Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

3154 Haematology > IC6 Acute Myocardial Infarction > Flashcards

IC6 Acute Myocardial Infarction Flashcards

1
Q

ACS vs CCS

A

ACS: STEMI, NSTEACS

  • SOB at rest (dyspnea)

CCS: stable angina, stable IHD

  • SOB on exertion, relieved with rest
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Describe the difference in ECG findings between STEMI and NSTEACS

A

STEMI: ST elevation

  • implies complete blockage of coronary artery

NSTEACS: ST depression/normal/inversion

  • implies partial blockage of coronary artery
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Describe the difference in troponin levels (hs-trop) in STEMI and NSTEACS

A

STEMI: because of complete blockage, more muscular death, hence larger amount of troponin release

NSTEACS: partial blockage, lower amount of troponin release

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What other conditions may present with troponin rise?

A
  • Myocarditis
  • Takotsubo syndrome (heart muscle weakened)
  • Congestive heart failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Besides ECG and troponin, what other lab tests might be done to diagnose ACS?

A
  • Renal function
  • Baseline CBC and coagulation panel
  • Fasting lipid panel
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Which groups of patients may have atypical/silent presentation of MI and why?

What are some examples of atypical symptom presentation?

A

Diabetics (underlying neuropathy), >=75yo, women, impaired renal function, dementia

  • Atypical symptoms include: epigastric pain, indigestion, stabbing, pleuritic chest pain, exertional dyspnea
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Differential diagnosis of MI

A
  • GERD: exclude sour taste in mouth, burping
  • PUD
  • Hypoglycemia: exclude sweating, dizziness
  • Pneumonia: exclude fever, cough
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is percutaneous coronary intervention (PCI)?
What is the aim?

A

PCI - coronary angioplasty used to open clogged arteries

  • Catheter with balloon inserted via catheter insertion site (either femoral or radial approach) to open blocked vessel by inflating the balloon that will compress the plaque

AIM: to achieve reperfusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Types of stents used in PCI, and their thrombogenicity

A

Bare metal stent

  • Highly thrombogenic

1st gen drug-eluting stent

  • Paclitaxel, Sirolimus
  • More thrombogenic

2nd gen drug-eluting stent

  • Everolimus, Zotarolimus
  • Less thrombogenic

3rd gen drug-eluting stent

  • Use polymer-free stent, or bioresorbable stent, or drugs with high lipophilicity - for faster transfer
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Discuss the advantages and disadvantages of drug-eluting stents

A

Advantage:

  • Immunosuppressive and anti-proliferative drugs prevent inflammation from highly thrombogenic stent
  • Combat restenosis (prevent cell proliferation and narrowing of the artery)

Disadvantage:

  • Longer time to heal => higher bleeding risk
  • Therefore although default DAPT for ACS is 12 months, for DES may give for at least 3 months
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Difference between in-stent thrombosis and in-stent restenosis

A

In-stent thrombosis:

  • Thrombus form inside stent => risk of another MI
  • Therefore, DAPT is indicated to prevent clot formation

In-stent restenosis

  • Thrombus forms outside of stent due to the proliferation of endothelial cells
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

AMI Treatment Algorithm

What is the first line treatment for reperfusion in AMI?

A

Percutaneous coronary intervention (PCI)

Must be performed within 90min, (at most not exceeding 120min)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

AMI Treatment Algorithm

PCI procedure should be accompanied with what first choice of IV anticoagulant?

Describe the dosing and monitoring parameter, as well as any drug it might be used in combi with.

If previous LMWH or heparin was used, what should be done?

A

IV Bolus UFH 2000-5000 units should be administered to achieve activated clotting time (ACT) of 250-300 seconds; repeat bolus up 10000 units as needed to maintain ACT throughout PCI

If IV GP IIb/IIIa inhibitor (Eptifibatide) is used, repeat bolus of UFH up to max 7000 units as needed to maintain ACT throughout PCI

If previous LMWH or heparin was used, check ACT prior to bolus; if ACS >2000 secs, do not use bolus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

AMI Treatment Algorithm

Activated clotting time targets for UFH during PCI

A

Guidelines recommend target ACT values within 200 to 250 s with planned use of glycoprotein IIb/IIIa inhibitors for the guidance of UFH therapy during primary PCI procedures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Eptifibatide half life and renal adjustment

A

Short half-life (2-4h) therefore needs to be infused for 72h

Renal dose adjustment when CrCL <50ml/min; not to be used in ESRD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

AMI Treatment Algorithm

PCI procedure can be accompanied with what other IV anticoagulant?

Any monitoring parameters?

A

IV LMWH (Enoxaparin) is only used for PCI if last SQ LMWH is within specific timeframe of 8-12h before PCI procedure

Anti-Xa levels may be measured in renally impaired, or pregnant patients

17
Q

AMI Treatment Algorithm

What is the role of anticoagulants during PCI in AMI?

A

Anticoagulants combat thrombus expansion

18
Q

AMI Treatment Algorithm

In the event that PCI cannot be done, what should be done?

A

Start Tenecteplase for reperfusion in AMI

  • dosed by body weight
  • administered as single intravenous bolus over 5-10s
19
Q

AMI Treatment Algorithm

In what situations might Fibrinolysis be done instead of PCI

A
  • Primary PCI is delayed >120min
  • Contraindications to receiving contrast dye
20
Q

AMI Treatment Algorithm

What are some contraindications to the use of Fibrinolytics?

A

Absolute CI:

  • ischemic stroke within past 3 months (except onset in past 4.5h)
  • hemorrhagic stroke
  • severe uncontrolled HTN
  • intracranial or intraspinal surgery within 2m

Relative CI:

  • recent major surgery (<3 weeks)
  • active peptic ulcer
  • pregnancy
21
Q

AMI Treatment Algorithm

Describe the choice of P2Y12 inhibitor and duration of DAPT treatment in MI

A

Ticagrelor - ACS x 12m
Clopidogrel - CCS x 6m

Followed by lifelong SAPT

*If patient has high bleeding risk may consider shorter duration of DAPT (e.g., 3m)

22
Q

AMI Treatment Algorithm

If patient has high bleeding risk and ACS, what DAPT treatment should be used?

A

(a) shorten DAPT (ticagrelor) duration to only 3m;

OR

(b) use clopidogrel as the P2Y12i right from the outset;

OR

(c) de-escalate from DAPT (ticagrelor) to DAPT (clopidogrel) to complete the recommended 12 months.

23
Q

AMI Treatment Algorithm

Loading and maintenance doses of Ticagrelor, Clopidogrel, Aspirin

A

Ticagrelor: 180mg LD, 90mg BD

Clopidogrel: 300/600mg LD, 75mg OD

Aspirin: 300mg LD, 100mg OD

24
Q

AMI Treatment Algorithm

When might Clopidogrel 300mg or 600mg loading dose be considered?

A

600mg: stable CAD pt undergoing coronary stent implantation

300mg: pt =<75yo, received thrombolysis

*300-600mg for CCS; 300mg for ACS

FYI: Clopidogrel may be used as monotherapy for PAD: 75mg

25
Q

Bleeding risk assessment

  • What score signifies high bleeding risk
A

PRECISE-DAPT score >=25

26
Q

List the major criterias for high bleeding risk (at the time of PCI)

A
  • Anticipated use of long-term oral anticoagulation / concurrent use
  • Severe or end-stage CKD (eGFR <30ml/min)
  • Hb <11g/dL
  • Spontaneous bleeding requiring hospitalization or transfusion in the past 6m OR at any time, if recurrent
  • Moderate or severe baseline thrombocytopenia (platelet count <100 x 10^9 /L)
  • Chronic bleeding diathesis
  • Liver cirrhosis with portal hypertension
  • Active malignancy within the past 12m (excluding nonmelanoma skin cancer)
  • Previous spontaneous ICH (at any time)
  • Previous traumatic ICH (within past 12m)
  • Presence of bAVMModerate or severe ischemic stroke (within pas 6m)
  • Nondeferrable major surgery on DAPT
  • Recent major surgery or major trauma within 30d before PCI

*ANY 1 MAJOR CRITERIA: HBR

27
Q

List the minor criterias for high bleeding risk (at the time of PCI)

A
  • Age >=75y
  • Mod CKD (eGFR 30-59ml/min)
  • Hb: 11-12.9g/dL for male, Hb: 11-11.9g/dL for female
  • Spontaneous bleeding requiring hospitalization or transfusion within the past 12m, not meeting the major criterion
  • Long-term use of oral NSAIDs or steroids / Concurrent use
  • Any ischemic stroke at any time not meeting the major criterion

*ANY 2 MINOR CRITERIA: HBR

28
Q

What are the high thrombogenic risk criteria for extended duration treatment (DAPT >12m)?

A

High thrombogenic risk: complex CAD + at least 1 criterion

  • DM requiring meds
  • Hx of recurrent MI
  • Any multivessel CAD
  • Polyvascular disease (CAD + PAD)
  • Premature (<45y) or accelerated (new lesion within a 2y time frame) CAD
  • Concomitant systemic inflammatory disease (e.g., human immunodeficiency virus, systemic lupus erythematosus, chronic arthritis)
  • CKD with eGFR 15-59ml/min/1.73m^2
  • At least 3 stents implanted
  • At least 3 lesions treated
  • Total stent length >60mm
  • Hx of complex revascularization
  • Hx of stent thrombosis on antiplatelet treatment
29
Q

What are the moderate thrombogenic risk criteria for extended duration treatment (DAPT >12m)?

A

Moderate thrombotic risk: non-complex CAD + at least 1 criterion

  • DM requiring meds
  • Hx of recurrent MI
  • Polyvascular disease (CAD + PAD)
  • CKD with eGFR 15-59ml/min/1.73m^2

FYI: complex vs non-complex CAD is based on clinical judgement + pt’s cardiovascular history and/or coronary anatomy

30
Q

Discuss the treatment options for extended dual antithrombotic or antiplatelet therapies in AMI

A

DAPT regimens (+ Aspirin 75-100mg OD)

  • Clopidogrel: 75mg/day up 30m
  • Ticagrelor: 90mg BD, up 12m; followed by 60mg BD up 36m

*Ticagrelor - 90mg is subsidized, but 60mg is not

31
Q

DAPT discontinuation

A

If antiplatelet agents are discontinued, resumed ASAP within 7 days

DAPT should not be discontinued in the 90 days post-acute coronary syndrome or 30 days post-coronary stenting

  • Lower GI bleed: DAPT needs to be continued if <30days following bare metal stent placement, <3m following DES placement
  • Cardiac surgery: discontinue Clopidogrel 24h, up 5d before surgery
  • Non-cardiac surgery: DAPT needs to be continued if <30days following bare metal stent placement, <3m
    following DES placement
  • Coronary artery stent: premature interruption of therapy may result in stent thrombosis with subsequent MI
32
Q

Other drugs used in AMI

A
  • Nitroglycerin
  • Morphine
  • Oxygen
  • BB/CCB
  • High intensity statins
  • ACEi/ARB
  • MRA (e.g., spironolactone)

3154 Haematology (14 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions