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Flashcards in MI Deck (90):
1

What's stable angina?

chest/arm discomfort/pain that's reproducibly associated with physical exertion/stress and is relieved within 5-10 minutes by rest or SL nitroglycerin

2

What's unstable angina?

angina pectoris/equivalent ischemic discomfort associated with one of the following 3:

occurs at rest usually lasting >10 min
is severe and of new onset
occurs with a crescendo pattern

3

What's an MI?

clinical features of unstable angina + myocardial necrosis (increased cardiac biomarkers)

4

What are modifiable risk factors of MI?

smoking
hypertension
diabetes
hyperlipidemia
obesity
sedendary lifestyle
diet
cocaine use

5

What are non-modifiable risk factors of MI?

male gender
age
genetics

6

Describe CAD.

Plaque with fibrous cap-->cap ruptures-->blood clot forms around the rupture, blocking the artery

7

What's a red thrombi?

RBC's in fibrin mesh

8

What's the consistency of a red thrombus?

soft

9

What's the mechanism of a red thrombus?

stagnation

10

Where are red thrombi located?

venous

11

What are examples of red thrombi?

DVT/PE
intracardiac clot
clot on mechanical heart valved

12

How do you treat red thrombi?

anticoagulants

13

What's the composition of a white thrombus?

platelets in fibrin mesh

14

what's the consistency of a white thrombus?

firm

15

What's the mechanism of white thrombi?

shear stress/turbulence

16

Where are white thrombi located?

arterial

17

What are examples of white thrombi?

ischemic CVA
peripheral arterial disease
coronary artery disease

18

How do you treat a white thrombus?

antiplatelets

19

What are Q waves indicative of?

Q waves are indicative of a prior MI event

20

What are the two main cardiac biomarkers?

Troponin T
CK-MB

21

Describe troponin T

peaks in 12-20 hours
check with lab for threshold value
remains elevated for up to 10 days
renally cleared

22

Describe creatinine kinase myocardial band

5% of CK
peaks in 6-24 hours
returns to normal in 48 hours

23

What are the symptoms of an MI?

midline anterior chest discomfort
arm/back/jaw pain
N/V
dyspnea
diaphoresis
anxiety, feeling of impending doom

24

Silent MI's happen more likely in:

diabetics
women
elderly

25

What are the four subsets of ACS?

1. non-cardiac chest pain
2. unstable angina
3. NSTEMI
4. STEMI

26

What is non-cardiac chest pain?

could be due to anxiety, GERD, etc

27

What is unstable angina?

normal cardiac markers
ST segement depression, or T-wave inversion or normal ECG

28

What is NSTEMI?

elevated cardiac biomarkers
ST segment depression or T-wave inversion or normal ECG

29

What is STEMI?

Elevated cardiac biomarkers
ST segment elevation at least up a mm

30

What are the treatment goals for ACS?

minimize infarct size
salvage ischemic myocardium
medically
PCI (angioplasty, stents, atherectomy)
surgically (CABG)

31

US and NTEMI general treatment strategy

antiischemic and antithrombotic therapy

32

What's the early invasive treatment strategy in US/NSTEMI?

angiography and PCI within 48-72 hours of symptom onset

33

When should you do early invasive treatment in US/NSTEMI?

strongest evidence supporting EI is in patients with ST segment depression, increased troponins and/or >3 TIMI score

34

What's the early conservative treatment strategy in US/NSTEMI?

catheterization/revascularization only if ischemia recurs or is unresolved

35

What's MONA?

morphine
oxygen
nitrates
aspirin

36

What's the dosing scheme for morphine and why is it used?

1-4mg IV Q5-15 minutes PRN
used because morphine's an analgesic, anxiolytic, and reduces preload

37

When should you use oxygen?

if O2 sat is

38

What's the dosing scheme used for nitrates?

nitroglycerin 0.4mg SL x 3 doses PRN
if pain persists after 3 doses-->nitroglycerin 5mcg/min infusion-->5-10mcg/min Q5-10 minutes up to 200mcg/min

39

What's the dosing for aspirin?

162-325mg STAT then 75-162mg daily for life

40

What's the goal of anticoagulation therapy?

prevent total occulsion of infarct-related artery

41

What are the 4 options to halt the coagulation cascade?

1. UFH drip
2. LMWH
3. Fondaparinux
4. Bivalirudin

42

What's the dosing for heparin?

heparin should be dosed at 60-70units/kg bolust then 12-15 units/kg/hour infusion

43

What's the benefit in using LMWH over UFH?

lower 30 day incidence of death/nonfatal MI

44

What drugs are considered LMWH?

enoxaparin and dalteparin

45

What's the dosing scheme for enoxaparin?

1mg/kg SubQ every 12 hours
can consider loading dose of 30mg IV
dose Q24 hours if CrCl

46

What's the dosing scheme for dalteparin?

120units/kg SubQ Q12 hours

47

What's fonaparinux?

synthetic heparin pentasaccharide
it binds to AT
no aPTT monitoring

48

What's the dosing for fondaparinux?

2.5mg IV x 1 dose then 2.5mg SubQ daily

49

When is fondaparinux contraindicated?

when CrCl

50

What's bivalirudin?

direct thrombin inhibitor

51

What three drugs are thienopyridines?

ticlodipine
clopidogrel
prasugrel

52

What drug is considered thienopyridine-like?

ticagrelor

53

How is ticlodipine dosed?

ticlodipine is 250mg BID

54

how is clopidogrel dosed?

clopidogrel is dosed 300-600mg loading, then 75 mg QD. ideally, want loading dose to be >6 hours before a PCI

55

How is prasurgrel dosed?

60mg loading and then 10 mg daily

56

If patient is

5mg daily

57

Does prasugrel need to be dose adjusted for renal/hepatic impairment?

NO

58

Should NSAIDS be avoided with prasugrel?

YES

59

When is prasugrel contraindicated?

if patient has had a prior TIA/CVA

60

How long should prasugrel be held before CABG?

>7 days prior to CABG

61

When is ticargrelor contraindicated?

history of intracranial bleeding
severe hepatic dysfunction
CYP3A4 inhibitors/inducers
ASA>100mg daily

62

When are thienopyridines used?

in place of aspirin if asprin allergic
in addition to aspirin up to 9 months if EC
in addition to aspirin up to 12 months if after PCI

63

What's the goal of glycoprotein IIB/IIIA inhibitors?

prevent total occulsion of infarct-related artery

64

Why are glycoprotein IIB/IIIA inhibitors used?

to prevent ishemic complications

65

Do glycoprotein IIB/IIIA inhibitors replace anticoagulation?

No! glycoprotein IIB/IIIA inhibitors increase mortality if used without LMWH/UFH

66

EI strategy is when PCI is planned. What's the protocol for glycoprotein IIB/IIIA inhibitors?

use abciximab or acceerated dosed eptifibatide if PCI within 4 hours of presentation
Use tirofiban or eptifibatide if treated medically for first 48 hours

67

When to NOT use GPIIb/IIIA?

if clopidogrel 300mg loading was given >6 hours prior to cath

68

Is there a benefit to using abciximab in EC?

no, there's no benefit

69

How do beta-blockers work?

slow the heart rate to 55-60bpm-->reduce cardiac workload-->decrease myocardial oxygen consumption

70

How is metoprolol dosed?

5mg IV Q5min x 3 doses, then 25-50mg PO BID

71

What are the absolute contraindications of beta-blockers?

HR

72

What are relative contraindications of beta-blockers?

history of asthma
current use of non-dihydropyridine CCB
severe PVD
uncontrolled insulin-dependent diabetes

73

When are ACEI used?

use in patients with hypertension, diabetes, LVEF

74

AMI artificially depresses cholesterol profile by 1/3 to 1/2.

TRUE.

75

When do you use an aldosterone blocker?

patients who are post-MI symptomatic HF with EF

76

Which aldosterone blocker do you start with?

spironolactone. If patient experiences breast enlargement-->do eplerenone.

77

STEMI treatment.

MONA
BB-stronger data in STEMI (don't do if patient also has HF!)

78

Primary PCI vs. Thrombolytic

primary PCI preferred in hospitals with cardiac cath lab.
Primary PCI also preferred for: high risk patients, contraindications to fibrinolysis, late presentation, diagnosis of STEMI is in doubt

Thrombotic needs to happen within 30 minutes of getting to hospital

79

When does cath lab need to happen?

within 90 minutes of hospital arrival

80

Which drug needs to be given ASAP before PCI?

abciximab

81

When does a thrombotic need to happen?

within 30 minutes of hospital arrival

82

Which thrombolytics are non-selective?

streptokinase
anistreplase
urokinase

83

Which thrombolytics are selective?

alteplase
reteplase
tenecteplace

84

Difference in outcomes between cath lab and thrombolytics?

stent group had less than half the mortality as the TPA group-->GO TO CATH LAB

85

Absolute contraindications to thrombolytics?

any prior hemorrhagic CVA
ischemic CVA within 3 months
active internal bleeding
aortic dissection
BP>200/120

86

Relative contraindications to thrombolytics?

BP >180/110
history of TIA
INR >2
recent trauma

87

Should you use glycoprotein IIB/IIA inhibitor?

NO, BAD IDEA

88

In STEMI patients, is anticoagulation DC'ed immediately after PCI/CABG?

YES

89

if patient's stented-->add thienopyridine

....

90

When do you start ACEI in a STEMI patient?

after SL nitroglycerin and BB