fibrinolytics
21
Q
Goals of Therapy of Reperfusion?
A
- decrease mortality and complications
- reduce or contain infarct size
- salvage functioning myocardium and prevent remodelling
- re-establish potency of the infarct-related artery
22
Q
Reperfusion therapy should be administered to all eligible patients with symptom onset within the prior____ hours
A
12
23
Q
What is the recommended method of repercussion when it can be performed in a timely fashion by experienced operators?
A
primary PCI
24
Q
What is the ideal door-to-balloon (medical contact to device) time for primary PCI?
A
< 90 mins
25
If a STEMI initially presents to a non-PCI capable hospital, immediate transfer to a PCI capable hospital for primary PCI should be considered if a medical contact-device time of _______ can be achieved.
< 120 mins
26
When fibrinolytic therapy is indicated or chosen as the primary repercussion strategy, it should be administered within ______ mins of hospital arrival
30
27
Describe the TIMI Grade Flow
adopted scoring system for 0-3 referring to the level of coronary blood flow assessed during PCI
0 = bad (no flow)
3 = good (complete perfusion)
28
What is a DES
drug eluting stent
29
Patients who received DES will require dual-antiplatelet therapy (DAPT) for a minimum of ??
1 year
30
Greatest mortality reduction is achieved when fibrinolytics is given within _____ hours
0-2
31
fibrinolytics are only administered to patients with ______
STEMI
32
Why are fibrinolytics not administered to NSTEMI/UA patients?
bc there is not much fibrin in NSTEMI and UA, mostly made up of platelets
33
What is the fibrinolytic of choice?
Tenecteplase (TNK)
34
List some points about Tenecteplase (TNK)? (3)
- 5 second singel bolus
- weight-tired dosing
- most fibrin-specific agent
* more on slide 29
35
What is the major concern of fibrinolytic therapy?
bleeding complications
36
What are some absolute CI to fibrinolytic use?
- any prior ICH (intracranial hemorrhage)
- suspected aortic dissection
- severe uncontrolled hypertension
37
What are some relative CI to fibrinolytic use?
- dementia
- pregnancy
- active peptic ulcer
38
What types of meds should be administered to STEMI patients getting a PCI?
- ASA 162 - 325 mg given before PCI
- loading dose of P2Y12 receptor inhibitor (ex. clopidogrel 600 mg) as early as possible before PCI
- ASA 81 - 162 mg PO daily PLUS a P2Y12 receptor inhibitor at maintenance dose should be considered (ex. clopidogrel 75 mg daily)
- LMWH or UFH is usually initiated on presentation and discontinued after PCI
39
What types of meds should be administered to STEMI patients receiving fibrinolytics?
- ASA 162 - 325 mg given on presentation
- Clopidogrel 300mg LD in patients < 75 or Clopidogrel 75 mg LD in patients > 75
- Clopidogrel 75 daily should be continued for 14 days unless pt undergoes subsequent PCI
- LMWH or UFH should be initiated at time of fibrinolysis and continued for a minimum of 48 hours and up to 8 days (or until revascularization with PCI)
40
What is the dose of enoxaparin in STEMI patients < 75?
- Give enoxaparin 30mg IV bolus before TNK
- continue enoxaparin 1mg/kg SC q12h after TNK
- maximum dose enoxaparin 140 mg SC q12h after the first 24 hours
41
What is the dose of enoxaparin in STEMi patients > 75?
- do not give enoxaparin IV bolus
- enoxaparin 0.75mg/kg SC q12h after TNK
- maximum dose enoxaparin 100 mg SC q12h after the first 24 hours
42
Heparin is used in patients > _____kg.
149
| *little evidence to support LMWH in these patients
43
Heparin is used in those with renal impairment, a CrCl of ______.
< 30 mL/min
44
Dose of heparin?
UFH 60 units/kg IV load, followed by 12 units/kg/hr IV infusion
*target aPTT 49-65 seconds
45
What are the new P2Y12 antagonists?
prasugrel and ticagrelor
46
For DAPT (dual anti platelet therapy), what is the best P2Y12 antagonist to be combined with ASA?
```
ASA + prasugrel
OR
ASA + ticagrelor
are both more efficacious compared to:
ASA + clopidogrel
```
47
What types of patients should prasugrel not be used in?
patients with history of stroke or TIA due to higher rates of major bleeding in these populations
48
In ACS, patients who undergo PCI should receive DAPT for ?
- minimum of 1 year (PCI with DES)
- minimum of 1 month, but 1 year recommended (PCI with Bare metal stent)
- minimum of 1 year (CABG in the setting of ACS)
49
In ACS, ASA should be continued _______
forever
50
For STEMI patients who are treated medically with fibrinolytics, how long is DAPT?
it is not warranted - but many of these patients will continue to have a PCI and prescribed clopidogrel or prasugrel
51
What is triple therapy?
DAPT + warfarin
52
Who is triple therapy indicated for?
STEMI patients with low ejection fraction or has concurrent AF
53
Reperfusion (PCI or fibrinolytics):
| How do we monitor efficacy?
signs and symptoms of ongoing chest pain, eCG changes, serial monitoring of biomarkers
54
Reperfusion (PCI or fibrinolytics):
| Complications?
arrhythmias, HF, pericarditis, major and minor bleeding complications
55
What are clinical signs of bleeding?
-bloody stools
-melena (dark, tarry stools)
-hematuria (blood in urine)
hematemesis (vomiting blood)
-bruising
-oozing form arterial or venous puncture sites
56
List some STEMI complications
- heart failure
- cardiogenic shock
- arrhythmias
- pericarditis
57
Goals of adjunct therapy?
- reduce the risk of short term and long term complications associated with STEMI
- slow progression of coronary heart disease and minimize the risk of future CV events and other morbidities
- improve mortality and restore quality of life
58
MOA of B blockers
reduce oxygen demand
59
When should B blockers be initiated and who should get them?
Everyone post MI unless contraindicated should get a BB within 24 hours after onset
*start at low dose and titrate to maintain resting heart rate of 55-60 bpm
60
Who are BB CI for?
- hypotension (SBP < 90)
- bradycardia (HR < 50 bpm)
- acute heart failure (requiring inotropes)
- cardiogenic shock
- asthma
- 2nd or 3rd degree AV block
61
What do you monitor for patients on B blockers?
BP, HR, signs/symptoms of HF
62
Dose of Metoprolol?
Start at 25mg BID, titrate to max 100mg PO BID
63
Dose of Atenolol?
12.5-25 mg daily, up to 100 mg daily
64
Dose of Carvedilol?
3.125mg BID, titrate to 25mg BID
65
MOA of ACEi
- reduce ventricular remodelling
| - reduce oxygen demand and myocardial wall stress by decreases both preload and afterload
66
When should ACEi be initiated?
24 hrs post MI once BP has been stabilized unless CI
67
ACEi:
| Use with caution in those with ??
renal impairment and hyperkalemia
68
What do you need to monitor for ACEi?
SCr, electrolytes, watch for hyperkalemia ( K > 5.5) especially with concurrent spironolactone
69
Dose of ramipril?
1.25 - 2.5 mg daily, target 10mg/day
70
Dose of enalapril?
2.5mg BID, target 10-20 mg BID
71
Dose of lisinopril?
2.5 - 5mg daily, target 40 mg daily
72
Dose of captopril?
6.25mg TID, target 25-50 mg TID
73
Who are ARBs indicated for?
ACEi intolerant patients
74
Monitoring for ARBs?
SCr, electrolytes, watch for hyperkalemia ( K > 5.5) especially with concurrent spironolactone
75
Dose of candesartan?
4mg daily, target 32 mg daily
76
Dose of telmisartan?
40mg daily, target 80 mg daily
77
Dose of valsartan?
20mg PO BID, target 160 mg BID
78
What is the goal LDL for pts on statins?
< 2 mmol/L or < 1.8 mmol/L in very high risk patients
79
Monitoring for statins?
- Lipid panel
- CK
- LFTs ???
- signs of myopathy and rhabdomyolysis
80
Dose of atorvastatin?
20-80 mg daily
81
Dose of fluvastatin?
20-80 mg daily
82
Dose of pravastatin?
20-40 mg daily
83
Dose of lovastatin?
20-80 mg daily
84
Dose of simvastatin?
20-80 mg daily
85
Dose of rosuvastatin?
5-40 mg daily
86
What is evolocumab?
monoclonal antibody (biologic) that inhibits PCSK9 - lowers LDL
87
Why is evolocumab not cost-effective?
$1.2 million per year to prevent one MI
88
List 2 mineralocorticoid receptor/aldosterone antagonists?
- spironolactone
| - eplerenone
89
Who is an aldosterone antagonist recommended for?
patients with significant LV dysfunction (EF < 40%)
90
Who are aldosterone antagonists cautioned in?
CrCl < 30 mL/min
| K > 5 mEq
91
When do you check potassium for an aldosterone antagonist?
at baseline and within 1 week of initiation
92
Dose of spironolactone?
12.5 mg daily, titrate to 25 mg daily
93
Dose of eplerenone?
25mg daily, titrate to 50mg daily
94
Non-pharm therapy for ACS?
- Weight management
- Physical exercise
- Stress management
- Depression screening
95
What are some modifiable risk factors for CHD?
- smoking cessation
- hypertension
- dyslipidemia
- obesity
- sedentary lifestyle
- stress
