Term
| How does a myocardial infarction occur? |
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Definition
| When a plaque ruptures, a thrombus is formed and gets so big that it obstructs blood flow. Total occlusion causes cells to die. |
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Term
| What is the difference between Unstable Angina and Acute MI? |
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Definition
Unstable Angina is self resolving, death does not occur.
In an MI, body is unable to halt thrombus progression, cell death and ventricular remodeling occurs. |
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Term
| What are classical signs and symptoms of an MI? |
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Definition
- N/V and SOB, arm/back/jaw pain
- NO relief with NTG
- Lasts > 30 minutes
- JVD and rales, possible arrhythmia |
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Term
| How is an initial diagnosis made and confirmed of a STEMI vs. NSTEMI? |
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Definition
- Made: Stemi has a very obvious ST elevation, NSTEMI has no ST elevation or T wave inversion.
- Positive Troponin I or 2 CK-MB levels |
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Term
| What are the timing goals for reperfusion? |
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Definition
30 minutes door to thrombolytic
90 minutes door to PCI |
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Term
| What is the dosing of morphine for initial management of STEMI/NSTEMI and why is it given? |
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Definition
| Morphine sulfate 2-4 mg IV q5-10 min to relieve pain/anxiety and for vasodilation |
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Term
| What and how are nitrates used for the initial management of STEMI/NSTEMI? |
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Definition
Give first SL, if symptoms persist give topically, if persists give IV:
must be uptitrated every hour.
- AE: Hypotension and HEADACHE. Monitor BP, HR, pain and headache |
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Term
| How should Beta Blockers be used for the initial management of STEMI/NSTEMI? |
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Definition
| - Initiate beta blocker within 24 hours of admission.
When to avoid: Age >70, SBP >120, 60 |
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Term
| When should CCBs be used in STEMI/NSTEMI, and which CCBs? |
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Definition
Used when intolerant or unresponsive to beta blockers, or COPD rxn. CANNOT use in decompensated HF.
- Only use non-DHP CCBs Verapamil and Diltiazem |
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Term
| What initial aspirin therapy do patients receive for MI? |
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Definition
| CHEW a 325 mg ASA x1 dose, give plavix if intolerant. |
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Term
| Why is PCI preferred to thrombolytics? |
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Definition
| PCI can open 90% occluded arteries whereas thrombolytics can only open 60%, hemorrhage risk w/ thrombolytics |
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Term
| What is an angiogram? How is this used to remove blockages? |
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Definition
| A catheter is threaded through the femoral artery, dye is injected to visualize occlusions. A balloon catheter can then be threaded with or without a stent |
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Term
| In STEMI/NSTEMI, how are PCI patients anticoagulated? |
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Definition
- UFH 60 units/kg (max 5000), 12 units/kg/hr drip (max 1000). Check aPTT
- LMWH 1 mg/kg SQ q12h. Monitoring unnecessary, decreased chance of HIT
- Do not use together
- Bivalirudin used sometimes, not with Gp2b3a inhibitors
- Arixtra used rarely |
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Term
In STEMI, what Gp2b3a inhibitors are used?
Are they used after PCI or thrombolytics? |
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Definition
- Abciximab/Reopro - cannot use with thrombocytopenia, bleeding, STROKE
- Eptifibatide/Integrilin - more contraindications
- Only used in PCI patients |
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Term
| What antiplatelet options are used in PCI? |
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Definition
- Plavix/Clopidogrel - 600 mg loading, then 1 qd x12 months.
- Effient/ Prasugrel - 60 mg loading, then 1 qd x12 months. Less interactions, but weight dependent. DO NOT USE IN STROKE, can cause angioedema
- Ticagrelor/Brilinta - 180 mg loading, then 90 mg q12h. ASA can reduce effectiveness, do not use in bleeding/liver impairment. 3A4 inhibitor, increases Statin conc. |
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Term
| How is Plavix metabolized and what interactions does it have? |
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Definition
| Lots of CYP enzymes, primarily CYP2C19. PPIs, specifically omeprazole. 3A4 inhibitors (FAB4) - no active drug, 3A4 inducers (carb, phenyt, phenobarb) - too much |
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Term
| How is ASA used to treat PCI patients? |
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Definition
161-325 mg for:
- 1 month for bare metal
- 3 months for sirolimus stent
- 6 months for paclitaxel stent
Then 75-162 mg FOREVER |
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Term
When are thrombolytics indicated?
How are they used?
How are they anticoagulated? |
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Definition
Only in STEMI
Alteplase - also used for stroke -- can lead to intracranial hemorrhage
- Monitor S/S of bleeding, BP, mental status
- Only use Heparin - 60 unit/kg bolus and 12 unit/kg/hr
- Plavix - 300 mg loading dose then 1 tab po QD x 12 months |
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Term
| What drugs are used in long term management of STEMI/NSTEMI patients? |
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Definition
- Beta blockers used indefinitely
- AceI used indefinitely w/ patients in HF, HTN, Diabetes, CKD
- Eplerenone maybe
- LDL goal <100, get a statin |
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Term
| How is pain managed in ACS patients? |
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Definition
NOT with NSAIDS - vasoconstrictor and fluid retention, displaces ASA
Use Tylenol and ASA, low dose narcotics |
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Term
| How is risk assessed for UA/NSTEMI patients? |
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Definition
7 point scoring system
gives a risk of death |
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Term
How is anticoagulation strategy for PCI patients different for NSTEMI?
Medically managed patients? |
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Definition
Use an ADP antagonist OR a GP2b3a inhibitor. Eptifibatide is first choice, but not necessary
Medically managed patients just get Plavix |
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Term
| How are NSTEMI patient's antithrombotic therapy managed? |
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Definition
- Medically managed - ASA 81 mg FOREVER and Plavix 75 mg for one month or up to one year
- Bare metal stent - ASA 162/325 mg x1 month then 81 mg FOREVER, Plavix 75 mg or Effient 10 mg for 1 year
- Drug Eluting Stent - ASA 161/325 mg for 3-6 months, then 81 mg FOREVER, Plavix or Effient for 12 months |
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Term
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Definition
- 70% obstruction in many arteries or poor LV function
- Major surgery, must D/C Plavix 5 days before |
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Term
| What polymorphisms exist in the 2C19 gene and how do these effect Plavix? |
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Definition
2C19*1 - normal
2C19*2 and *3 - Decreased activity, decreased production of active metabolite and no anticoagulation. Can be hetero or homozygous
2C19*17 - Increased activity - Ultra-rapid metabolizers, increased anti-coagulation
Asians have higher ratio of loss of function
- *2/*3 and *17 cancel each other out, equal to wild type |
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Term
How are *2/*3 carriers affected when taking plavix?
What about *17?
What is the solution? |
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Definition
Increased risk of adverse cardiovascular events and stent thrombosis with clopidogrel
*17 - increased risk of bleeding
Solution: If indicated, switch to Effient (PCI) or Brilinta (ACS) |
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Term
| What is the purpose of using stents in patients with ACS? |
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Definition
Reduces complications and risk of restenosis
Drug eluting reduces proliferation of cells, reduce restenosis by 50% |
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Term
| What kind of procedure is used to place a stent? |
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Definition
| Threaded along a catheter through the femoral or radial artery, guide wire run through coronary arteries. Artery is dilated w/ a balloon and stent placed. Performed under local anesthesia |
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Term
| What complications occur with stents? |
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Definition
- New MI
- Coronary dissection
- Stent thrombosis due to stent placement and non-compliance
- Restenosis - artery closes again |
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