Term
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Definition
| angina or chest pain related to myocardial ischemia; associated with Ischemic Heart Dx (IHD); |
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Term
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Definition
angina or chest pain that changes or worsens to produce myocardial necrosis;
symptoms occur at rest due to plaque ruptures;
symptoms upon exertion; pt has stable plaques;
(-) Troponin;
limited necrosis --> transient occlusion;
"White clot" - platelets > fibrin;
lower mortality |
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Term
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Definition
Non-ST Elevation Myocardial Infarction;
(+) Troponin;
Subendothelium myocardium --> significant occlusion;
"White clot" - platelets > fibrin;
High mortality |
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Term
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Definition
ST Elevation Myocardial Infarction;
(+) Troponin;
Transmural wall injury --> more complete occlusion;
"Red Clot" - fibrin > platelets;
Highest mortality; |
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Term
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Definition
atherosclerosis/increased lipids;
smoking;
HTN;
"Unhealthy diet" (saturated fat, processed foods);
salt;
physical inactivity;
overweight;
EtOH intake;
Stress;
Hereditary |
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Term
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Definition
cardiogenic shock (mortality approaches 60%);
HF; valvular dysfunction;
arrhythmias; stroke;
venous thromboembolism; |
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Term
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Definition
midline anterior chest pain (>20 min, men > women);
arm, back or jaw pain;
nausea; vomiting (Elderly & women > men);
SOB; diaphoresis (sweating);
numbness or burning; |
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Term
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Definition
no classic ones;
may present with acute HF: JVD, rales, S3;
may present iwth arrhythmias: brady/tachycardia, heart block; |
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Term
| History of "Typical" Chest Pain or Angina - Clinial Presentation |
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Definition
substernal pain (squeezing, heaviness, crushing or tightness) precipitated by exertion --> relieved by rest or SL NTG;
"Typical" Angina --> 1) substernal chest pain, 2) provoked by something, 3) relieved by rest or SL NTG;
"Atypical" angina --> only 2 of above criteria;
"Non-cardiac" Chest Pain --> chest pain <1 of criteria (Dif. Diagnosis: GERD, PUD, biliary dx, sleep apnea, hyperventilation, musculoskeletal, pulmonary) |
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Term
| Laboratory Tests - Clinical Presentation |
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Definition
Obtain Biochemical Markers (Troponin, CK-MB):
(+) Troponin: STEMI and NSTEMI;
(-) Troponin: UA;
Serial blood levels obtained: ED, 2x over next 12-24 hrs;
(+) for MI: 1 Troponin value above MI decision limit (elevated for 10 days) + 2 CK-MB values above MI decision limit (elevated in blood for 48 hrs);
Troponin > or = 1.5 ng/mL --> MYOCARDIAL DAMAGE!!! |
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Term
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Definition
ST-segment elevation (>1 mm in 2 contiguous leads);
earliest sign of MI, within hourse of pain onset;
Q-waves: develop within 1-2 hrs of pain onset but may take 12-24 hrs to be noted;
Increased Biochemical Markers; |
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Term
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Definition
ECG may be normal or have:
1) ST-segment depression: suspect NSTE ACS --> Normal biochemical markers --> Unstable Angina (UA); (+) biochemical markers --> NSTEMI;
OR:
2) T-wave inversion: suspect NSTE ACS --> normal biochemical markers --> Unstable Angina (UA); if (+) biochemical markers --> NSTEMI |
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Term
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Definition
early restoration of blood flow to occluded artery: 1) MI - prevent expansion of infarct, 2) UA - prevent complete occlusion/MI;
Prevention of death or other complications;
Prevention of reocclusion of arteries;
Relief of ischemic chest discomfort; |
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Term
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Definition
| restore blood flow to an organ |
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Term
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Definition
| surgical procedure to restore blood flow to a part or organ (i.e. coronary artery or heart) |
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Term
| PCI (Percutaneous Coronary Intervention [aka Coronary Angioplasty]) |
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Definition
procedure to open coronary artery;
balloon angioplasty +/- coronary stents; |
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Term
| Coronary Artery Bypass Graft (CABG, bypass surgery) |
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Definition
| arteries or veins are grafted to coronary arteries to bypass atherosclerotic narrowings & improve blood supply to coronary circulation |
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Term
| Fibrinolytic = Thrombolytic agents |
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Definition
| drugs given to dissolve thrombus blocking coronary artery |
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Term
| General Initial Approach to Treatment |
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Definition
hospital admission;
oxygen (if saturation <90%);
continuous ECG monitoring;
frequent measurement of vital signs;
stool softeners to avoid Valsalva maneuver;
pain relief (SL NTG or Morphine) |
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Term
Risk Stratification for NSTE ACS - Calculate TIMI risk score - 1 point assigned to each PMH/Clinical Presentation finding;
Helps determine approach to treatment |
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Definition
Past Medical Hx:
- age >=65 yrs old;
- known CAD;
- use of aspirin in last 7 days;
- >= 3 Risk Factors for CAD (hypercholesterolemia, HTN, DM, smoking, family hx of premature CHD);
Clinical Presentation:
- ST-segment deviation (>= 0.5 mm);
- >= 2 episodes of chest discomfort within past 24 hrs;
- positive biochemical marker;
Risk Stratification:
1) High Risk: 5-7 points OR if pt has acute HF, DM, or CKD;
2) Medium Risk: 3-4 points;
3) Low Risk: 0-2 points;
High Risk Patients --> undergo "Early Invasive Strategy" |
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Term
| Non-Pharmacologic Therapy for STE ACS |
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Definition
fibrinolysis (alteplase, reteplase, tenecteplase) OR primary PCI is treatment of choice;
Grid:
ST-segment elevation --> initiate reperfusion therapy (fibrinolysis OR primary PCI) --> Serial troponin & CK-MB are confirmatory, continuous ECG monitoring --> Initiate adjunctive STE ACS pharmacotherapy |
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Term
| Non-pharmacologic Therapy for NSTE ACS |
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Definition
TIMI risk is Moderate to High (3-7 pts) --> PCI or CABG revascularization;
Grid:
NO ST-segment elevation --> TIMI risk score, continuous ECG, serial troponin & CK-MB ---- (initiate pharmacotherapy for NSTE ACS based on TIMI risk score) ---> 1) Low Risk (0-2 pts) --> Stress test --> (+) stress test --> angiography with revascularization (PCI or CABG), (-) stress test --> diagnosis of non-cardiac chest pain syndrome;
2) Moderate Risk (3-4 pts) --> Stress Test OR initiate Angiography with revascularization (PCI or CABG) immediately, if (+) stress test --> PCI or CABG, if (-) stress test --> diagnosis of non-cardiac chest pain syndrome;
3) High Risk (5-7 points) --> initiate Angiograpy with revascularization (PCI or CABG) immediately |
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Term
| Overall Summary for Acute Management of STE ACS |
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Definition
1) morphine (refractory angina not suppressed by SL NTG);
2) oxygen (sat <90%);
3) NTG SL (IV if indicated);
4) aspirin;
5) clopidogrel (Plavix) - always use!;
6) fibrinolytics (alteplase, tenecteplase, reteplase);
7) beta-blocker (PO or IV) |
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Term
| Overall Summary for Acute Management of NSTE ACS |
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Definition
1) morphine (refractory angina that does not respond to SL NTG);
2) oxygen (sat <90%);
3) SL NTG (IV if indicated);
4) aspirin;
5) Anticoagulation (UFH, enoxaparin, etc);
6) Fibrinolytics are CONTRAINDICATED!!! - DO NOT USE!!!;
7) beta-blocker (PO or IV) |
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Term
| STEMI Pharm Therapy upon Initial Admission |
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Definition
O2, SL NTG, Aspirin (162-325 mg chewable then 75-162 mg daily), Clopidogrel (300 mg loading dose [<75 yrs old] then 75 mg daily) ---->
1) Symptoms > 12 hrs --> PCI or CABG or fibrinolysis for selected pts, administer abciximab (ReoPro) or eptifibatide (Integrilin) at time of PCI and clopidogrel (Plavix);
2) Symptoms < or = 12 hrs --> Reperfusion Therapy -->
a) Fibrinolysis (preferred, use if pt CANNOT receive primary PCI w/in 90 min upon arrival - use alteplase) --> IV UFH OR SC enoxaparin --> beta-blocker (PO or IV), statin, ACE-I, eplerenone;
b) Primary PCI (if fibronlysis is C/I'd in pts) --> UFH (preferred) or enoxaparin + abciximab (preferred GpIIb/IIIa receptor blocker) or eptifibatide --> beta-blocker (PO or IV), statin, ACEI, eplerenone(or spiranolactone) |
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Term
| Guidelines for STEMI Pharm Therapy |
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Definition
Administer fibrinolytic with STE ACS who present to pharmacy within 12 hrs of onset of chest pain & have at least 1 mm of STE on ECG;
Primary PCI is preferred in pts w/ C/I to fibrinolytic therapy |
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Term
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Definition
Non ST-segment elevation --> O2, SL NTG, Aspirin (162-325 mg chewable then 75-162 mg daily), IV NTG, Morphine, Anticoagulant (IV UFH, SC LMWH enoxaparin, SC fondaparinux or IV bivalirudin), clopidogrel (HOLD for 5 days before procedure if pt is receiving CABG) ------------->
1) Early Invasive Strategy --> Early PCI planned (<= 12 hrs from presentation, high risk pt) --> abciximab (ReoPro) or eptifibatide (Integrilin) started at time of PCI for pts receiving UFH, LMWH (enoxaparin), or fondaparinux --> Beta-blocker, statin, ACE-I --> following PCI, continue abciximab (ReoPro) for 12 hrs, eptifibatide (Integrilin) for 18-24 hrs; D/C NTG, anticoagulant (UFH, LMWH, fondaparinux);
2) Delayed PCI Planned (>12 hrs from hospital presentation) --> beta-blocker, statin, ACE-I --> high/moderate risk pt --> initiate eptifibatide or tirofiban either before or at time of angiography/PCI; D/C NTG, IV UFH, enoxaparin, fondaparinux, and bivalirudin POST-PCI;
3) Early Conservative Strategy --> No PCI planned (low risk pt) --------->
a) beta-blocker, statin, ACEI; D/C NTG, anticoagulant --> Stress test --> (+) for ischemia --> abciximab, eptifibatide w/ UFH or enoxaparin OR bivalirudin at time of PCI;
b) recurrent ischemia --> initiate eptifibatide or tirofiban either before or at time of PCI; D/C NTG, IV UFH, enoxaparin, fondaparinux, and bivalirudin POST-PCI |
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Term
| alteplase (t-PA, Activase), reteplase (r-PA, Retavase), tenecteplase (TNK, TNKase) |
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Definition
fibrinolytics (aka thrombolytics); fibrin-specific agents --> show lower mortality than non-fibrin specific agents;
Indication in ACS:
- Hall mark therapy of STEMI
- chest (>20 min), <12 hrs since sx onset, >1 mm STE;
- chest pain (>20 min), 12-24 hrs since sx onset, >1 mm STE;
- NO BENEFIT, worse outcomes in pts w/ UA/NSTEMI;
MoA: initiates fibrinolysis by binding fibrin in a thrombus & converting plasminogen to plasmin |
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Term
| alteplase (t-PA, Activase) |
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Definition
| fibrinolytic with a difficult dosing regimen: bolus w/ CI |
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Term
| reteplase (r-PA, Retavase) |
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Definition
| fibrinolytic that uses the same dose x 2 for everyone, not based on weight |
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Term
| tenecteplase (TNK, TNKase) |
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Definition
| fibrinolytic that provides 1 single dose that IS based on WEIGHT |
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Term
| Absolute Contraindications for use of Fibrinolytics (alteplase, reteplase, tenecteplase) |
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Definition
active internal bleeding;
previous intracranial hemorrhage at any time;
ischemic stroke within 3 months;
known intracranial neoplasm (active tumor);
known structural vascular lesion;
suspected aortic dissection;
significant closed head or facial trauma within 3 months |
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Term
| Adverse Effects & Monitoring Parameters for Fibrinolytics |
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Definition
ADEs:
- bleeding;
- intracranial hemorrhage (ICH) and stroke;
MPs:
- assess for evidence of coronary reperfusion (resolution of chest pain, resolution of baseline ECG changes);
- Adverse effects (sx of bleeding, CBC, Plts, mental status q2 hrs for stroke) |
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Term
| abciximab (ReoPro), eptifibatide (Integrilin), tirofiban (Aggrastat) |
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Definition
GP IIb/IIIa receptor antagonists;
Indications in ACS:
- UA/NSTEMI w/ active ischemia or in high-risk pts;
- Pts undergoing PCI;
ACS Guidelines:
1) STEMI: abciximab (& eptifibatide) indicated for primary PCI in combo w/ ASA, clopidogrel, & UFH;
2) NSTEMI: tirofiban or eptifibatide recommended for high-risk pts NOT undergoing revascularization OR pts w/ continued ischemia despite tx w/ ASA, clopidogrel, & an anticoagulant; abciximab or eptifibatide recommended for pts under going PCI;
ADRS:
- bleeding, thrombocytopenia;
Monitoring: Hb/Hct, Plt counts, S/sx of bleeding |
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Term
| UFH (Unfractionated Heparins) |
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Definition
anticoagulant;
Indications in ACS:
- used in STE ACS, NSTE ACS, and PCI --> decreases risk of death or MI;
Dosing:
Bolus - 60-70 units/kg (max 5000 units) followed by:
Infusion - 12-15 units/kg/hr (max 1000 units/hr), Titrate to aPTT 1.5-2.5 x control, Continue for up to 48 hrs or until end of PCI;
ADRs:
- bleeding, Heparin-induced thrombocytopenia (HIT);
Monitoring:
- aPTT, PT, CBC (Hb, Hct, Plts), Sx of bleeding |
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Term
| Guidelines for UFH in ACS |
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Definition
STEMI: 1st line anticoagulant for STE ACS & PCI;
NSTEMI: preferred anticoagulant following angiography in pts undergoing CABG; Option for planned early PGI and revascularization; May be used for planned initial conservative therapy |
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Term
| Low Molecular Weight Heparins (LMWH) - enoxaparin (Lovenox), dalteparin (Fragmin) |
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Definition
equivalent or superior to UFH;
Dosing:
1 mg/kg SC q12 hrs, 1st dose may be preceded by 30 mg IV bolus (give bolus if last dose of LMWH was given >8 hrs prior to PCI);
ADRs:
- bleeding, HIT;
Monitoring:
- aPTT, PT, CBC (Hb, Hct, Plts), sx of bleeding; |
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Term
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Definition
factor Xa inhibitor;
Dosing:
- 2.5 mg SC once daily;
ADRs: bleeding;
Monitoring: aPTT, PT, CBC (Hb/Hct, plts), sx of bleeding |
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Term
| Guidelines for Enoxaparin/Fondaparinux |
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Definition
STEMI: NOT recommended in primary PCI; alternative to UFH in pts NOT undergoing reperfusion OR receiving fibrinolytics;
NSTEMI: option for planned early angiography & revascularization (enoxaparin or UFH [UFH preferred if CABG w/in 24 hrs]); May be used for planned initial conservative strategey (enoxaparin or UFH 1st line, fondaparinux in pts w/ high bleeding risk) |
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Term
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Definition
direct thrombin inhbitor;
ADRs:
- bleeding;
Monitoring:
- aPTT, PT, CBC (Hb, Hct, Plts), sx of bleeding;
Guidelines:
NSTEMI: option for planned early angiography (PCI) and revascularization with or at risk of HIT |
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Term
| Nitrates - SL NTG, IV NTG, topical/PO nitrates |
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Definition
Indication in ACS:
- STE & NSTE ACS pts presenting w/ ischemic chest pain - sx relief only, NO mortality benefit;
Use IV form for pts w/ persistent ischemic symptoms, HF, or uncontrolled BP;
C/Is: phosphodiesterase-5 inhbiitor use;
ADRs:
- HA - biggest complaint, flushing, hypotension, tachycardia;
Monitoring:
- BP, HR;
Guidelines:
STEMI or NSTEMI: use in pts w/ persistent ischemia, symptoms of acute HF, or signs of HTN |
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Term
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Definition
Indication in ACS:
- STE & NSTE ACS pts whose sx are not relieved by NTG - sx relief only, NO mortality benefit;
ADRs:
- hypotension, bradycardia, respiratory depression;
Monitoring:
- BP, HR, RR;
Guidelines:
STEMI or NSTEMI: pts whose sx are NOT relieved with NTG |
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Term
| beta-blockers - metoprolol (Lopressor, Toprol XL), carvedilol (Coreg, Coreg CR) |
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Definition
Indications in ACS:
- STE ACE & NSTE ACS in absence of C/Is'
- early administration --> decreases recurrent ischemia & reinfarction, decreases ventricular arrhythmia, decreases mortality;
- late administration --> prevent recurrent infaction & death;
ADRs:
- hypotension, acute HF, bradycardia, heart block, bronchospasm, fatigue, depression, sexual dysfunction, masks hypoglycemic symptoms except sweating;
Monitor:
- BP, HR, RR
Guidelines:
STEMI or NSTEMI: give early to ALL pts in absence of C/Is; IV forms ONLY given to HEMODYNAMICALLY STABLE pts WITHOUT s/sx of decompensated HF |
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Term
| metoprolol (Lopressor, Toprol XL) |
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Definition
Beta-blocker;
Dose:
IR form: 100 mg PO BID;
CR/XL form: 200 mg PO daily |
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Term
| carvedilol (Coreg, Coreg CR) |
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Definition
beta-blocker;
Maintenance Dose:
- 25 mg PO bid |
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Term
| Calcium Channel Blockers (CCBs) - dihydropyridines - amlodipine (Norvasc), felodipine (Plendil) - non-dihydropyridines - diltiazem (Cardizem CD, Cartia XT), verapamil (Calan SR) |
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Definition
Inidications for ACS:
- Use for STE ACS & NSTE ACS in pts w/ C/I to beta-blockers, in pts w/ recurring ischemia DESPITE beta-blocker therapy --> no benefit on mortality, little benefit beyond sx relief (excetp in cocaine-induced ACS & Prinzmetal angina) --> 2nd or 3rd line behind nitrates & beta-blockers;
ADRs:
- hypotension, bradycardia, HF, constipation;
Monitoring:
- BP, HR |
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Term
| diltiazem (Cardizem CD, Cartia XT) |
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Definition
non-dihydropyridine CCB;
Dose:
- 120-360 mg SR PO daily |
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Term
|
Definition
non-dihydropyridine CCB;
Dose:
- 180-480 mg SR PO daily |
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Term
|
Definition
dihydropyridine CCB
Dose:
- 5-10 mg PO daily |
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Term
| Long Term Goals of Therapy for ACS - Secondary Prevention Following MI |
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Definition
control modifiable risk factors (HTN, dyslipidemia, DM, smoking, weight);
prevent development of systolic HF;
preevnt recurrent MI, stroke;
prevent death, including sudden cardiac death; |
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Term
| ACC/AHA Guidelines Following a STEMI or NSTEMI |
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Definition
For ALL PATIENTS:
- ASA, beta-blocker, ACE-I, statin INDEFINITELY; SL NTG for ischemic chest discomfort; Annual inluenza vaccination;
MOST PATIENTS:
- clopidogrel (duration of therapy individualized), warfarin |
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Term
|
Definition
- decreases risk of death, recurrent MI, & stroke;
- quality care indicator for MI pts;
- continue INDEFINITELY unless C/I'd;
Dosing:
No stent - 162-325 mg PO once on hospital day 1, then 75-162 mg PO daily;
W/ Stent: 162-325 mg PO daily for 30 days in pts receiving bare metal stent, 3 months w/ sirolimus-eluting stent, and 6 months w/ paclitaxel-eluting stent, FOLLOWED BY 75-162 mg PO daily;
ADRs:
- dyspepsia, bleeding, gastritis;
Monitoring:
- S/sx of bleeding, GI upset, CBC & plts |
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Term
| Thienopyridines - clopidogrel (Plavix), prasugrel (Effient) |
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Definition
Indications for Use:
- in pts w/ documented ASA allergy;
- in addition to ASA;
Dose:
- 300-600 mg PO loading dose on hospital day 1 followed by maintenace dose of 75 mg PO daily starting on hospital day 2 - no loading dose if >75 yrs old;
Guidelines:
- administer for most pts, duration of therapy is individualized according to: type of ACS, if pt is medically treated or undergoes revascularization (PCI);
STEMI treated w/ medical management only: 14-28 days;
NSTEMI treated w/ medical management only: 9 months;
Post-PCI stented pts: 12 months;
Agent of choice for pts who have received prior fibrinolytic therapy;
Avoid with PPIs (omeprazole/esomeprazole);
ADRs: bleeding, rash, GI upset;
Monitor: S/sx of bleeding, CBC w/ plts |
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Term
|
Definition
consider anticoagulation in select pts following ACS:
- LV thrombus;
- Hx of thromboembolic dx;
- chronic atrial fibrillation; |
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Term
| ACE Inhibitors - lisinopril (Zestril, Vasotec), ramipril (Altace) |
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Definition
Indications for use:
- ALL pts following an MI - decreases mortality, decreases reinfarction, prevents development of HF;
Guidelines:
- should be administered to ALL STEMI & NSTEMI pts in absence of C/Is;
- Acute: start PO drug within 24 hrs of MI;
- Discharge: quality care indicator;
- Long term: continue indefinitely in pts w/ CAD, LVEF <40%, HTN, DM, CKD;
ADRs:
- hypotension, hyperkalemia, cough, angioedema, prerenal azotemia;
C/I:
- pregnancy, bilateral renal artery stenosis, angioedema, serum K > 5.5 mEq/L;
Monitoring: BP, SCr, K |
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Term
| Lisinopril (Zestril, Vasotec) |
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Definition
ACE-I;
Initial Dose:
- 2.5-5 mg PO daily;
Target Dose:
- 10-20 mg PO daily; |
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Term
|
Definition
ACE-I;
Initial Dose:
- 1.25-2.5 mg PO daily;
Target Dose:
- 5 mg PO BID or 10 mg PO daily; |
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Term
| ARBs - valsartan (Diovan), candesartan (Atacand) |
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Definition
Indications:
- for pts unable to tolerate ACE-I;
ADRs:
- hypotension, hyperkalemia, cough, angioedema, prerenal azotemia;
C/I's: pregnancy, bilateral renal artery stenosis, angioedema, serum K >5.5 mEq/L;
Monitoring:
- BP, SCr, K |
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Term
|
Definition
ARB;
Initial Dose:
- 40 mg PO BID;
Target Dose:
- 160 mg PO BID |
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Term
| aldosterone antagonists - spironolactone (Aldactone), eplerenone (Inspra) |
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Definition
Indications:
- STEMI in pts already on ACE-I with LVEF <40% AND either diagnosis of HF or DM --> decreases mortality;
- can be used in NSTEMI but NO decrease in mortality;
ADRs:
- hypotension, hyperkalemia, prerenal azotemia;
- S only: gynecomastia, breast tenderness & menstrual irregularities;
- E only: lower incidence of S's ADRs;
C/I's: pts w/ SCr > 2.5 mg/dL OR K >5 mEq/L;
Monitoring:
- BP, HR, SCr, K |
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Term
| Lipid Lowering Agents - statins, niacin, fibrates |
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Definition
Indications:
- HMG-CoA reductase inhibitors for ALL ACS pts --> decreases mortality, incidence of stroke;
Goal LDLs:
ACC/AHA: <100 mg/dL;
NCEP: <70 mg/dL;
Consider fibrates or niacin in pts w/ HDL <40 mg/dL and/or TG>200 mg/dL;
Guidelines:
- Statin therapy + diet for all ACS pts regardless of LDL cholesterol levels;
ADRs:
- myalgia, myopathy, elevated LFTs, rhabdomyolysis;
Monitoring:
- lipid panel, LFTs |
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Term
| Guidelines for 2ndary Prevention |
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Definition
Smoking: complete cessation;
Blood Pressure: <130/80 mmHg;
Physical Activity: 30 min/day, 7 days/wk;
Weight Management: goal BMI 18.5-24.9 kg/m^2, waist circumference <40 (men) and <35 (women);
Diabetes Management: HbA1c <7%, tight glucose control; |
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