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79 Cards in this Set
- Front
- Back
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What is the common pathophysiologcal cause of ACS
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coronary thrombosis following rupture ot erosions of a n atheroscelertoic plaque cuasing ischemia in the mycardial area
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What is the main cause of ischemia heart disease, cerebrovascular disease, cornary atherosclerosis and acute MI
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vascular disease
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What are the leading causes of death in the US
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ACS
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Does acute contary syndromes ocur at random
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NO
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The extent of intraconrary thrombisis and ebolization determine the type of ACS
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YES
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What are 2 catergoies of ACS
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Non-ST Segment Evevation MI
NSTEMI ST Segment elevation MI |
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NSTEMI is further grouped in
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unstable agina, and NSTEMI
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What is Unstable Agngina coronary lesion
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lesion demonstarates severe stenosis or narrowing but with LITTLE thrombosis
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In patients with NSTEMI, what are the cornary lesions
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exists partial THROMBOTIC occlusion with or without distal emoblization orsevere stenossi
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In patients with STEMI what are the coronary lesion
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TOAL and PERSISTANT thormbotic occlusion
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ACS is disagnosed based on 3 major finding
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1. Clinical signs and symptsoms
2. EKG changes 3. presence of biomarkers |
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What are the Hallmark symptoms of ACS
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anginal chest pain at rest, increase angian , discomfort that radiates to left arm, back shoulder, ro jaw
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Hallmark signs of ACS is increase angina greater than
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20minutes
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The electrocardiography alows for classifcation into STEMI and NSTEMI should be obtained within
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10 minutes arrival in to ER
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What are EKG changes in NSTE ACS
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ST segment Depression >0.1 in TWO or more contious leads or T-wave inversion >0.1
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Q wave MI what drugs are used to prevent remodeling
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Aldosterone antagoinsts and ACE inhibtiors
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MI is diagnosed with blood levels of of waht are increased
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Troponins T nad I, and CK-MB
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Troponins T and I< and CK-MB are markes that indicate myocardial damages without actucally telling you where--what pateints Do you ONLY see elevated biomarkers
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STEMI and NSTEMI
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Why do you not see elevated biomarkers with UA--
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they have no myocardial necorsis
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What is the preferred biomarker for Myocaridal damge
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Troponins T and I--
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When are Troponins T and I NOT normally dectable in blood, and peak values are obsereved when
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6 hours onset of MI, and peak with 12-48 hours, and may stay elevated for 10 days after myocaridal necrosis
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How often will we measure tropinins
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every 6-8 hours X24hrs
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Where is CK-MB found
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skeletal muscle and blood of healthy subjects
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CK-MB not specific to the heart--stays elevated for 48 horus, and for dianosis what do you NEEDD
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2 elevated CK-MD---
ROLE---Better for idententification of re-infarcation--as tropin levels stay elevated for 10 days post MI |
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What are the 2 types of RISK stratification (BOTH EQUAL)
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Grace Score and the TIMI risk score---bother predict 30 day mortality
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The STEMI --TIMI Risk score predicts 30 day morality post MI, and what is VALUE of SCORE
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predicts risk of Death from MI, and as well as dictates intervention (PCI or drug therapy
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What are the2 TIMI categories (NSTEMI)
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Historical Factors, and Presentation
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What are the historical factors
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age 65 or great,
3 or more CAD (HTN, DM< smoker) Know CAD (stenosis 50% or greater) ASA use in last 7 days |
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What is presentation
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Recent severe angina
Increase Cardiac marker ST devication 0.5 greater |
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What does Timi Risk Score stand for
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Thrombolysis in Myocaridal infaraction
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What is considered a LOW TIMI risk score
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0-2
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What is consider a moderate TIMI risk score
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3-4
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What is HIGH TIMI risk score
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5-7
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What are 2 methods of myocardial revascularization
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PCI or CABG(coronary artery bypass graft)
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Primary PCI consists of urgent ballon angioplasty (with/or without stenting) with NO admiinstration of
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fibrinlytic therapy
glycoprotine inhbitiors to open the artery |
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PCI is primarily use for pateitns with
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STEMI and HIGH-RISK NSTEMI
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What is DES (drug-eluding stent)
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one that contains a time-release drug, which is slowly released to keep the stent from restenosing or clogging
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What are the 2 types of DES
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paciliaxel and sirolimus
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What the main problems of bare metal stents
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problem of restenosis, b/c bare metal stents cause direct vessel injury when can initate restenosis
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What are 2 general strageties for treatmnet of NSTEMI ACS
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1. invasive (PCI)
2. Conservative (drug thearpy) |
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What are pts characteristic that require invasive therapy
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SPERM HHH VL
ST segment depression PCI within <6months or CABG Elevated cardiac biomakers Recurrent agingina at rest Mitral regurgitation HF Hemodynamic instability High risk TIMI score Ventricular Tachycardia LVD <40% |
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What are considered a high risk TIMI score
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>5
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When is really the ONLY time you would CHOOSE the conservative strategy, and when would OPT to go PCI
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Low TIMI RISK score (0- 2), OR Patient or Doc preferance in the absence of HIGH risk
GO TO PCI if have recurrent symptoms |
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When a pt presents to ER wtih with chest pain what is first thing you give
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1. Bite and swallwoing 325mg ASAa---NOT EC
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What are ALL the agents that are ADDED when pt initally present to ER
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BONAAS
BB ORAL within 24 hours of contraindcations Oxygen to staturation >90% ASA 325mg NON-EC Bite and Swallow ACE in all pts with Pulmonary congestion or EF <40% High Dose statin as it shown to reduce mortailty |
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What is a moderate timi risk score
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3-4
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After administration of ASA or clopdigogrel you selectve your managemtn strategy which is either
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convervation treatment or invasive
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What is invasive strategy for UA/STEMI
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iniate antigcoagulatnt therapy either enoxaparin or UFH
less evidence is biavliruin or fondaparinux |
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What is perferred insavise therapy OVERALL and DOSING
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UFH---becuase these pts are getting a lot dyes and can damage kidneys
60 Units/Kg IV BOLUS (4000) followed by 12 units/kg/hr (1000) to maintat APPT at 1.5-2.0 |
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After adminstratino of ASA or clopidorgen and UFH or enoxaparin, what is iniated
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1. Clopidogrel
2. GP IIb/IIIa inbhitior 1 or other |
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When would you give both Clopdiogrel or GPIIb/IIIa inhibitor
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1. Delay to angiograpy >24hrs
2. High or Moderate TIMI risk score 3. Still have sytmpomts of ischemic discomfrot |
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After adminstiration of ASA, Antigcoagulatnaterpy (UFH or enxaparin) then Clopidogrel/ IV GP IIb/IIIa (1 or both) then you have
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diagnostic angiography
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What is conservative treatment of UA/NSTEMI
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1. ASA or clopidogrel is intolerant
2. Anticoagulatnt therpaty (fondaparinun or enoxaprin preferrable_ |
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Why is Enoxaparin or Fondiparinux perferable to UFH, and do YOU add PLAVIX and at what dose
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1st line in GUIDLINES shows superiority to UFH,
have better outcomes, less risk of bleeding, and no monitoring DO add plavix 300mg is preferred dose in consevative apporach |
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What is acute dose of Clopidogrel with STEMI or NSTEMI on day 1 of hospital (ACUTE DOSE)
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300mg load on hospital day 1
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What is dosing of clopidogrel prior to PCI
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300mg load 6 hours prior to PCI with GP 2B3A
600mg load 6 hours prior with GP 2B3A |
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When a 600mg load dose of Clopidogrel given prior to a PCI
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when GP IIB/IIIA inbhitior is NOT given
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What is dose of UFH given for STEMI
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60units/kg bolus, then 12 units kg/hr infusion
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When do you check aPPT with UFH
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4-6 hours or 3 hours if given thrombolyti c
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What is goal aPPT
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1.5-2.5 x normal
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What is acute enoxaprin dose for NSTEMI
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1mg/kg SC every 12 hours for 2-12 days
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What is actue enxoaprin dose for CrCl<30
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1mg/kg sq every 24hrs for 2-12 days
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What is chronic dose for Metrolol
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50-100mg po twice daily.
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Statins should be iniated when during ACS
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as sson as individuals enter ER
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Should a statin be initatied regardless of LDL
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YES
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What are benefits of statins
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pleotirpic effects--they improve endothelial cell fuction, and have anti-thombotic properties
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What statins should be used
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HIGH potency statins should be used
Simvastatin 40mg Crestor 20-40 Lipitor 80mg |
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When should an ACE inhibtior be added to STEMI
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ORALLY within the 1st 24hrs
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What pts with NTEMI require ACE inhibitor
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Pulmonary congestions
LVEF <.40 |
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What are ACE inhibtiors contraindicated in
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SBP <100 or 30 mm HG below baseline
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What 3 approved ACE inihbitors with STEMI/NSTEMI
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Captopril
Enalapril Lisinpril |
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What is Acute Dosing of Captopril
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6.25-12.5mg
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Should ACE inhibitors be continued indefinitely after STEMI or NSTEMI
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YES
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What is chronic dosing of
Captoril Enalapril Lisinopril |
Captopril--50mg BID-TID
Enalatpril 10 mg BID Lisinpril 10-20mg Qd |
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What NSTEMI patients require an ACE inhibtior
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HF EF <40%
HTN Type 2 Diabetes |
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What STEMI/NSTEMI pts are candidates for Aldosterone antagoinsts
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Already receving ACEI
EF <40$ HF symptoms or DM |
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What are contraindiactions fo Aldosterone antagoinsts (Spironolactone/Eplerenone)
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Creatine must be less than or equal to 2.5 for men, and 2.0 in women and K <5.0
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What is dosing of Spironolactone
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12.5-100mg qd
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What is dosing of Eplerenone
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25-50 mg qd
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