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ACS
Overview
90
Astronomy
4th Grade
02/09/2014

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Cards

Term
should be determined within 10 minutes; helps determine location of infarct
Definition
Electrocardiogram
Term
Infarct location: Left Anterior Descending (LAD) Artery
Definition
highest rate of mortality (~10%); heart failure may develop
Term
Infarct location: Circumflex (Cx)
Definition
Lateral wall of LV
Term
Infarct location: Right Coronary Artery (RCA)
Definition
bradycardia and heart block
Term
no increase in cardiac enzymes (CK-MB, Troponin); 10-20% risk of progression for Acute MI; coronary occlusion lasts < 20 minutes; ST-segment depression or T-wave inversion
Definition
Unstable Angina
Term
elevated cardiac enzymes; ST-segment depression or T-wave inversion; coronary occlusion lasts 20 minutes to 2 hours
Definition
Non-ST Elevation MI (NSTEMI)
Term
elevated cardiac enzymes, ST-segment elevation, remains occluded without reperfusion
Definition
ST Elevation MI (STEMI)
Term
Rise: 3-6 H; Peak 12-24 H; Persistence 2-3 days
Definition
CK-MB (0-6%)
Term
Rise: 2-6 H; Peak: 12-48 H; Persistance: 10-14 days
Definition
Troponin-T variable
Term
Rise: 2-6 h; Peak: 18-24 H; Persistance: 5-7 days
Definition
Troponin-I variable
Term
at least 65 yo; at least 3 risk factors (smoking, diabetes, hypertension, hyperlipidemia, family history of CAD); prior history of CAD; aspirin use in past 7 days; St-segment depression or transient (<20 min) elevation; cardiac enzyme increased
Definition
TIMI Risk Stratification
Term
TIMI score 0-1
Definition
Low Risk; outpatient
Term
TIMI score 3-4
Definition
Intermediate Risk; admit to step-down
Term
TIMI score 5-7
Definition
High Risk; admit to CCU
Term
General ACS Treatment Goals
Definition
minimize infarct size; salvage ischemic myocardium; eliminate and relieve s/s of angina; prevent or minimize complications; prevent mortality
Term
Timeline for STEMI: 0-10 minutes
Definition
Prompt assessment and general treatment
Term
Timeline for STEMI: 0-30 minutes
Definition
Thrombolytic Rx Door to Drug
Term
Timeline for STEMI: 0-90 minutes
Definition
Cath Lab Door to Balloon
Term
Pre-Hospital/Early ER Care
Definition
obtain IV access; ECG; Draw labs; MONA
Term
Treatment of chest pain; peripheral arterial dilation; slows heart rate; decreases anxiety, decreases myocardial oxygen demand
Definition
Morphine 2-8 mg IV q 5-15 min
Term
administer to patient <90%; reasonable for all patients for first 6 hours
Definition
Oxygen 2-4 L/min by nasal cannula
Term
relieves ischemia via coronary/peripheral vasodilation; if symptoms persist IV infusion indicated
Definition
Nitroglycerin 400 mcg SL or spray Q 5 min (total 3 doses)
Term
Avoid nitrates in patients:
Definition
SBP < 90 mmHg or greater than or equal to 30 mmHg BELOW baseline; severe bradycardia; tachycardia; suspected right ventricular infarction
Term
Nitroglycerin side effects
Definition
hypotension and headache
Term
produces rapid antithrombotic effect; should be given PROMPTLY and continued INDEFINITELY
Definition
Aspirin: initial dose 162-325 mg (CHEW, non-enteric preferred)
Term
for ASA intolerant patients
Definition
Clopidogrel
Term
40% decreased mortality (NSTEMI and STEMI)
Definition
early beta blockers
Term
early administration of beta blockers
Definition
reduces likelihood of: ventricular arrhythmias, recurrent ischemia, re-infarction, mortality in pts with AMI
Term
Use B1 selective agent; Goal HR 60-90 beats/min
Definition
Metoprolol tartrate 25-50 mg ever 6-12 hours
Term
Beta Blocker Contraindications
Definition
HR < 60 bpm; systolic BP < 100 mmHg; signs of sock; 2nd or 3rd degree heart block; PR interval > 0.24 seconds
Term
Use in the first 24 hours for STEMI pts with anterior infarct or HF with EFs < 40%; reasonable for all STEMI patients with no CIs
Definition
ACE-I
Term
patient has history of accelerating ischemic symptoms
Definition
unstable angina high risk
Term
patient has prior MI, PVD, CVA, CABG
Definition
unstable angina intermediate risk
Term
patient has ongoing pain at rest (>20 minutes)
Definition
unstable angina high risk
Term
patient has pain > 20 minutes at rest (resolves)
Definition
unstable angina intermediate risk
Term
patient's pain is new onset < 20 minutes
Definition
unstable angina low risk
Term
Patient's ECG: ST-segment changes
Definition
unstable angina high risk
Term
Patient's ECG: T-wave inversion
Definition
unstable angina intermediate risk
Term
Patient's ECG: unchanged
Definition
unstable angina low risk
Term
Patient's cardiac markers: marked increase
Definition
unstable angina high risk
Term
Patient's cardiac markers: slight increase
Definition
unstable angina intermediate risk
Term
Patient's cardiac markers: normal
Definition
unstable angina low risk
Term
Definite ACS with continued ischemia
Definition
High Risk Unstable Angina/NSTEMI
Term
Likely or Definite ACS
Definition
Intermediate Risk Unstable Angina/NSTEMI
Term
Possible ACS
Definition
Low Risk Unstable Angina/NSTEMI
Term
High Risk Unstable Angina/NSTEMI
Definition
ASA and Clopidogrel (DAT) plus +/- GP IIb/IIIa plus UFH/LMWH x 48 hours
Term
Intermediate Risk Unstable Angina/NSTEMI
Definition
ASA and Clopidogrel (DAT) plus GP IIb/IIIa plus UFH/LMWH x 48 hours
Term
Low Risk Unstable Angina/NSTEMI
Definition
ASA
Term
PCI eligibility
Definition
STEMI pts; high risk unstable angina/NSTEMI (persistant symptoms, recurrent ischemia, depressed LV function, widespread ECG changes, prior AMI, PCI, CABG)
Term
Bare Metal Stents (BMS)
Definition
easy placement, less expensive, early onset re-stenosis, smooth muscle proliferation
Term
Drug Eluting Stents (DES)
Definition
decreased need for revascularization, late onset thrombosis, estimate 60-70% rate of restenosis if anti-platelets discontinued, Class III (harm) do NOT use if pts can't comply with DAP therapy
Term
Therapy for PCI patients
Definition
Anticoagulants (heparin, LMWH, Bivalirudin); Antiplatelets (Aspirin, clopidogrel, GP IIb/IIIa inhibitors)
Term
Does not actively lyse, but inhibits further thrombogenesis; useful in PCI patients
Definition
Unfractionated heparin (UFH)
Term
PCI patients if GP IIb/IIIa planned
Definition
UFH 50-70 U/kg IV bolus, titrate to achieve ACTs
Term
PCI patients without GP IIb/IIIa
Definition
UFH 70-100 U/kg IV bolus and titrate
Term
For PCI patients: anticoagulants
Definition
LMWH (compared to UFH) more effective but avoid in renal impaired or if surgery is planned
Term
Preferred in patients with high risk of bleeding
Definition
Bivalirudin (direct thrombin inhibitor) 0.75 mg/kg IV bolus the n1.75 mg/kg/hr
Term
Not recommended with IIb/IIIa inhibitor in most patients; monotherapy in PCI patients (decreased adverse events/major bleeds)
Definition
DTI: Bivalirudin
Term
Blocks ADP receptors, prevents fibrinogen binding --> decreased platelet adhesion/aggregation
Definition
Clopidogrel: 600 mg loading dose then 75 mg daily
Term
Clopidogrel
Definition
used in combo with 81-325 mg ASA daily for DAT; can be used in ASA intolerant patients
Term
Relatively new thienopridine agent; quicker onset than clopidogrel, better platelet inhibitor, increased bleeding risk but decreased major CV events
Definition
Prasugrel (Effient) 60 mg load, then 10 mg daily; use 5 mg daily if < 60 kg not rec for age > 75 years
Term
not a thienopyridine, binds reversibly to P2Y12 platelet receptor; more rapid onset vs. clopidogrel; use with 75-100 mg aspirin
Definition
Ticagrelor Load 180 mg then 90 mg twice daily
Term
block the fibrinogen binding and platelet aggregation
Definition
GPIIb/IIIa inhibitors
Term
Used in NSTEMI pts on UFH with continuing ischemia, increased troponin, or other high risk factors not previously treated with bivalirudin and not adequately managed with clopidogrel; reasonable to use in high risk pts on clopidogrel or pts undergoing PCI
Definition
GP IIb/IIIa inhibitors
Term
chimeric Fab antibody frag, half life 30 min; no dose adjustment for renal dysfunction
Definition
Abciximab (GP IIb/IIIa inhibitor)
Term
cyclic heptapeptide; 2.5 hr half life; Dose adjust for renal dysfunction
Definition
Eptifibatide (GP II/IIIa inhibitor)
Term
non-peptide, half life 2 hours, dose adjust for renal dysfunction
Definition
Tirofiban (GP II/IIIa inhibitor)
Term
Should be initiated or continued in all patients with STEMI and no contraindications
Definition
high dose statins
Term
Selection of Reperfusion Strategy: ideally inside 3 hrs can go to 12 hrs
Definition
Fibrinolytics
Term
Section of Reperfusion Strategy: if diagnosis of NSTEMI vs STEMI is in doubt or high risk for STEMI, use PCI
Definition
DO NOT use fibrinolytics in NSTEMI
Term
enhance the body's natural fibrinolytic system to break down clots
Definition
Thrombolytic agents
Term
If not CI, should be given to pts with STEMI and onset of ischemic symptoms within 12 hours when it is anticipated that primary PCI cannot be performed within 120 min of first medical contact
Definition
fibrinolytics
Term
ABSOLUTE CIs for Thrombolytic Therapy
Definition
previous hemorrhagic stroke at any time or other strokes within 1 yr, known intracranial neoplasm, active internal bleeding, suspected aortic dissection, severe HTN (>180/110)
Term
RELATIVE CIs for Thrombolytic Therapy
Definition
hx of prior CVA; active PUD, or severe HTN; high likelihood of left heart thrombus; current use of anticoagulants, known bleeding diathesis or recent internal bleeding; recent trauma or major surgery; noncompressible vascular punctures; prior exposure or allergic rxn to streptokinase; pregnancy
Term
Thrombolytics AEs
Definition
bleeding, hypotension, embolization of plaque/clot, reperfusion arrhythmias; reocclusion
Term
naturally occurring enzyme produced by recombinant DNA technology; cleaves plasminogen bond- binding site for fibrin, preferentially binds and lyses clot vs. circ plasminogen
Definition
Alteplase (tPA)
Term
genetically modified tPA, convenient single IV bolus over 5-10 min based on weight; equivalent efficacy to TPA with less bleeding based on ASSENT-2
Definition
Tenecteplase (TNK)
Term
very similar to tPA; two 10U bolus doses 30 min apart
Definition
Reteplase (r-PA)
Term
Adjunctive Therapy to Fibrinolytics
Definition
anti-platelet therapy (ASA, Clopidogrel, Prasugrel); Anti-coagulation (UFH, LMWH)
Term
Drugs at 24 Hour Mark
Definition
aspirin; clopidogre; beta blocker; ACEI (after stabilization of BP)
Term
Complications of AMI
Definition
pump failure (CHF)- remodeling; recurrent ischemia and re-infarction; arrhythmias; death
Term
Secondary Prevention Drugs for the Rest of Your LIfe
Definition
AABCC (aspirin, ACEI, BB, Cholesterol Lowering Agent, Clopidogrel)
Term
Low dose for all ACS patients indefinitely; high dose may be used for several months immediately after stent placement
Definition
aspirin
Term
prevents ventricular remodeling and development of heart failure; treat post-MI indefinitely; reasonable to use in all other patients
Definition
ACE Inhibitor
Term
helps prevent recurrent MI and sudden death; start and continue for 3 years in all patients
Definition
Beta Blocker
Term
First like in heart failure patients, shown to decreased mortality
Definition
Metoprolol succinate and carvedilol
Term
All ACS patients with LDL level >70mg/dL should receive at discharge
Definition
statin
Term
1 month minimum for medically managed; 12 months for PCI/stent patients; consider even longer therapy in patients with DES placement
Definition
Thienopyridine (Clopidogrel)
Term
Cornerstone of therapy for AMI
Definition
reperfusion (mechanical or pharmacologic)
Term
Immediate general treatment
Definition
"MONA greets all her patients at the door"
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