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45 Cards in this Set

  • Front
  • Back
Risk factors for ACS
HTN
Diabetes
Dyslipidemia
Family history
Smoking
Sedentary lifestyles
Chronic Kidney Disease
Symptoms of ACS
Chest pain (radiating to jaw, arm, back, shoulder)
Shortness of breath
Fatigue/weakness
Nausea
Diaphoresis
Lightheadedness
Differential diagnosis of ACS
Pericarditis
Aortic dissection
Pneumothorax
Pulmonary embolism
GI causes
Muskuloskeletal
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
Unstable angina/ NSTEMI
3 principal presentations of unstable angina
Rest angina
New onset angina ( at least CCS class III)
Increasing angina
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
Class I
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
Class II
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
Class III
Inability to carry on any physical activity without discomfort - anginal symptoms may be present at rest - which class CCS
Class IV
Diagnosis of ACS
H&P
EKG
CXR
Biomarkers
Cardiac imaging
What do you look for in focused history taking in diagnosis of ACS
Symptoms
Risk factors
Allergies
Medicaitons
PMH
PSH
Social
Review of systems - claudication, dyspnea
EKG goal for diagnosis of ACS
Within 10 minutes of presentation
Biomarker of choice in diagnosis of ACS, very sensitive and specific, detectable as early as 2 hours, present up to 14 days
Troponins T and I
These biomarkers are detectible in 2-4 hours, NOT as sensitive as Troponin, useful to detect re infarction
CPK and CPK MB
Earliest biomarker to rise
Very sensitive
Not specific
Any minor trauma can cause rise – can be from working out, trauma of chest, etc
Myoglobin
May be measured as an adjunct to determine overall risk of patient
Elevated levels are markers of poorer outcomes
Brain natriuretic peptide
ECHO in patients with ACS tests for _
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
What should you do first before doing stress test in patients with ACS
RULE OUT MI
Who mostly benefits from stress test
Low risk patients
Gold standard from imaging standpoint
Can diagnosis and tx in same setting – can see lesion and treat it at the same time
Cardiac cath
Recommended aspiring dosing
162-325 mg chewed and swallowed upon presentation – 2-4 baby ASA, buccal and mucosal absorption
81-325 mg daily thereafter for life
Recommended clopidogrel dosing
300-600 mg loading dose early in hospital course (before cath)
75 mg daily for 1-12 months
Major risk with IIb/IIIa inhibitors
Bleeding
Drugs that should be used in all patients suspected of ACS
Anticoagulants
-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
-Anti XA factor
-May have better outcomes (lower risk of bleeding)
-Easy to use
-No need to monitor
-Expensive
Low molecular weight heparin - ENOXAPARIN
What should the dosing be for low molecular weight heparin - ENOXAPARIN
subqutaneous q 12 hours
-Direct thrombin inhibitor
-Bolus and infusion/no monitoring (easy to use)
-Does not activate plts
-Reduced risk of bleeding
-Expensive
Bivalirudin
-Binds to AT III
-Inhibits factor Xa
-Inhibits thrombin

Agent of choice for conservative rx if increased bleeding risk
Fondaparinux
Absolute contraindication for thrombolytics
Unstable angina

NSTEMI
Anti ischemics used in acute treatment of ACS
Bed rest
O2
Β-blockers
Nitrates
Opiates
Ace-I/ARB
CA++ channel blockers
-Decrease HR, BP & contractility
-DECREASES MYOCARDIAL WORKLOAD (MVO2)
-Decrease infarct size and reinfarction
-Decreases Arrhythmias
-Decreases mortality
Beta blockers
Drugs that should be used in all patients w/o contraindications
(Shock, pulmonary edema, bradycardia)
Beta blockers
-Coronary artery and venodilator
-Decreases BP by decreasing preload
-Decreased BP means decreased O2 demand
-“Dilates coronary artery”
Nitrates
Can you use nitrates instead of ACE inhibitors or beta blockers in patients with ACS
NO survival benefit ever proven therefore should not preclude use of β-blocker or ACE-I
-Decreases anxiety, BP & HR (slight)
-No survival benefit proven
Opiates
Patient presents with ACS, EF <40, pulmonary congestion - drug of choice
ACE inhibitor or ARB
May be used if contraindications to β-blocker – lower HR and lower BP only if intolerant to beta blockers – no known survival benefit
Nondihydropyridine CCB’s (verapamil & diltiazem)
May be used in conjunction w/ β-blockers for refractory ischemia
Dihydropyridine CCB’s
Side effects and complications of intraortic balloon pump
Limb ischemia
Bleeding at the insertion site
Thrombocytopenia
Immobility of the balloon catheter
Balloon leak
Infection
Aortic dissection
Compartment syndrome
What are the recommendations for statins in patients with ACS
Start with high dose and keep taking no matter what cholesterol is --> pleotropic (anti inflammatory effect)
Name TIMI risk factors - get one point for each
-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
Name 4 goals of acute invasive treatment of ACS
-Decrease risk of death
-Decrease risk of MI & recurrent MI
-Decrease re-hospitalization
-Decrease need for antianginals
Name long term treatment of ACS
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
Which drugs should you avoid in pain management of patients with ACS
NSAIDS
-Use nonselective only if absolutely necessary
-Separate dose 4 hours from ASA