Term
THROMBOLYTICS AND ANTICOAGULANTS
Pathophysiology of an MI |
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Definition
| Atherosclerotic plaque rupture;endothelial wall damage>>platelet adhesion>>platelet aggregation>>thromboplastin>>prothrombin-->Thrombin--fibrinogen>>fibrin>>THROMBUS |
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Term
| PATHOPHYSIOLOGY OF MI (cont)... |
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Definition
-Clot forms on plaque which breaks off and takes away endothelium.
-the body responds as if to an injury
-Clot forms on the wall of the blood vessel and then blocks the vessel completely
CCMC management philosophy: Percutaneous angioplasty-flat a wire to the clot and then push open the vessel with a balloon/stent |
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Term
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Definition
| a narrowing of the vessel; not a complete occlusion |
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Term
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Definition
Pathophysiology
--Thrombus superimposed on antherosclerotic plaque-te area that is exposed when the plaque breaks off-The body CAN reverse this itself...but not likely
-prolonged ischemia
-irreversible damage in 4-6hrs
-Scar tissue...enough damage: heart failure
-LV dysfunction |
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Term
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Definition
-Decrease mortality
-minimize morbidity
-limit infarct size
-control arrhythmias
-treat pain, anxiety |
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Term
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Definition
-600,000 deaths per year
-50% die in the first hours-decreased dramatically in recent years-most in pre-treatment hours
-Electrical instability
--10 to 15% mortality in the first year-down also
-3 to 4% mortality per year |
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Term
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Definition
PAIN-may not be present, and they are STILL havin an MI
--Only 50% of patient will present with classic pain-can manifest in many ways-"weakness", cocaine overdose, chronic marijuana use
-Hyper OR Hypotensive
-Anxious
-Nausea, vomiting
-Diaphoretic
-Victor H. Note**Not al angina reveals increased enzymes or 12-lead changes |
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Term
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Definition
-Hypoxia
STRESS-any form
-Exertion-any form
-Cold
-Meals
-Hypoglycemia
-Trauma, hemorrhage
-Drugs |
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Term
Coronary Artery Disease (CAD)
Risk Factors |
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Definition
-Gender
-Age
-Smoking
-Obesity
-Lifestyle
--Cocain and Marijuana use
-Diabetes-"silent MI"
-HTN
-Hyperlipidemia
-Family Hx |
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Term
Thrombolytic Therapy
*not commonly used at CCMC...BUT KNOW IT FOR THE TEST!!! |
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Definition
Goals
-Lyse coronary thrombi-the earlier you break the clot the better chance of saving the muscle
-Limit the infarct size
--early reperfusion
-Decrease morbidity
--Preserve LV function
-Decrease mortality |
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Term
Thrombolytic Therapy
ABSOLUTE CONTRAINDICATIONS |
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Definition
-Major surgery within 6 weeks
-GI bleed within 6 months
-Intracranial neoplasm-tumor in the brain effecting the vasculature of the brain
-Stroke within 6 months
-Active bleeding
-head trauma within 1 month
-pregnancy |
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Term
Thrombolytic Therapy
RELATIVE CONTRAINDICATIONS |
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Definition
-Deciscions on thes would be made at the time of therapy
-CPR >10minutes
-Age: the younge the patient, the more likely they will benefit
-Hypertension >180/110
-Remote history of a stroke
-VICTOR NOTE** the extent of damage can be guages by a bedside echo in order to determine viability (eg, EF of 10% determines that it would not be beneficial) |
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Term
Thrombolytic Therapy
(age as a contraindication) |
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Definition
Patients > 75
-Determine more benefit from thrombolytics
-greater reduction in mortality
-are at risk for bleeding complications |
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Term
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Definition
STREPTOKINASE (no longer available) derived from ad antibiotic FAR MORE ALLERGENIC THAN OTHER AGENTS
-Tissue Plasminogen activator (TPA)
-Anisoylated plasminogen streptokinase activator complex (APSAC)
-Urokinase (no longer used for AMI)
-Recombinant plasminogen activator (retevase) |
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Term
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Definition
ADVANTAGES: Inexpensive, Large clinical experience, less chance of CVA
DISADVANTAGES: Hypotension, Allergic reaction, nonselective thrombolysis
DOSE: 1.5 million units over 60 minutes |
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Term
| Tissue Plasminogen Activator (TPA, Activase) |
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Definition
ADVANTAGES: Selective thrombolysis, nonallergenic, improved mortality in subsets
DISADVANTAGES: Expensive, complex administration process, higher chance of CVA
DOSE: 15mg bolus, 0.75 mg/kg over 30min (not to exceed 50mg), 0.5 mg/kg over 60min (no to exceed 35mg)**
**text bok says 90mg over 90minutes |
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Term
| Acetylated Streptokinase (APSAC, Eminase) |
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Definition
ADVANTAGES: Simple Administration
DISADVANTAGES: Hypotension, Allergic Reaction, Nonselective thrombolysis
DOSE: 30Units over 2-5 minutes |
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Term
Recombinant Plasminogen Activator
(Retavase) |
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Definition
ADVANTAGES: simple Administration, Less Allergic reations
DISADVANTAGES: No age/weight dosing adjustments, Increased risk of CVA if small body weight or elderly
DOSE: Two 10 unit bolus injections asminstered 30 minutes apart over 2 minutes*
*Medical Director can the CCEMTP the order to give this drug in transport EVEN IF IT IS NOT ON THE STATE LIST. MC can give a one time order for all meds. Most important is porvider level of comfort |
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Term
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Definition
THE MOST IMPORTANT DRUG TO TREAT AMI!!!
PHARMOCOLOGY-keeps the clot from forming in the first place
--blocks throboxane a2 production
-inhibits platelet aggregation
-Platelet 1/2 life: 5-7 days
-DOSAGE: 324mg p.o.; four 81mg baby ASA
AS SOON AS YOU CAN GIVE IT!! |
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Term
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Definition
*EVEN IF THEY TOOK SOME BEFORE YOU GOT THERE, GIVE IT!!
Use in unstable angina
--Give ASAP
--Dose: 324mg
--Decreases mortality and reinfarction rate by 40%
-Primary prevention trial
--DOSE: 324mg q daily
-Decreases MI by 47% |
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Term
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Definition
-17,187 paitients
-Thrombolytics decreased mortality by 25%
-Aspirin alone decreased mortality by 23%
TOGETHER: 42% |
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Term
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Definition
Pharmaclogy
-Binds to antithrombin III and catalyzes its activity (prevents conversion of fibrinogen to fibrin)
-halts further thrombus formation-stops the clot; DOSE NOT DISSOLVE IT
PHARMOKINETICS
1/2 life: 60-90 minutes
MONITORING PARAMETER
-Aptt 1.5-2 times control (INR) |
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Term
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Definition
DOSING
-5,000 unit (70units/kg) bolus follwed by 1000 units (14-17 units/kg per hour) ONLY FOR TEST! REALITY: weight-based protocol
-Used in unstable angina
--with ASA decreases refractory angina and MI
--heparin alone causes reactivation of angina
-USE in MI
--heparin and TPA start immediately
--Heparin and SK-start after SK infusion |
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Term
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Definition
-thrombocytopenia-herparin induced (HIP)-certain people on heparin have idiosyncratic reaction where their platelets are reduced
-Bleeding-new clots are stopped from forming
-Antagonist
--Protamine-if they are anticoagulated and actively bleeding |
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Term
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Definition
Pharmocology
-inhibits vitamin K dependant clotting factors
-Factors VII, IX, X, II
-Pharmokinetics
--1/2 lives 6,24,40,and 60hours respectively
-2 to 7 days for maximum benefit |
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Term
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Definition
-Never in acute phases
-anterior wall infarction
--30 to 40% LV thrombus formation
--Treatment: 3 months post infarction
--Decreases incidence of CVA
-Atrial Fibrillation-at risk for small blood clots due to disruptive flow
-thromboembolism
-valve replacement |
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Term
Warfarin (Coumadn)
Monitoring Parameter |
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Definition
-International normalized ratio (INR)
-GOAL: INR 2-3
--Mechanical heart valves 2.5-3.5
-Antagonist
--Vitamin K |
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Term
Warfarin (Coumadin)
DRUG INTERACTIONS |
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Definition
Decreased Efect: Rifampin, Phenytoin, Carbamazepine, Phoenobarbital, Cholestyramine
Increased Effect: Quinolones, Bactrim, Amiodarone, Alcohol, Cimetadine, NSAIDS, ASA, Erythromycin, Allopurinol |
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Term
Warfarin (Coumadin)
ADVERSE EFFECTS |
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Definition
SKIN Necrosis-easy bruising
Bleeding
--Risk 2-8% per year
--Increases with age, intensity |
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Term
| ADP-Platelet Receptor Inhibitors |
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Definition
-Ticlopidine (ticlid)
-Clopidogrel (plavix)
-Block platelet-platelet adhesion-similar to ASA, but not as fast
-Agent not used for acute intervention due to slow onset (up to 4 days)
-Second-line anti-platelet therapy
--Drug of choice if intolerant to ASA |
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Term
| Glycoprotein 2b/3a receptor Antagonists |
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Definition
-There are ~40,000-80,0000 receptors per platelet
-Favorable results when goven with thrombolytics
--May actually allow for lower doses of lytic agents
-Drug modifies platelet aggregation and subsequent thrombus formation |
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Term
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Definition
-Fab fragment of antibody 7E3
-Administration: IV with 1/2 life of 10 minutes, requires infusion
DURATION: Effects remain for 2 weeks, but platelet function return in 48hrs
-Used with Heparin and ASA
INDICATION-Cardiac cath within 1 hr-can be useful in reducing the use of fibrinolytic drugs |
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Term
Eptifibatine (Integralin)
(longer lasting) |
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Definition
-Derived from venom of Southeastern pigmy rattlesnake.
-Bolus + infusion only
--effects dissapate after cessation
-1/2 life 2.5hrs
INDICATIONS: Acute coronary syndrome
-CABG
-PCTA |
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Term
Tirofiban (Aggrastat)
Easier to use because given as a bolus |
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Definition
-Derivative of venom from saw-scaled viper
-DURATION: works within 5min; 1/2 life is 2hrs
-Platelet function returns within 3-4hrs
DOSE: 0.4mcg/kg bolus
INDICATIONS: Acute coronary syndromes, IUnstable Angina, Non Q-wave MI |
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Term
| Low molecular Weight Heparin |
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Definition
-Produced by depolymerization of heparin-given by injection-lasts 24hrs
-Used in Europe for the past 10 years
-Examples (each have different molecular weights)
--Ardeparin (normiflo)
--Dalteparin (fragmin)
--Enoxaparin (lovenox)-What Crozer Uses
INDICATION: DVT prophylaxis |
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Term
Low Molecular Weight Heparin
Mechanism and Administration |
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Definition
-Binds to antithrombin III
-then inactivates factor X and Factor II
--BLOCKS CONVERSION OF FIBRINOGEN TO FIBRIN
ADMINISTRATION: SQ ONLY
-therapeutic levels within 30minutes--good for outpatient treatment of DVT
-Adjust dose for renal patients |
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Term
| Lovenox Indications and Dosing |
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Definition
-DVT prophylaxis--30mg SQ q12
-UNSTABLE ANGINA/NQMI--1mg/kg q12h-GIVE WITH ASA
-Inpatient treatment of DVT--1mg/kg SQ q12h; 1.5 mg/kg qd
-Outpt treatment of DVT--1mg/kg q12h |
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Term
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Definition
-2915 patients evaluated at 1 year from acute coronary syndrome presentation
-15% reduction in MI
-13% reduction CABG or PCTA
-11% reduction in UA
-COST: equivocal to heparin |
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Term
| Beta Blockers-reduce contractility of the heart |
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Definition
-decrease mortality by 20%
-Limit infarct size
-Decrease incidence of VF
--Decrease sudden cardiac death
-Decrease reinfarction-when combined with thrombolytics
Lopressor
-5mg every 5minutes for a total of 15mg |
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Term
ACE Inhibitors
(angiotensin converting enzyme) |
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Definition
-limit LV dilatation
-Extensively studied in CHF-most common use
--Decreased mortality
--improved symptoms |
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Term
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Definition
-compared TPA, SK, APSAC
-N=41,299
-No difference in mortality
-increased cerebral hemorrhage with TPA
-Increased allergic reactions with SK |
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Term
Thrombolytic therapy
Prehospital Administration |
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Definition
-Field assessment is crucial
-Quick relay of information
--Decrease time to administration
-Clinical trials
-Discussion |
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Term
Thrombolytics....
....what's coming down the pike? |
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Definition
Hypothermia
-90seconds of CPR...induce hypothermia |
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