PATHO/PCT LECTURE 51&52 DUNN (10/10&11) [EXAM 4]

what are clinical manifestations of ACS

sudden chest pain unrelieved by rest and nitroglycerin, shortness of breath, N/V, lightheadedness, sweating, increased or decreased HR & BP and increased RR

in what patients do ACS symptoms vary such as having atypical or silent sx

women, elderly, and diabetics

for PQRST in ACS = P - precipitating factors and palliative measures -> ??

· Typically occurs at rest and not always relieved by rest or SL NTG

for PQRST in ACS = Q - quality of pain -> ??

· Heavy, squeezing, crushing, or burning (may be mistaken as indigestion)

for PQRST in ACS = R - region of pain and radiation of pain -> ??

· Substernal region; radiates to arms, abdomen, back, lower jaw, and neck

for PQRST in ACS = S - severity of pain -> ??

· Worst pain ever experienced - more severe than angina (8-10/10)

for PQRST in ACS = T - temporal pain -> ??

· Lasts > 20 minutes (longer than angina) and is more frequent

when presenting with signs and sx of ACS how fast should immediate assessment happen

within 10 minutes

what labs and tests should be initially run when presenting with signs and sx of ACS

EKG within 10 minutes, cardiac enzyme lab, electrolytes (K or Mg), CBC, lipids, BUN/SCr, glucose, coags, chest x-ray

how many cardiac enzymes should occur over first 12-24 hours

3-4: one at sx onset or presentation to ED and one 3-6 hours after admission and additional measurements q6h to ensure trending down if elevated

is one negative troponin level enough to clear someone of MI

no, get 2nd and if that is negative then we feel better...if catch MI really early, don't have time to see troponin elevation

what is emergent care that should be taking place when someone presents with signs and symptoms of ACS

-IV access

-Continuous cardiac monitoring

-ASA (chewable tablets STAT)

-NTG (can take as many SL as tolerated)

-Oxygen if O2 sats < 90%

when present with ACS what is mnemonic for initial acute supportive care

MONA-B

what is goal of TIMI score with STEMI reperfusion

TIMI 3 flow = complete reperfusion

for STEMI, what treatment approach is preferred and how quickly

primary PCI with or without stenting within 90 minutes

if cannot reach PCI location within ________ minutes, what should be done and how quickly

within 120 minutes...fibrinolysis within 30 minutes

what are the two branches of NSTEMI treatment approach

ischemia guided management (conservative - only PCT) and invasive (PCI) approach

do STEMI or NSTEMI get risk assessment

only NSTEMI

based on what TIMI score do NSTEMI patients get early invasive approach

medium (3-4 pts) and high risk (5-7 pts)

what are pts with TIMI risk score assessment

age ≥ 65, 3 risk factors for CAD (hypercholesterolemia, HTN, DM, smoker, family history of premature CHD), known CAD, use of ASA within past 7 days, ST segment depression, ≥ 2 episodes of chest discomfort in past 24 hours, positive cardiac enzymes

what do low risk (0-2 pts) TIMI risk score patients get

ischemia guided approach

symptom control (MONA-B) should ideally be done within what time frame??

within 30 minutes

what is the M of MONA-B

morphine

what is the general MOA of morphine

arterial and venous vasodilation

what are AE of morphine

hypotension, respiratory depression, N/V, constipation

is morphine a class I recommendation for NSTEMI?

no (it is for STEMI still due to chest pain severity)

what does the O in MONA-B stand for

oxygen

when should ACS patients receive oxygen

if O2 sats < 90% (maintain > 90%)

what is the N in MONA-B

nitroglycerin

who should receive IV NTG

hypertensive patients (especially if hypertensive crisis), HF, ongoing ischemia, refractory angina

what are AE of NTG

hypotension, tachycardia, HA/flushing, tolerance

what are contraindications for NTG

PDE-5 inhibitor, hypotension - SBP < 90mmHg

if using PDE-5 inhibitor for pulmonary HTN (dosed not prn) what should we do about giving NTG

don't give NTG try something else

what is the A in MONA-B

aspirin/antiplatelet

what is the LD of aspirin (MONA-B)

chew 81mg tablet x4

what is the maintenance dose of aspirin (MONA-B)

81-162mg/day indefinitely

what are AE of aspirin

GI upset and bleeding

what are contraindications to aspirin

aspirin allergy (use clopidogrel) and active bleeding

what does the B stand for in MONA-B

beta blocker

what beta blocker should be used in MONA-B

metoprolol (prefer PO over IV)

what are contraindications for metoprolol use in MONA-B

bronchospastic disease, high degree heart block, symptomatic bradycardia (<60bpm), hypotension (SBP < 90), risk factors for cardiogenic shock

what is monitoring for metoprolol in MONA-B

goal HR of 50-60bpm and monitor BP

what is another agent that could be used outside of MONA-B

non-dCCB if contraindication to beta blocker (diltiazem and verapamil) except if HF

these may be indicated in STEMI patients who present within 12 hours of sx onset and if primary PCI cannot be performed within 120 minutes

fibrinolytics

fibrinolytics for STEMI are contraindicated with what risk??

high bleeding risk

in patient > 75 years, do we always use fibrinolytics

not always, have risk/benefit convo with patient and family

what is general MOA of fibrinolytics

will cause clot dissolution and restoration of blood flow to ischemic tissues

what are important absolute contraindications for fibrinolytics

any prior ICH

known malignant intracranial neoplasm

ischemic stroke within 3 months

suspected aortic dissection

active bleeding or bleeding predisposition (diathesis)

what are relative contraindications to fibrinolytics

BP > 180/100 on presentation

current anticoagulant use in therapeutic dose

pregnancy

recent internal bleeding

T/F: Alteplase, reteplase, Tenecteplase are all comparable in usage for STEMI (Tenecteplase has the highest fibrin specificity of the three)

true

what should be monitored with fibrinolytics

· EKG

· BP

· Sites of bleeding

· CBC

· Mental status q2h

· Need baseline aPTT and INR

what are some advantages of fibrinolysis vs PCI for STEMI

· More universal access

· Short time to treatment

· Results less dependent on physician experience

· Lower system costs

what are disadvantages of fibrinolytics vs PCI

· ICH and major bleeding are most serious side effects -Risk factors included older age and uncontrolled HTN

· No TIMI-3 flow in 30-50% of patients - Even with TIMI-3 flow, abnormal reperfusion in 16-30% of patients

what do we need alongside fibrinolytics

dual anti platelet therapy and one anticoagulant

what are antiplatelet options for combo with fibrinolysis

ASA 81mgx4 LD then 81mg/day indefinitely

clopidogrel/plavix

what is dosing for clopidogrel used with fibrinolytics

LD of 300mg + maintenance dose of 75mg

when would we not give 300mg LD of clopidogrel in fibrinolysis

if > 75 years

T/F: clopidogrel is the ONLY P2Y12 that can be used for fibrinolysis due to lowest bleeding risk in the class

true

what are anticoagulant options for use alongside fibrinolytics

UFH x 4h (60u/kg with max of 4000u + 12u/kg/hr with max of 1000u/hr)

LMWH x8 days or until d/c

Enoxaparin

Fondaparinux

what is dosing of enoxparin when used with fibrinolytics? what about if CrCl < 30mL/min

1mg/kg BID; 1mg/kg QD

what is dosing of fondaparinux if used with fibrinolytics

2.5mg QD x 8days or until d/c

when is invasive strategy for STEMI (PCI) preferred

o Skilled PCI lab available (get to ED within 120 minutes, get to cath lab from door within 90 minutes)

o High risk for STEMI (shock)

o Contraindications to fibrinolytic (such as ICH history)

o Dx of STEMI in doubt

when is fibrinolysis for STEMI preferred

o If invasive strategy not an option

Delay to invasive strategy (cannot get there within 120 minutes)