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43 Cards in this Set
- Front
- Back
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Symptoms of ACS
Pain |
Chest pressure, tightness, heaviness
Radiation to the shoulders, neck, jaw, back or arms |
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GI Symptoms
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Indigestion, heartburn, nausea and vomiting
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Respiratory symptoms
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Shortness of breath
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Neurological symptoms
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Weakness, dizziness, lightheadedness, loss of conciousness
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9 traditional risk factors
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Hypertension
Diabetes Mellitus Elevated LDL or low HDL Family hx of early heart disease Cigarette Smoking Hypertriglyceridemia Obesity BMI>30 Physical inactivity Age >55 men; 65 women |
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6 non traditional risk factors
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Renal disease esp proteinuria
Metabolic syndrome Small dense LDL Increased Lipoprotein a Chronic infections Hyperhomocysteinemia |
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Troponins
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Rise in 3-6 hrs
Peak in 24 hrs Remain elevated for 7-14 days |
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Elevated troponins and normal EKG
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Unstable angina
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Ck-MB
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Rise in 4-6 hrs
Return to normal in 36-48 hrs pos if increase by 25-50% or >5% of total CK |
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Myoglobin
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Elevated in 1- 2 hrs
Elevated for < 24 hrs Useful early in pts with sxs and EKG changes |
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Fibrinolytic therapy
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Elevated STsegment in 2 or more lead > 1mm
May or may not have T wave inversions or Q waves |
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Comparison of cardiac markers
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CK-MB subforms, myoglobin most effecient for early diagnosis < 6 hrs
cardiac troponins highly specific, effecient for late diagnosis |
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Management of STEMI
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Relief of Pain
Assess hemodynamic state, Correct abnormalities Reperfusion therapy PCI vs Fibrinolysis Antithrombotic therapy Antiplatelet therapy Prevention of LV remodeling ACE, ARB Beta blockers to prevent recurrent ischemia and arrhythmias Statin therapy Anticoagulation if LV thrombus or AFib |
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What are the High risk features of STEMI
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older age, low BP, tachcardia, Heart Failure, Anterior MI
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What are the characteristics of the TIMI score
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Age >75 3
Age 65-74 2 Hx of DM, HTN, angina 1 SBP < 100 3 HR > 100 2 Kilip Class 2-4 2 WT <67 kg 1 Ant MI/LBBB 1 Reperfusion time >4 hrs 1 Total 14 |
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What is the hospital mortality
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TIMI Score Mortality
0-2 <5% 3-5 10-20% >6 20-60% |
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When should aspirin and clopidogrel be used
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PCI
ACS Unstable angina NSTEMI Acute STEMI |
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When should aspirin and clopidogrel not be used
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Stroke, TIA
Multiple risk factors Chronic Stable angina |
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How should aspirin be used in STEMI
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ASAP 162-325mg uncoated, chewed
Continued indefinitely at doses 75-162 mg If sensitive to aspirin use clopidogrel Low dose aspirin should be given to those who require warfarin (DVT, Afib) Cosider as prophylactic for those at high risk |
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How should clopidogrel be used in STEMI
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Equal in efficacy to aspirin
600mg loading dose then 75mg daily If PCI done urgently give after PCI with loading dose. Withhold Clopidogrel 5-7 days before CABG |
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How long should clopidogrel be used
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Duration of treatment Bare metal stent 1 month
Drug eluting stent > 1 yr Up to 1 yr for ACS with low risk of bleeding. |
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How is NTG used in STEMI
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Sublingual tabs 0.4mg up to 3 q 5 mins
Intravenous NTG in the first 48 hrs for treatment of ischemia, CHF or hypertension. can be used with beta blockers and ACE I Contraindications SBP <90 or 30 below baseline HR <50 or >100 |
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When should Oxygen be used
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Use O2 for the first 6 hrs
Use > 6 hrs for PO2 <90 or pulmonary congestion. |
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How should morphine sulfate be used
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IV MS for CP and anxiety 2-4mg increments of 2-8mg q 5-15mins
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Does PCI have increased survival over thrombolysis
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PCI has 1-2% increased survival over thrombolysis
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Does beta blocker use improve mortality in Acs
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Good For secondary prevention
During ACS IV followed by PO showed no benefit in mortality |
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Name the contraindications to beta blocker use in ACS
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HR <60
SBP <100 Moderate to severe LV failure Shock 2nd/3rd deg heart block Cocaine use |
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What are the ACC recommendations for beta blocker use in ACS
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ACC/AHA Recommends BB in the 1st 24 hrs in all patients with acute MI
Suggest IV BB in hypertensive hemodynamically stable patients. |
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When is fibrinolytic therapy used
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ST-segment elevation or new LBBB
Sx onset no more than 12 hrs prior to treatment May be given after 12 hrs if sxs persist No upper age limit use with caution in the elderly |
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Name the non-selective fibrinolytic agents
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Streptokinase 1.5MU over 30-60 mins
Anistreplase 30mg over 5 mins Antigenic Heparin coadministration not routine. |
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Name the selective fibrinoolytic agents
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Alteplase 100mg over 90 mins
Reteplase 10U repeat in 10 mins Non antigenic Heparin coadministration routine. |
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What are the contraindications to fibrinolytic therapy
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Previous hemorrhagic stroke
CVA < 1 yr Intracranial neoplasm Active internal bleeding Suspected aortic dissection BP > 180/110 INR > 2 Pregnancy Prior exposure to streptokinase or anistreplase (up to 2 years) |
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Anticoagulation with Heparin
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PCI (24-48 hrs)
Reperfusion with alteplase/reteplase (24-48 hrs) NSTEMI (24-48 hrs) High risk for systemic emboli( large or ant MI, prev embolus, LV thrombus) Dosage Bolus 60U/kg max 4000 U Maintenance 12U/kg/hrMax 1000U/hr Lovenox 1mg/kg bid IV Heparin is commonly used in PCI and reperfusion therapy while LMWH is used in NSTEMI and high risk for systemic emboli. ACE INHIBITORS ACC/AHA ClASS 1 Use within 24 hrs |
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When are ACE inhibitors used
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ACC/AHA ClASS 1
Use within 24 hrs STEMI CHF LV EF <40 ACC/AHA CLASS IIA within 24 hrs to others without contraindications. |
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What are the Contraindications of
ACE INHIBITOR use |
Hypotension
Hyperkalemia Creat > 3 |
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When should ARB be used
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Use if patient is intolerant to ACEI
Should not be used in addition to ACEI |
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Describe CCB usage
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Adjunctive for ongoing or recurrent iuschemia
No mortality reduction Usually used Amlodipine Felodipine |
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Describe Aldosterone antagonist usage
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To all STEMI pts receiving ACE inhibitor
LV EF <40% Have symptomatic HF or Diabetes Men Creat < 2.5 and women < 2 K < 5 Spironolactone start at 25mg daily Eplerenone start at 25mg/day then increase to 50mg/day after 4 wks. |
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How do you handle recurrent ischemia and chest pain
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Ischemia in 20-30%
Reinfarction in 3-5% Diagnosis < 18 hrs of initial MI should be accompanied by recurrent ST segment elevation and one other supporting criterion - chest pain or hemodynamic decompensation. >18hrs of initial MI a biomarker rise of at least 50% and another supporting criterion. Management Escalation of therapy - beta blockers, nitrates Anticoagulation PCI |
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How do you prepare for discharge
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Early discharge after an uncomplicated MI(no angina, ischemia, heart failure, arrhythmia
72 hrs after event is considered safe for d/c Evaluation of LV function Usually measured before d/c Improvement can be seen in 3-14 days due to myocardial stunning. Stress testing Predischarge testing not needed in pts who have had PCI/CABG Low level predischarge testing for those with partial or no revascularization who are stable. Bedside commode allowed for stable pts in 24 hrs Bedrest for no more than 12-24 hrs in asymptomatic pts return to non-physical activities in 2 weeks |
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What should the diet be
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< 7% total cals as saturated fat
<200mg cholesterol Increased Omega 3 fatty acids AHA 1 fish serving daily |
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What at the features of cardiac rehab
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Education and risk reduction
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What is the risk of sexual activity
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Absolute increase in risk is very small
Low risk safely initiate or resume sexual activity Intrmediat risk Recent MI >2 weeks but< 6 wks High risk stabilize before resuming sexual activity. PDE5 Inhibitors safe in men with stable CAD not taking nitrates |
