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24 Cards in this Set
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Acute Coronary Syndrome (ACS)
Definition Conditions included (6) |
Acute Coronary Syndrome (ACS)
Definition Chest pain secondary to cardiac ischemia…Uncertainty - are you having unstable angina pain, panic attack or an MI? Conditions included • UA – Unstable angina • PA - Prinzemetal angina • AMI – Acute myocardial infarction • STEMI – ST elevation MI • NSTEMI – Non ST elevation MI • NQWMI – Non Q Wave MI |
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Acute Coronary Syndrome (ACS)
Drugs to give when patient presents (MONA-BA) |
Acute Coronary Syndrome (ACS)
Drugs to give when patient presents (MONA-BA) • Morphine (Check BP 1st – SBP must be ˃90mg Hg) • Oxygen give to everyone • Nitrates (Check BP 1st – SBP must be ˃90mg Hg) • Aspirin • Beta Blocker • ACEI – after 6 hrs, before 24hrs (Check BP 1st – SBP must be ˃100mg Hg) |
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Acute Coronary Syndrome (ACS)
Differential Diagnosis Diagnostic tool for MI (1) |
Acute Coronary Syndrome (ACS)
Differential Diagnosis Do EKG: • ST elevation – definite MI, clot blocking vessel, so give thrombolytic w/i 6hrs… past 6 hrs do a PCI • ST depression – severe angina; platelets getting too close, could cause MI, put patient on Glycoprotein IIb/IIIa antagonists (Eptifibatide (Integrilin)) Diagnostic tool for MI (1) Check Tropin I levels… check 3x. Very sensitive and specific indicators of damage to the myocardium. Differentiates between unstable angina and MI in patients with chest pain or acute coronary syndrome. Stays elevated |
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Acute Coronary Syndrome (ACS)
Morphine MOA & Effect (3) SE (6) Dose |
Morphine* Dose (ACS) 1-5mg IV, repeat q5-30mins PRN for comfort/symptom relief; No MAX dosage
MOA & Effect • Relieves pain & anxiety →↓BP →↓O2 demand • Venodilation→↓Preload →↓O2 demand • In CHF patients with pulmonary edema, morphine redistributes volumes and helps clear lungs of fluid SE • Hypotension- Avoid in hypotensive patients - SBP must be ˃90mg • Constipation (prevalent), N&V • Sedation • Respiratory depression (hi dose) (give Naloxone 0.4-2mg IV) • Urine retention • Dependence * If allergic give meperidine 50-150mg IM/SQ/PO q3-4h… watch seizures |
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Acute Coronary Syndrome (ACS)
Nitrates MOA & Effect (3) SE (3) |
Nitrates (ACS)
MOA & Effect • Vasodialtes ALL vascular smooth muscle – coronary, peripheral arteries (↓afterload), and venous vessels (↓preload) • Administer to all patients to alleviate ischemic myocardial pain • Patient MUST have SBP ˃90mg SE • Flushing (give ASA 30 min prior) • Hypotension • Lupus like syndrome/exfoliative derm (ISDN only) |
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Acute Coronary Syndrome (ACS)
Nitrates Dosage Forms Cautions |
Nitrates (ACS)
Dosage Forms • IV for early treatment & precise control • SL or spray for stable patients 3x q5mins • Send home on oral or patch Cautions • DO NOT use if patient is hypotensive ( MUST have SBP ˃90mg), severe bradycardia or tachycardia • DO NOT use if patient has taken a ED med w/i 24hrs… can cause severe hypotension |
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Acute Coronary Syndrome (ACS)
β-Blocker MOA & Effect (4) |
β-Blocker (ACS)
MOA & Effect • ↓ HR (neg chronotropic) and ↓ contractility (neg ionotropic)→↓ workload & O2 demand • Blocks sympathetic vasoconstriction→vasodilation & ↓ ventricular afterload • Can ↓ infarct size • ↓ chance of A Fib & Flutter following MI (AV blocker) and ventricular ectopy |
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Acute Coronary Syndrome (ACS)
β-Blocker Benefits (3) |
β-Blocker Benefits (ACS)
• Evidence suggests prolongation of survival • ↓ mortality and sudden death (Favorable effects on ischemia & sudden death) • ↓ rate of re-infarct |
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Acute Coronary Syndrome (ACS)
β-Blocker ASC Uses (4) BB to use for ASC (MAP) |
β-Blocker ASC Uses (4)
• Give to everyone presenting with ACS • Patients with ST elevation • Patients with non ST elevation infarcts, • Patients with tachyarrhythmias • Patients with continuing ischemic pain (everyone) • Use Metoprolol, Atenolol, Propranolol |
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Acute Coronary Syndrome (ACS)
Aspirin Caution Dose Use/Benefit |
Aspirin (ASC)
Caution • Check to ensure no active peptic ulcer dx, bleeding disorder, or ASA hypersensitivity • Use clopidogrel (Plavix) if hypersensitive Dose • 160-325mg immediately; chewed enhances absorption Use/Benefit • Given to all ACS patients. Causes immediate, near total inhibition of thromboxane A2, reducing coronary re-occlusion and recurrent event after fibrinolytic therapy |
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Acute Coronary Syndrome (ACS)
Heparin & LMWH When to use in ACS Contraindication in ACS |
Heparin
When to use • If the patient needs anticoagulant- hi risk for systemic emboli (large anterior infarct, or in A-Fib) use heparin • LMWH (Lovenox) Approved unstable angina and NQWMI • No labs needed just watch for signs of bleeding Contraindication • DO NOT use if patient has been given a thrombolytic |
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Acute Coronary Syndrome (ACS)
ACEI (KNOW These!!) When to use in ACS Beneficial Effects |
ACEI
When to use: • Wait 6 hrs after MI, start within 24hrs of diagnosis and after BP stable ACEI – Beneficial effects: • Early ACE inhibition ↓ mortality and CHF associated with MI • ACE prevents adverse left ventricular remodeling • ACE delays progression of heart failure • ACE ↓ sudden death and recurrent MI |
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Acute Coronary Syndrome (ACS)
ACEI Dosage |
ACEI
Dosage • Start low dose and titrate up as quickly as patient tolerates it • Use oral formulation, not IV (can cause ↑ hypotension) • If patient never on ACE before, start with Captopril … has shortest ½ life • Remember ACE causes diuresis, ↓Na+ & ↑K+ |
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Acute Coronary Syndrome (ACS)
ACEI Contraindications |
ACE contraindicated
• Pregnancy • Angioedema • SBP ˂ 100mg Hg • Clinically relevant renal failure or bilateral renal artery Stenosis (↑K+) |
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Acute Coronary Syndrome (ACS)
Evaluate for Thrombolytic (Reperfusion) Therapy |
Evaluate for Thrombolytic (Reperfusion) Therapy
• If we are told patient has ST segment elevation, we must break up clot with thrombolytic or PCI • AMI (STEMI) results from thrombus occluding coronary vessel • Thrombolytics dissolve clot, salvage myocardium, and limit the damage. Give early… irreversible damage to muscle after 20mins |
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Acute Coronary Syndrome (ACS)
7 Questions to ask before Thrombolytic (Reperfusion) Therapy |
7 Questions to ask before thrombolytic therapy:
1. Is BP ˂ 180/110 mmHg? 2. History of stroke? 3. Hemorrhagic stroke history? 4. Known bleeding disorder? 5. Active bleed in past 2-4 wks? 6. Surgery/trauma in past 3 wks? 7. Aortic dissection? If any answer is yes, give NO thrombolytic!! |
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Acute Coronary Syndrome (ACS)
Choice of Thrombolytics |
Choices of thrombolytics:
• Streptokinase (SK) • Reduces mortality, additive with ASA • ANTIGENIC, cannot give again for 12 mons (Ab formation) • Alteplase (t-PA) • Naturally occurring enzyme, reproduced in DNA technology |
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Acute Coronary Syndrome (ACS)
Glycoprotein IIb/IIIa Antagonists (3) When to use anti-platelet therapy |
Glycoprotein (GP) IIb/IIIa
• Abciximab (ReoPro) • Eptifibatide (Integrilin) • Tirofiban (Aggrastat) When to use GP IIb/IIIa therapy • ACS - Hi-Risk Unstable Angina/NSTEMI • Don’t have MI, but one might occur • Ensure that platelets don’t aggregate • Give Glycoprotein IIb/IIIa in Hospital ONLY • PCI |
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Acute Coronary Syndrome (ACS)
Abciximab (ReoPro) Dosage Precautions |
Abciximab (ReoPro) Dosage
• Acute coronary syndrome with planned PCI w/i 24hrs: 0.25mg/kg IV bolus (10-60 mins before procedure), then 0.125mcg/kg/min IV infusion • PCI only – 0.25mg/kg IV bolus, then 10mcg/min IV infusion Abciximab precautions: • Must use with heparin • Binds irreversibly with platelets (48hrs for regeneration) • Re-administration may cause hypersensitivity (antigenic mouse anti-body) |
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Acute Coronary Syndrome (ACS)
Eptifibatide (Integrilin) Dosage Actions Precautions |
Eptifibatide (Integrilin)
Dosage • ACS/PCI: 180mcg/kg IV bolus, then 2mcg/kg/min infusion • Use with ASA and heparin OR Lovenox (Exoxaparin) Action • Platelet function recover w/i 4-8hrs after D/C Precautions • D/C infusion prior to a CABG • Watch for- thrombocytopenia |
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Acute Coronary Syndrome (ACS)
Tirofiban (Aggrastat) Dosage Actions |
Tirofiban (Aggrastat)
Dosage • ACS/PCI: 0.4mcg/kg/min IV for 30 mins, then 0.1mcg/kg/min IV infusion Action • Platelet function recovers 4-8 hrs after D/C |
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Acute Coronary Syndrome (ACS)
What to do for MI patient on admission (MONA BATS) |
What to do for MI patient (MONA BATS)
• First MONA then (morphine & nitrates SBP ˃ 90mg Hg) • β-Blocker if stable, and at discharge • ACE – after 6hrs, before 24hrs (SBP ˃ 100mg Hg) • Thrombolytic or PCI to bust clot • Statin before discharge… even if lipids not high |
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Acute Coronary Syndrome (ACS)
MI - Discharge meds |
MI - Discharge meds:
• ASA or Plavix (definite Plavix if stent for at least 12 mons) • β-Blocker • ACE • Statin • Nitroglycerin |
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Acute Coronary Syndrome (ACS)
PCI – Drug Therapy before & After |
PCI – Drug Therapy before & After
• Loading dose of 300mg clopidogrel (Plavix) at least 6hrs prior to PCI procedure • JAMA study showed this to ↓risk of MI & stroke by 38% • Don’t Rx until CABG is ruled out • After PCI, clopidogrel 75mg/day for at least 12 mons |
