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Acute Care I > ACS: STEMI > Flashcards

ACS: STEMI Flashcards

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1
Q

Requirements for STEMI on ECG

A

> /= 2 contiguous leads w/ ST-segment elevation >/= 2.5mm in men < 40 years
/= 2 mm in men >/= 40 years
/= 1.5mm in women in leads V2-V3 &/or >/= 1mm in other leads (in absence of LVH or LBBB

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2
Q

STEMI occurs due to what?
Exposure of circulating blood to cholesterol-rich material w/n plaque stimulates what? which has what effect?

A

erosion or sudden rupture of atherosclerotic plaque w/n wall of coronary artery
blood clotting (thrombosis); obstructs blood flow w/n the coronary artery

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3
Q

STEMI is most often caused by what?
As soon as blood supply is interrupted what occurs?
In animal models of experimental coronary artery occlusion, a ‘wave-front’ of what goes where?
In those who survive STEMI, infarcted muscle is gradually replaced by what? & extent of damage will determine what? & is a determinant of what?

A

complete & persistent occlusion of a coronary artery thrombus.
myocardial damage begins & the longer the blood supply is occluded, the greater the amount of heart muscle lost.
myocardial injury spreads from inner layer of heart muscle (subendocardial myocardium) to outermost layer (sub-epicardial myocardium), whereupon the infarction is then said to be ‘full thickness’.
fibrosis; contractility; heart failure & longer-term survival

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4
Q

NSTEMI may be a flow-limiting condition such as?

A

stable plaque
vasospasm-Prinzmetal angina
coronary embolism
coronary arteritis

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5
Q

Non-coronary injury to heart can also produce NSTEMI, these injuries can include?

A

cardiac contusion
myocarditis
presence of cardiotoxic substances

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6
Q

Conditions unrelated to coronary arteries or myocardium itself can lead to NSTEMI because increased O2 demand cannot be met. These conditions include?

A

Hypotension
HTN
Tachycardia
AS
PE

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7
Q

STEMI patient who is a candidate for reperfusion.
Initially seen at PCI-capable hospital, what are the following steps?

A

Send to cath lab for primary PCI; FMC-deve time </= 90 min
Diagnostic angiogram
1 of the following 3:
Medical therapy only
PCI
CABG

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8
Q

STEMI patient who is a candidate for reperfusion
Initially seen at a non-PCI capable hospital, what decision is initially made?

A

Patient is either transferred for primary PCI; DIDO </=30 min; FMC-device time ASAP and </= 120 min

or

Administer fibrinolytic agent w/n 30 min of arrival when anticipated FMC-device time > 120 min

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9
Q

STEMI patient who is a candidate for reperfusion
For patients who receive fibrinolytic agent, what is the next step?

A

Urgent transfer for PCI for patients w/ evidence of failed reperfusion or reocclusion

or

Transfer for angiography and revascularization w/n 3-24 hrs for other patients as part of an invasive strategy

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10
Q

Primary PCI & STEMI should be done when:
Ischemic symptoms are < how long?
Ischemic symptoms are < how long and contraindications to what?
the patient experiences what irrespective of time delay from MI onset?

A

12 hours
12 hours and contraindications to fibrinolytic therapy irrespective of time delay from FMC
Cardiogenic shock or acute severe HF

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11
Q

Placement of what is useful in primary PCI for patients w/ STEMI?

A

bare-metal stent or drug-eluting stent

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12
Q

Bare Metal Stent (BMS) should be used in patients w/?

A

high bleeding risk
inability to comply w/ 1 yr of DAPT
anticipated invasive or surgical procedures in the next yr

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13
Q

Drug-eluting stent (DES) should not be used in primary PCI for patients w/ STEMI who are what?

A

unable to tolerate or comply w/ a prolonged course of DAPT because of the increased risk of stent thrombosis w/ premature discontinuation of one or both agents

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14
Q

Anti-Platelet therapy to use for STEMI patients

A

Aspirin
P2Y12 inhibitors
IV GP IIb/IIIa receptor antagonists in conjunction with UFH or bivalirudin in selected patients

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15
Q

Aspirin
Loading dose before PCI?
daily maintenance dose? Preferred maintenance dose?

A

162-325mg
81-325mg daily
81mg daily

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16
Q

P2Y12 inhibitors
Loading doses

A

Clopidogrel 600 mg as early as possible or at time of PCI
Prasugrel 60 mg as early as possible or at time of PCI
Ticagrelor 180 mg as early as possible or at time of PCI

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17
Q

P2Y12 inhibitors
Maintenance doses and duration of therapy
DES placed: Continue therapy for?

A

1 year
clopidogrel 75mg daily
prasugrel 10mg daily
ticagrelor 90 mg twice a day

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18
Q

P2Y12 inhibitors
Maintenance doses and duration of therapy
BMS placed: continue therapy for?

A

1 year
Clopidogrel 75mg daily
prasugrel 10mg daily
ticagrelor 90mg twice a day

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19
Q

P2Y12 inhibitors
Maintenance doses and duration of therapy
DES placed what medications are continued beyond 1 year?
Patients w/ STEMI or prior stroke or TIA should receive?

A

clopidogrel, prasugrel, ticagrelor
prasugrel

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20
Q

IV GP IIb/IIIa receptor antagonists in conjunction with UFH or bivalirudin in selected patients
What medications are used here?

A

Abciximab
Tirofiban
Eptifibatide

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21
Q

IV GP IIb/IIIa receptor antagonists in conjunction with UFH or bivalirudin in selected patients
Abciximab loading dose? maintenance?
Tirofiban loading dose? maintenance?
Eptifibatide loading dose? maintenance? what is administered 10 min after loading dose?

A

0.25mg/kg IV bolus then 0.125mcg/kg/min (max 10mcg/min)
25mcg/kg IV bolus then 0.15 mcg/kg/min
180mcg/kg IV bolus then 2mcg/kg/min followed by a second 180mcg/kg bolus 10 min after initial loading dose

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22
Q

IV GP IIb/IIIa receptor antagonists in conjunction with UFH or bivalirudin in selected patients
Tirofiban dose reduction for CrCl < 30ml/min?
Eptifibatide dose reduction for CrCl < 50 ml/min? avoid giving this in patients on?

A

reduce infusion by 50%
reduce infusion by 50%; Hemodialysis

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23
Q

Anticoagulation therapy
UFH
With GP IIb/IIIa receptor antagonist planned what dose is administered to achieve therapeutic what?
W/o GP IIb/IIIa receptor antagonist planned what does is administered to achieve therapuetic what?

A

50-70 U/kg IV bolus to achieve therapuetic ACT
70-100 U/kg IV bolus to achieve therapuetic ACT

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24
Q

Anticoagulation therapy
Bivalirudin
what dose is given w/ or w/o prior treatment w/ UFH?
If needed an additional bolus of what can be given?

A

0.75mcg/kg IV bolus then 1.75 mcg/kg/hr infusion
0.3 mg/kg

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25
Anticoagulation therapy Bivalirudin Reduce infusion to what w/ estimated CrCl < 30ml/min? Preferred over UFH w/ GP IIb/IIIa receptor antagonist in patients w/ what?
1mg/kg/hr high risk of bleeding
26
Anticoagulation therapy What medication is not recommended as sole anticoagulant for primary PCI?
Fondaparinux
27
Recommendations for Reperfusion at a Non-PCI hospital: Ischemic symptoms < how long? Evidence of ongoing ischemia between how long after onset, and a large are of what, or the patient is experiencing what?
12 hours 12-24hours; myocardium at risk; hemodynamic instability
28
Recommendations for Reperfusion at a Non-PCI hospital: Not recomended if ST depression except if? or when associated w/ ST-elevation in lead?
true posterior (inferobasal) MI suspected aVR
29
Doses of fibrinolytic therapy: Streptokinase?
1.5 million units over 30-60 min IV
30
Doses of fibrinolytic therapy: Alteplase (tPA)?
15mg IV bolus 0.75mg/kg IV over 30m min (up to 50 mg) then 0.5mg/kg IV over 60 min (up to 35mg)
31
Doses of fibrinolytic therapy: Tenectaplase if < 60kg if 60 to <70kg if 70 to <80kg if 80 to <90kg if >/= 90kg it is recommended to reduce dose to what in what patients?
30mg 35mg 40mg 45mg 50mg half dose in patients >/= 75 years old
32
Doses of antiplatelet co-therapies w/ fibrinolytic therapy Aspirin?
Starting dose of 150-300mg PO (or 75-250mg IV if PO is not possible), followed by maintenance dose of 75-100mg/day
33
Doses of antiplatelet co-therapies w/ fibrinolytic therapy Clopidogrel loading dose then maintenance dose? In patients >/= 75 years of age loading dose then maintenance dose?
Loading dose of 300mg PO followed by maintenance dose of 75mg/day. 75 mg followed by maintenance dose of 75mg/day
34
Doses of anticoagulant co-therapies w/ fibrinolytic therapy Enoxaparin In patients < 75 years of age
30 mg IV bolus followed 15 min later by 1mg/kg s.c. q12 hrs until revascularization or hospital dc for a max of 8 days. the first 2 doses of s.c. should not exceed 100mg per injection
35
Doses of anticoagulant co-therapies w/ fibrinolytic therapy Enoxaparin In patients >/= 75 years of age
no IV bolus; start w/ first s.c. dose of 0.75mg/kg w/ max of 75mg per injection for the first two s.c. doses
36
Doses of anticoagulant co-therapies w/ fibrinolytic therapy Enoxaparin In patients w/ eGFR < 30ml/min/1.73cm2 regardless of age the s.c. doses are given at what frequency?
q 24 hrs
37
Doses of anticoagulant co-therapies w/ fibrinolytic therapy UFH Loading dose and maintenance? Target aPTT?
60 IU/kg IV bolus w/ a max of 4000 IU follwed by IV infusion of 12 IU/kg w/ a max of 1000 IU/hour for 24-48 hours. 50-70s or 1.5-2.0 times that of control to be monitored at 3, 6, 12, and 24 hrs.
38
Doses of anticoagulant co-therapies w/ fibrinolytic therapy Fondaparinux Only given with what other medication? loading dose then maintenance for how long?
Streptokinase 2.5mg IV bolus followed by a s.c. dose of 2.5mg daily up to 8 days or hospital dc
39
Indications for Transfer for Angio after fibrinolysis
Cardiogenic Shock or acute severe HF that develops after initial presentation Intermediate- or high-risk findings predischarge noninvasive ischemia testing Spontaneous or easily provoked myocardial ischemia Failed reperfusion or reocclusion after fibrinolytic therapy Stable patients after successful fibrinolysis before dc and ideally between 3 and 24 hrs
40
Absolute Contraindications for Fibrinolytic therapy
Any prior ICH Known structural cerebral vascular lesion (eg, AVM) Known malignant intracranial neoplasm (primary or metastatic) Ischemic stroke w/n 3mo (except acute ischemic stroke w/n 4.5 hrs) Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed-head or facial trauma w/n 3 mo Intracranial or intraspinal surgery w/n 2 mon Severe uncontrolled hypertension (unresponsive to emergency therapy) For streptokinase prior treatment w/n the previous 6 mo
41
Relative Contraindications for Fibrinolytic therapy
Hx of chronic, severe, poorly controlled HTN Significant HTN on presentation SBP > 180 or DBP > 110) Hx of prior ischemic stroke > 3 mo Dementia Known intracranial pathology not covered in absolute contraindications Traumatic or prolonged (> 10min) CPR Major surgery < 3wk Recent (w/ 2-4wk) internal bleeding Noncompressible vascular punctures Pregnancy Active peptic ulcer PO anticoagulant therapy
42
Routine Medical Therapies: Beta-Receptor Antagonists Indications
PO: All patients w/o contraindication; IV Patients with refractory HTN or ongoing ischemia w/o contraindication
43
Routine Medical Therapies: Beta-Receptor Antagonists Dose/admin Metoprolol Tartrate Carvedilol IV Metoprolol Tartrate
Metoprolol tartrate 25-50mg q6-12hr PO then transition over next 2-3days to BID dosing of metoprolol tartrate or to daily metoprolol succinate, titrate to daily dose of 200 mg as tolerated Carvedilol 6.25mg BID , titrate to 25mg BID as tolerated Metoprolol Tartrate IV 5mg q5min as tolerated up to 3 doses, titrate to HR and BP
44
Routine Medical Therapies: Beta-Receptor Antagonists Avoid/Caution
Signs of HF Low output state Increased risk of cardiogenic shock Prolonged First-degree or high-grade AV block Reactive Airway disease
45
Routine Medical Therapies: ACE Inhibitors Indications
For patients with anterior infarction post-MI LV systolic dysfunction (EF
46
Routine Medical Therapies: ACE Inhibitors Dose/Admin Lisinopril Captopril Ramipril Trandolapril
2.5-5mg/d to start; titrate to 10mg/d or higher as tolerated 6.25-12.5 mg TID to start; titrate to 25-30mg TID as tolerated 2.5mg BID to start; titrate to 5mg BID as tolerated test dose 0.5mg; titrate up to 4mg daily as tolerated
47
Routine Medical Therapies: ACE Inhibitors Avoid/Caution
Hypotension Renal failure Hyperkalemia
48
Routine Medical Therapies: ARB Indicaitons
For patients intolerant of ACE inhibitors
49
Routine Medical Therapies: ARB Dose/Admin Valsartan
20mg BID to start; titrate up to 160mg BID as tolerated
50
Routine Medical Therapies: ARB Avoid/Caution
Hypotension Renal failure Hyperkalemia
51
Routine Medical Therapies: Statins Indications
All patients w/o contraindications
52
Routine Medical Therapies: Statins Dose/Admin
High dose atorvastatin 80mg daily
53
Routine Medical Therapies: Statins Avoid/Caution
Caution w/ drugs metabolized via CYP3A4 fibrates Monitor for myopathy, hepatic toxicity Combine w/ diet and lifestyle therapies Adjust dose as dictated by targets for LDL cholesterol and non-HDL cholesterol reduction
54
Routine Medical Therapies: Nitroglycerin Indications
Ongoing chest pain Hypertension and HF
55
Routine Medical Therapies: Nitroglycerin Dose/Admin
0.4mg sublingual q5min up to 3 doses as BP allows IV dosing to begin at 10 mcg/min; titrate to desired BP effect
56
Routine Medical Therapies: Nitroglycerin Avoid/Caution
Avoid in suspected RV infarction Avoid w/ SBP < 90 or if SBP >30mg below baseline Avoid if recent (24-48 hr) use of 5-Phosphodiesterase inhibitors
57
Routine Medical Therapies: O2 Indications
Clinically significant Hypoxemia (SpO2 < 90%) HF Dyspnea
58
Routine Medical Therapies: O2 Dose/Admin
2-4 L/min via NC Increase rate or change to face mask as needed
59
Routine Medical Therapies: O2 Avoid/Caution
COPD and CO2 retention
60
Routine Medical Therapies: Morphine Indication
Pain Anxiety Pulmonary edema
61
Routine Medical Therapies: Morphine Dose/Admin
4-8mg IV initially w/ lower doses in elderly 2-8mg q5-15min if needed
62
Routine Medical Therapies: Morphine Avoid/Caution
Lethargic or moribund patient Hypotension Bradycardia Known hypersensitivity
63
Class I Recs Measurement of LVF One of the strongest predictors of what? Most commonly evaluated w/ what? If significatn LV systolic dysfunction during initial hospitalization, LVF should be reevaluated when?
survival in patients w/ STEMI contrast ventriculography during cardiac cath or TEE day 2-3 >/=40 days later to assess need for ICD therapy after allowance for recovery from myocardial stunning
64
Class I Recs Type of rehab? Education needed?
Cardiac rehab med adherence, appointments, diet, exercise, smoking cessation
65
Complications of STEMI Cardiogenic Shock Definition:
Persistent Hypotension (SBP <90) despite adequate filling status w/ signs of hyoperfusion &/or if inotropes &/or mechanical support are needed to maintain SBP > 90
66
Complications of STEMI Cardiogenic Shock Causes
LV infarction or mechanical comps (papillary muscle rupture, vent septal rupture, free-wall rupture w/ tamponade, RV infarctions)
67
Complications of STEMI Cardiogenic Shock Occurs in what % of all STEMI cases & remains to be what?
6-10%; leading cause of death w/ in hospital mortality rates 50%
68
Complications of STEMI Cardiogenic Shock ID mechanism and correct any reversible causes such as?
hypovolemia drug-induced hypotension arrhythmias tamponade
69
Complications of STEMI Heart Failure Treatment includes?
diuretics vasodilators inotropic agents when required RAAS inhibitors as tol. Beta blockers as tol.
70
Complications of STEMI RV infarction Occurs in ~ how many patients w/ what? Associated w/? Symptoms?
1/3 of patients w/ inferior STEMI d/t proximal occlusion of RCA higher mortality risk Hypotension, clear lung fields elevated JVP are characteristic
71
Complications of STEMI RV infarction ECG shows? Treatment?
1mm STEE in lead V1 & in R precordial lead V4R are most sensitive markers of RV injury Maintenance of RV preload, reduction of RV afterload, restore NSR, Inotropic support, prn & immediate reperfusion if not already performed.
72
Complications of STEMI RV infarction AVOID what?
Nitrates and diuretics
73
Complications of STEMI Mitral Regurgitation Due to what? S/Sx are?
Papillary muscle rupture or post-infarction LV remodeling w/ displacement of the papillary muscles, leaflet tethering, and annular dilatation pulmonary edema & or Shock
74
Complications of STEMI Mitral Regurgitation Consider what while temporary stabilization is attempted w/ what? Treatment?
urgent surgery; medical therapy & IABP timely reperfusion, diuretics, afterload reduction
75
Complications of STEMI Ventricle septal rupture Usually c/w what? what is necessary?
loud systolic murmur, HF, Shock Emergency surgical repair
76
Complications of STEMI Free-wall rupture S/Sx?
Recurrent chest pain ST-T wave changes rapid progression to HD collapse Electromechanical dissociation Death
77
Complications of STEMI Free-wall rupture Usually seen w/? PSA w/ contained rupture & tamponade can be seen on what? Consider what? Mortality rates as high as?
first MI, ant infarction, elderly, women TTE Emergency surgery; 60%
78
Complications of STEMI Ventricular Arrhythmias Due to what? ICD is indicated before DC wwhen?
ongoing ischemia, HD & electrolyte abnormalities, reentry, enhanced automaticity if sustained VT/VF > 48 hours after STEMI
79
Complications of STEMI AF/SVT Due to what?
excessive sympathetic stim atrial stretch d/t LV or RV volume/pressure overload Atrial infarction pericarditis electrolyte abnormalities hypoxia underlying lung disease
80
Complications of STEMI Bradyarrhythmias SB is common early after STEMI, Particularly with what location? d/t what? Hold what? Consider what for treatment?
inferior location d/t increased vagal tone beta blockers +/- atropine, temp pacing
81
Complications of STEMI Bradyarrhythmias AV block/BBB is associated w/ what? AV block of varying degree and persistnet BBB develop in ~ what % of patients? High-grade AV block & persistent BBB assoc. w/ what?
extent of infarction 5-7% worse short- & long term prognosisT
82
Complications of STEMI Bradyarrhythmias Temp pacing is indicated for what?
symptomatic bradyarrhythmias unresponsive to medical treatment
83
Complications of STEMI Pericarditis Treatment?
ASA
84
Complications of STEMI Thromboembolism Prevention and treatment are similar to what?
other critically ill patients
85
Complications of STEMI Bleeding General rec is to transfuse when Hgb < what?
8mg/dL
86
Complications of STEMI Renal complication? Hyperglycemia: goal BG is what? Avoid what?
AKI < 180mg/dL; hypoglycemia

Acute Care I (30 decks)

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