Acute Coronary Syndromes Part 3 Flashcards
Maintenance therapies: long term goals of therapy
Control CAD risk factors
Prevent MACE
* Reinfarction
* Stroke
* Heart Failure
Improve quality of life
Beta blockers
Initiate within the first 24 hours of ACS
* Reasons not to start beta blocker: Bradycardia, HF or other low-output state, Risk for cardiogenic shock; Other contraindications to beta blockade: PR interval > 0.24s, Second or third degree heart block, Active asthma or reactive airway disease
if initially patients have contraindications, re-evaluate to determine eligibility
Use sustained release…
metoprolol succinate, carvedilol, or bisoprolol in patients with heart failure with a reduced ejection fraction (HFrEF)
Consider IV BB only when hypertensive or ongoing ischemia - Metoprolol tartrate 5mg IV q5min (up to 3 doses)
Beta 1 selective
atenolol, metoprolol, bisoprolol, nebivolol, acebutolol
Beta 1 and 2
propanolol, nadolol, labetalol, sotalol, carvedilol, pindolol
ISA selective
pindolol, acebutolol
Alpha selective
labetalol, carvedilol
Beta Blockers and Cocaine
Controversy over BB in cocaine induced chest pain or use in patients who abuse cocaine
Cocaine stimulates both alpha and beta receptors: Giving a beta blocker allows all of the cocaine to stimulate alpha receptors (unopposed alpha effects) - Hypertensive complications or increased troponin; Consider non-selective BB such as carvedilol (alpha blockade as well)
Beta Blockers and Heart Failure
Avoid starting or increasing beta blockers during an acute heart failure exacerbation: What are the signs and symptoms of an acute heart failure exacerbation?- edema in legs/lungs, SOB, flash pulmonary edema
Why do we avoid them?: Beta blockers slow down the heart and can decrease cardiac output; Starting/increasing them during an exacerbation can cause pulmonary edema
Is it safe to continue their maintenance beta blockers?: Yes. Worse outcomes have been shown when beta blockers are discontinued. Continue at home dose, but do not increase until euvolemic. COMET trial.
Patient counseling: beta blockers
This medication will lower your blood pressure and your heart rate. If you feel dizzy, especially when standing up, it may be a sign these are too low.
This medication is often used for blood pressure control. That is not what we are using it for in you. Even if your blood pressure is under control we want to continue to use it to prevent future heart attacks and help you live longer.
If you have diabetes, this medication can mask the symptoms of hypoglycemia. It will not mask a cold sweat.
Calcium Channel Blockers (CCB)
Administer nondihydropyridine CCB to patients with recurrent ischemia and contraindications to beta blockers: Nondihydropyridine CCB are diltiazem and verapamil
Do not use in patients with: LV dysfunction, Increased risk for cardiogenic shock, PR interval >0.24 s, Second- or third-degree atrioventricular block without a cardiac pacemaker
Statins
Initiate or continue high intensity statin; Obtain a lipid profile; Most common side effect is muscle pain
atorvastatin 40-80 mg daily
rosuvastatin 20-40 mg daily
Patient counseling: statin
Need to take lifelong to prevent future heart
attack
Helps lower cholesterol, but continue to take even if your cholesterol is normal
Most common side effect is muscle pain: Let your doctor know if you experience unexpected muscle pain
Angiotensin Converting Enzyme (ACE) Inhibitor
Recommenced in all patients, but especially important in patients with HFrEF, DM or CKD: Decreases mortality and MACE; Use cautiously in the first 24 hours of AMI, because it may result in hypotension or renal dysfunction
Class effect: Captopril, enalapril, lisinopril, ramipril and trandolapril have indication in ACS
An angiotensin receptor blocker (ARB) may be substituted for an ACE inhibitor with similar benefits on survival
When not to use ACEi
Hypotension/shock
Bilateral renal artery stenosis or history of worsening of renal function with ACE inhibitor/ARB exposure
Acute renal failure
Drug allergy/angioedema
