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45 Cards in this Set
- Front
- Back
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Risk factors for ACS
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HTN
Diabetes Dyslipidemia Family history Smoking Sedentary lifestyles Chronic Kidney Disease |
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Symptoms of ACS
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Chest pain (radiating to jaw, arm, back, shoulder)
Shortness of breath Fatigue/weakness Nausea Diaphoresis Lightheadedness |
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Differential diagnosis of ACS
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Pericarditis
Aortic dissection Pneumothorax Pulmonary embolism GI causes Muskuloskeletal |
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Clinical syndrome subset of ACS that is usually but not always caused by atherosclerotic CAD and is associated with increased risk of cardiac death and subsequent MI
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Unstable angina/ NSTEMI
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3 principal presentations of unstable angina
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Rest angina
New onset angina ( at least CCS class III) Increasing angina |
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Ordinary physical activity does not cause... angina such as walking or climbing stairs. Angina occurs with strenuous, rapid or prolonged exertion at work or recreation - Which class CCS
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Class I
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Slight limitation of activity - angina occurs on walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, in wind or under emotional stress or only after few hours after awakening. Angina occurs on walking more than 2 blocks on the level or climbing more than 1 flight of ordinary stairs under normal conditions - which class CCS
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Class II
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Marked limitation of physical activity - angina occurs on walking, 1-2 blocks on walking and climbing 1 flight of stairs under normal conditions - which class CCS
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Class III
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Inability to carry on any physical activity without discomfort - anginal symptoms may be present at rest - which class CCS
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Class IV
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Diagnosis of ACS
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H&P
EKG CXR Biomarkers Cardiac imaging |
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What do you look for in focused history taking in diagnosis of ACS
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Symptoms
Risk factors Allergies Medicaitons PMH PSH Social Review of systems - claudication, dyspnea |
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EKG goal for diagnosis of ACS
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Within 10 minutes of presentation
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Biomarker of choice in diagnosis of ACS, very sensitive and specific, detectable as early as 2 hours, present up to 14 days
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Troponins T and I
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These biomarkers are detectible in 2-4 hours, NOT as sensitive as Troponin, useful to detect re infarction
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CPK and CPK MB
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Earliest biomarker to rise
Very sensitive Not specific Any minor trauma can cause rise – can be from working out, trauma of chest, etc |
Myoglobin
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May be measured as an adjunct to determine overall risk of patient
Elevated levels are markers of poorer outcomes |
Brain natriuretic peptide
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ECHO in patients with ACS tests for _
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LV size and systolic function
Wall motion abnormalities – inferior wall not contracting as anterior – high suspicion for acute event Mitral regurgitation – leaky valves Pericardial effusion – fluid around heart |
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What should you do first before doing stress test in patients with ACS
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RULE OUT MI
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Who mostly benefits from stress test
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Low risk patients
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Gold standard from imaging standpoint
Can diagnosis and tx in same setting – can see lesion and treat it at the same time |
Cardiac cath
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Recommended aspiring dosing
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162-325 mg chewed and swallowed upon presentation – 2-4 baby ASA, buccal and mucosal absorption
81-325 mg daily thereafter for life |
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Recommended clopidogrel dosing
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300-600 mg loading dose early in hospital course (before cath)
75 mg daily for 1-12 months |
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Major risk with IIb/IIIa inhibitors
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Bleeding
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Drugs that should be used in all patients suspected of ACS
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Anticoagulants
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-Factor III inhibitor
-inactivates thrombin -IV bolus and infusion -Had been standard for years -Initial use easy and cheap -Hard to control and monitor -Increased bleeding risk -Activates plts |
Unfractionated heparin
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-Anti XA factor
-May have better outcomes (lower risk of bleeding) -Easy to use -No need to monitor -Expensive |
Low molecular weight heparin - ENOXAPARIN
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What should the dosing be for low molecular weight heparin - ENOXAPARIN
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subqutaneous q 12 hours
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-Direct thrombin inhibitor
-Bolus and infusion/no monitoring (easy to use) -Does not activate plts -Reduced risk of bleeding -Expensive |
Bivalirudin
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-Binds to AT III
-Inhibits factor Xa -Inhibits thrombin Agent of choice for conservative rx if increased bleeding risk |
Fondaparinux
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Absolute contraindication for thrombolytics
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Unstable angina
NSTEMI |
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Anti ischemics used in acute treatment of ACS
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Bed rest
O2 Β-blockers Nitrates Opiates Ace-I/ARB CA++ channel blockers |
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-Decrease HR, BP & contractility
-DECREASES MYOCARDIAL WORKLOAD (MVO2) -Decrease infarct size and reinfarction -Decreases Arrhythmias -Decreases mortality |
Beta blockers
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Drugs that should be used in all patients w/o contraindications
(Shock, pulmonary edema, bradycardia) |
Beta blockers
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-Coronary artery and venodilator
-Decreases BP by decreasing preload -Decreased BP means decreased O2 demand -“Dilates coronary artery” |
Nitrates
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Can you use nitrates instead of ACE inhibitors or beta blockers in patients with ACS
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NO survival benefit ever proven therefore should not preclude use of β-blocker or ACE-I
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-Decreases anxiety, BP & HR (slight)
-No survival benefit proven |
Opiates
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Patient presents with ACS, EF <40, pulmonary congestion - drug of choice
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ACE inhibitor or ARB
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May be used if contraindications to β-blocker – lower HR and lower BP only if intolerant to beta blockers – no known survival benefit
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Nondihydropyridine CCB’s (verapamil & diltiazem)
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May be used in conjunction w/ β-blockers for refractory ischemia
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Dihydropyridine CCB’s
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Side effects and complications of intraortic balloon pump
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Limb ischemia
Bleeding at the insertion site Thrombocytopenia Immobility of the balloon catheter Balloon leak Infection Aortic dissection Compartment syndrome |
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What are the recommendations for statins in patients with ACS
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Start with high dose and keep taking no matter what cholesterol is --> pleotropic (anti inflammatory effect)
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Name TIMI risk factors - get one point for each
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-Age >65
-3 risk fx for CAD – diabetes, smoking, men over 45, women over 55, HTN, low HDL -ASA use in prior 7 days -ST segment changes of ECG -Prior stenosis >50% -2 or more anginal events in prior 24 hours -+ biomarkers |
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Name 4 goals of acute invasive treatment of ACS
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-Decrease risk of death
-Decrease risk of MI & recurrent MI -Decrease re-hospitalization -Decrease need for antianginals |
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Name long term treatment of ACS
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ANTIPLATELETS
-ASA -Thienopyridines -Lifetime use -Warfarin – do not routinely use, only for special indications ANTI ISCHEMIC ANTI HTN Β-blockers Nitrates – only if need ACE-I/ARB - everyone CCB – only if need Goal BP <140/90 (130/80 w/ DM or CKD) LIPID LOWERING Statins – IMPORTANT, LIFETIME Goal LDL <100 (<70 in high risk pts) OR 50% reduction in baseline LDL Others |
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Which drugs should you avoid in pain management of patients with ACS
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NSAIDS
-Use nonselective only if absolutely necessary -Separate dose 4 hours from ASA |
