Term
| should be determined within 10 minutes; helps determine location of infarct |
|
Definition
|
|
Term
| Infarct location: Left Anterior Descending (LAD) Artery |
|
Definition
| highest rate of mortality (~10%); heart failure may develop |
|
|
Term
| Infarct location: Circumflex (Cx) |
|
Definition
|
|
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
|
|
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
|
|
Term
| Rise: 3-6 H; Peak 12-24 H; Persistence 2-3 days |
|
Definition
|
|
Term
| Rise: 2-6 H; Peak: 12-48 H; Persistance: 10-14 days |
|
Definition
|
|
Term
| Rise: 2-6 h; Peak: 18-24 H; Persistance: 5-7 days |
|
Definition
|
|
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
|
|
Term
|
Definition
|
|
Term
|
Definition
| Intermediate Risk; admit to step-down |
|
|
Term
|
Definition
|
|
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
|
|
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
|
|
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
|
|
Term
| 40% decreased mortality (NSTEMI and STEMI) |
|
Definition
|
|
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
|
|
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
|
|
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
|
Definition
|
|
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
|
|
Term
| Definite ACS with continued ischemia |
|
Definition
| High Risk Unstable Angina/NSTEMI |
|
|
Term
|
Definition
| Intermediate Risk Unstable Angina/NSTEMI |
|
|
Term
|
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
|
|
Term
|
Definition
| STEMI pts; high risk unstable angina/NSTEMI (persistant symptoms, recurrent ischemia, depressed LV function, widespread ECG changes, prior AMI, PCI, CABG) |
|
|
Term
|
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
|
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
|
|
Term
| Blocks ADP receptors, prevents fibrinogen binding --> decreased platelet adhesion/aggregation |
|
Definition
| Clopidogrel: 600 mg loading dose then 75 mg daily |
|
|
Term
|
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
|
|
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
|
|
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
|
|
Term
| Selection of Reperfusion Strategy: ideally inside 3 hrs can go to 12 hrs |
|
Definition
|
|
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
|
|
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
|
|
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
|
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
|
|
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
|
|
Term
| very similar to tPA; two 10U bolus doses 30 min apart |
|
Definition
|
|
Term
| Adjunctive Therapy to Fibrinolytics |
|
Definition
| anti-platelet therapy (ASA, Clopidogrel, Prasugrel); Anti-coagulation (UFH, LMWH) |
|
|
Term
|
Definition
| aspirin; clopidogre; beta blocker; ACEI (after stabilization of BP) |
|
|
Term
|
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
|
|
Term
| prevents ventricular remodeling and development of heart failure; treat post-MI indefinitely; reasonable to use in all other patients |
|
Definition
|
|
Term
| helps prevent recurrent MI and sudden death; start and continue for 3 years in all patients |
|
Definition
|
|
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
|
|
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" |
|
|
