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46 Cards in this Set

  • Front
  • Back
What are the 3 classifications of acute coronary syndrome (ACS)?
1. Unstable angina - acute angina at rest, prolonged greater than 20 minutes 2. Non STEMI - same as unstable angina with positive cardiac enzymes 3. STEMI - ST segment elevation on EKG with positive cardiac enzymes
What is the goal of therapy for ACS?
- minimize infarct size - salvage myocardial ishemia (by restoring oxygen ASAP) - minimize complications - improve outcomes
How do you acutely manage ACS?
MONA(H) - Morphine 1-5 mg IV 5-15 min. as need for pain - Oxygen - Nitroglycerin (sublingual tablet 0.4 mg x 3) - Aspirin 325 mg (one time) - Heparin
Name 4 anticoagulants to be used during ACS
- Plavix - Aspirin - Heparin - LMWH (Lovenox)
What anticoagulant should be used with a STEMI and why?
- definately use Heparin with STEMI - Heparin has a short half-life, so that can it can be stopped before a patient goes to cath lab
When should you not give LMWH?
- do not give LMWH for a STEMI - LMWH has a long half-life (12 hrs)
What drug is given to reverse the effects of Heparin?
- Protamine - give 1 unit of Protamine for every 100 units of Heparin
What receptor does Plavix work on?
plavix binds to the ADP receptor
What is the MOA for GP IIb-IIIa inhibitors?
- GP IIb-IIIa inhibtors displace fibrinogen and prevent further platelet cross-linking and thrombosis (prevents platelet aggregation)
What is the MOA of Heparin?
- blocks prothrombin - inactivates clotting factors (thrombin, Xa)
When should you give Nitroglycerin IV?
- if patient is given nitro sub-lingual and chest pain is unrelieved, then start IV - give dose at 10 mcg/min
What are contraindications of giving nitro?
a patient who has used sildenafil or valdenafil in the past 24 hours
What drug is first line in relieving chest pain?
What is the benefit of giving beta-blockers for relieving chest pain?
- decreases myocardial oxygen demand - reduces infarct size and left ventricular stress - negative inotropic effects
What is the dose of metoprolol?
- Metoprolol 5 mg IV every 5 mins x 3 doses - then 6 hrs later, Metoprolol 50 mg po, then Metoprolol 50 mg po Q 12hrs
What is a contraindication for Metoprolol?
What is a compelling indication to give an ACE inhibitor?
- left ventricular dysfunction (EF less than 40) - diabetic patient
What are 2 types of stents used?
1. bare metal stent 2. drug-alluding stent
What are the 2 types of drug alluding stents? how long should the patient be on Plavix with each type?
1. Sirolumous stent - needs to be on Plavix for at least 3 months 2. Taxol stent - needs to be on Plavix for at least 6 months
What is the dosage for Plavix?
300 mg loading dose, then 75 mg PO daily
What is the half-life of Plavix?
5-7 days
Name 3 GP IIb/IIIa inhibitors
- Eptifibatide (Integrillin) - Tirofiban (Aggrastat) - Abciximab (Reopro)
What percentage of platelets need to be inhibited to have full platelet inhibition?
What are the treatment goals of glycoprotein inhibitors?
- reduction in triple endpoint (death, MI, urgent revascularization) - minimize complications - decrease length of stay
What are indications to use Eptifibitide (Integrillin)?
- in medical management of ACS (no percutaneous coronary intervention [PCI]) - use as an adjunct to PCI (either emergent or elective PCI) - also has a IIB/IIIa recommendation from ACC(American College of Cardiology) to use for NSTEMI
What are indications of using Abciximab (ReoPro)?
- indicated in unstable angina with planned PCI - IIA recommendation for NSTEMI (higher recommendation rate that Integrillin) - also indicated for STEMI
Which glycoprotein inhibitor is a monoclonal antibody?
Abciximab (ReoPro)
What are indications for using Tirofiban (Aggrastat)?
- same as Integrillin - indicated in chest pain (unstable angina) - does not have indication in NSTEMI
What are contraindications of GP IIb/IIIa inhibitors?
- active internal bleeding - bleeding predisposition or evidence of active bleeding in the last 30 days - history of CVA or hemorrhagic CVA - intracranial neoplasm, AV malformation, or aneurysm - IV dextran (Dextran can act as an anticoagulant) - Nursing or pregnant women - oral anticoagulants in last 7 days - pediatrics (less than 17 y/o) - recent GI or GU bleeding (< 6 weeks) - recent major surgery, dental surgery or trauma - severe uncontrolled HTN (B/P > 200/100) - Thrombocytopenia or coagulopathy
What are baseline labs to monitor when using a GP inhibitor?
- baseline CBC, PT, aPTT, PLT, Type & Screen, SCr - CBC w/ PLT count 4& 12 hrs after bolus - Daily SCr in the morning
What is the appropriate action if a patient on a GP inhibitor has a platelet count that drops below 100,000?
stop drip and call MD or PA
What is the appropriate action if a patient on a GP inhibitor has a platelet count that drops below 60,000?
stop GP inhibitor, Heparin, ASA, and call MD or PA
What labs should be ordered STAT if there are signs of overt bleed?
What labs should be ordered on a patient prior to discharge?
What is the first line drug in ACS?
- Aspirin 325 mg daily or 81 mg for long term therapy
What are contraindications for using aspirin?
- contraindications are allergy, severe asthma, or current GI bleed
What is the definition and clinical presentation of a STEMI?
• definition is complete occlusion of an artery • clinical presentation: 1) Chest pain > 20 min 2) ST segment elevation 3) Positive cardiac enzymes
What are therapeutic goals in treating a STEMI?
• restore patency • prevent complications • control chest pain and associated symptoms
What are treatment options for STEMIs?
• thrombolytics • PCI (either PTCA or STENT implantation) * PTCA = Percutaneous Transluminal Coronary Angioplasty
What is the mechanism of thrombolytics?
activates plasmin, which digests fibrin clots
How soon after onset of STEMI symptoms must a thrombolytic be administered?
must adminster thrombolytic within 12 hours of symptoms
What is always the best option for treatment of STEMI?
primary PCI in hospitals with cath labs
Name 3 thrombolytics
• Alteplase (TPA): double bolus & infusion • Reteplase: bolus & infusion • Tenecteplase: weight-based bolus
What is the dose of Heparin when administering with a thrombolytic?
• give a lower bolus dose and infusion • 60 units/kg (bolus) & 12 units/kg/hr (infusion)
What is the dose of Enoxaparin (Lovenox) when given with a thrombolytic?
Lovenox 1 mg/kg sc Q 12hr
What other medications used in STEMI?
• ACE inhibitors (conserve cardiac muscle; decreasing remodeling of the heart) • Statins (improve morbidity and mortality)