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Theraputics Winter > IHD - ACS > Flashcards

IHD - ACS Flashcards

1
Q

What are the diagnostic for STEMI

A

ST elevation
Biomarkers +

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2
Q

What are the diagnostic for NSTEMI

A

ST depression or T-wave inversion
Positive biomarkers

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3
Q

What are the Diagnostic for unstable Angina

A

ST depression or T wave inversion
Negative biomarkers

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4
Q

ACS clinical symptoms

A

Chest pain - that could radiate
Nausea
Sweating
Impending doom
Low grade fever
4th heart sounds
3rd heart sounds

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5
Q

What does BBB (bradial branch block )

A

1 or 2 mm raise in 2 or more leads (1-6 lead)

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6
Q

When do you take cardiac draws in the hospital

A

Every 6-8 for 3-4 draw bc some biomarkers are later in onset

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7
Q

What is the most important function of the heart ?

A

LV function and if you cant fix it you get a scar that can cause death if it ruptures

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8
Q

What does everyone get if they have STEMI or NSTEMI

A

Oxygenation 90% or greater
ECG leads monitoring
Glycemic control (<180 glucose)
Pain relief
Stool softeners

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9
Q

Chest discomfort last ≥10mins flow chart (pic)

A
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10
Q

STEM flow chart for treatment (pic)

A

Usually do fibrinolytic or primacy PCI

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11
Q

What pharmacological treatment for STEMI do we think of

A

Mona

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12
Q

What is MONA?

A

M- + or - morphine 1-5mg IV every 5-30mins (may or may not give due to chest pain relief being unknown wether it be nitro or morphine, usually 3 dose may or may not give M)

O - only give below 90%

N- Nitro .4mg every 5 mins for 3 dose (tachyphylaxis sign of nitrate intolerance, usually not in STEMI pts)

A - aspirin give 81mg QID ( #1 drug to use )

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13
Q

What anticoagulant is the drug of choice

A

Heparin

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14
Q

Heparin STEMI dosing for Fibrinolysis, Primary PCI or medical management

A

Fibirnolysis
Bolus - 60 unit/kg/IV max 4000
Main - 12 unit/kg/IV max 1000 units

PCI and medical management
Bolus - 60 unit/kg/IV max 5000
Main - 12 unit/kg/IV max 1000 units

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15
Q

Heparin dosing adjustment chart

A
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16
Q

STEMI when and which BB

A

when - significant HTN or ongoing ischemia without Contra
Which - Metoprolol tartate 5mg IV q 5 mins up 3 doses

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17
Q

When do we avoid BB in STEMI

A

Advance age 70+
Bradycardia < 60 bpm
Hypotensive pt SBP < 120
Prolonged PR interval >0.24 sec or 2nd/3rd degree Heart block
Active asthma or airway disease

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18
Q

Reperfusion flowchart for STEMI

A
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19
Q

Do we prefer PCI or thrombolytic in reperfusion

A

PCI because a much higher flow so much so that we withhold treatment with fibrinolytic for 30mins max

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20
Q

What are the indication for fibrinolytics for STEMI

A
  1. Within the first 12 hours
  2. ST elevation at least 1 mm in 2+ leads
  3. PCI can not be preformed in 120mins
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21
Q

Which fibrinolytic have the lowest bleeding rate

A

Alteplase

22
Q

Which fibrinolytic is recommended for STEMI

A

Tenecteplase because fast dosing ( iv over 5 seconds)
<60 kg 30 mg
60-69 35 mg
70-79 40 mg
80-89 45 mg
>90 50 mg

23
Q

What are the 3 criteria for successful fibrinolytic

A
  1. > 50% reduction in ST segments of the ECG
  2. Relief of chest pain
  3. Appearance of reperfusion arrhythmias
24
Q

What are some options for antithrombotic during PCI

A
  1. Heparin as mono
  2. Heparin and cangrelor
  3. Stop heparin start Bivalirudin mono
  4. Stop heparin start Bivalirudin and cangrelor
  5. RARE use of glycoproteins IIb/IIIa add on to one above (salvage or bailout)
25
Q

Bivalirudin dosing

A

LD: 0.75mg per kg
Main: 1.75 mg per kg
DC after cath lab

26
Q

What are the P2Y12 inhibitors and what is it

A

Antiplatelet
Clopidogrel
Prasugrel
Ticagrelor
Cangrelor - IV ONLY

27
Q

How many days do you need to stop Antiplatelet before surgery

A

5 days

28
Q

What DDI do we need to worry about with clopidogrel

A

PPI inhibit 2C19 but Omeprazole and esomeprazole the worst and must change
Use pantoprazole

29
Q

What do we worry about with Plavix

A

Clopidogrel
Genetic variation is a huge consideration why we only use for medical management and not primary PCI

30
Q

What is Effient

A

Prasugrel

31
Q

What are some benefits of Prasugrel

A

Only primary PCI
Lack genetic variability and very reliable responses
More potent then clopidogrel

32
Q

What important consideration do we take with Prasugrel

A

Effient
Elderly ≥ 75 have increase fatal bleeding events ( not a X contra but try to avoid but risk analysis with high risk pts)
Low body weight < 60kg lower to 5mg daily

33
Q

What is an absolute contradiction for Prasugrel

A

history of TIA (transient ischemic attack) / stroke

34
Q

How many days do we need to hold Effient for surgery

A

7 days

35
Q

What is Ticagrelor

A

Brilinta

36
Q

Brilinta DDI

A

CYP 3A4/5
Pgp
Aspirin

37
Q

What previous bleeding contraindicates Ticagrelor

A

Intercranial bleeding

38
Q

What do we do with Brilinta and Aspirin

A

They have to be on 81mg to be effective Antiplatelet
Okay to give the 325 upon admission and will not have an effect on Ticagrelor

39
Q

What sensation do pts feel on Ticagrelor

A

SOB but doesn’t actually affect their breathing intake

40
Q

Antiplatelet oral comparison chart (PIC)

A
41
Q

What is brand of Cangrelor

A

Kengreal

42
Q

What is the wow factor of Cangrelor

A

100% inhibition within 2 mins
Full platelet recovery in 1 hour

43
Q

Dosing for Kengreal

A

30 mcg/kg bolus
4 mcg/kg/min for at least 2 hours

44
Q

Switching to outpt for pts on cangrelor

A

Brilinta 180mg any time

Effient 60mg and plavix 600 - Need to wait after infusion

45
Q

What are the Glycoprotien IIb/IIa inhibitor

A

Tirofiban
Eptifibatide

46
Q

Which glycoprotein IIa/IIIb cant be used for PCI STEMI

A

Tirofiban

47
Q

Secondary therapy ACEi indication

A

HF
HTN
AMI (acute phase post infraction of left ventricle)
Nephropathy
Cardiovascular protection

48
Q

What is indication is important for ACEi to start

A

MUST USE WITHIN 24hrs
AMI - STEMI that has LVEF ≤40%

49
Q

What is the one thing in treatment of NSTEMI that differs from STEMI

A

No use of fibrinolytic and risk stratify the pt

50
Q

Risk cut offs for NSTEMI

A

LOW
1 - 5%
2 - 8%
Medium 3-4
13%
20%
HIGH 5-7
26%
41%
41%

51
Q

Anticoagulation decisions between heparin, enoxaparin and fondaparinux

A

Usually heparin but if low risk not much to do after PCI easier for pt to switch to enoxaparin

Theraputics Winter (12 decks)

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