Unit 4: ACS

S/Sx of Heart attack

chest pain that may spread to back, neck, jaw, or arms, dizziness, N/V, Rapid/irregular heartbeats, SOB, weakness

Define UA (unstable angina) and what makes it different from other ACS forms

frequent chest pain, ischemia without necrosis, no biomarkers present, no ECG abnormalities

Define NSTEMI and what makes it different from other ACS forms

form of heart attack, seen on ECG with ST segment depression or T wave inversion, troponins can be elevated, a non-transmural infarct in cardiac muscle

Define STEMI and what makes it different from other ACS forms

most severe form of heart attack, troponins elevated, seen on ECG with ST segment elevation, transmural infarct in cardiac muscle

Besides ST segment changes what can indicate an MI has occurred and when do we see it?

pathological q waves, 1-3 days after event

Most common cause of ACS

rupture of fibrous cap of plaques leading to thrombus forming and blocking off artery

How much of an artery is blocked in NSTEMI and STEMI

NSTEMI-partially blocked; STEMI- full blockage

Diagnostic biomarker for ACS and why is it important?

troponins, specfic to myocardial injury, fast time to peak levels, stay elevated after MI

Purpose of angiography in ACS

helps us identify blocked coronary arteries

Diagnosis criteria for ACS

2 of these: Elevated troponin plus defined by pt history, ST changes on ECG, imaging showing new regional wall motion abnormality

Role of TIMI scores in ACS

used in NSTEMI to select a management strategy

TIMI score low Risk

0-2

TIMI score intermediate risk

3-4

TIMI score high risk

more than 5 pts

PCI definition

a non-surgical heart procedure using stents to open blocked arteries

Acute supportive care during ACS

O2 if sat is <90%, morphine or fentanyl- analgesics, nitroglycerin- analgesic, aspirin, Beta blocker

Nitroglycerin Acute supportive care dosing

SL tab 0.3-0.4 mg q5 min for 3 or less doses

Aspirin acute supportive care dosing

162-325 mg chewed and swallowed (non-enteric coating)

How soon should Beta blocker be initiated in ACS

within 24 hrs to reduce reinfarction risk and ventricular arrhythmias

NSAIDs in ACS? (other than aspirin)

NO, CONTRAINDICATED

Selective-invasive/noninvasive Management of NSTEMI

non-invasive testing to determine if angiography needed OR treat with meds only; lower risk scores only

Routine invasive management of NSTEMI

angiography and revascularization; timing determined by risk; low- before discharge, intermediate- within 72 hrs, high- within 24 hrs

Immediate PCI STEMI management

Preferred over fibrinolytics; door to balloon time of 90 minutes

Primary fibrinolytics STEMI management

Alternative treatment- done if <12 hrs from Sx AND PCI can’t be done within 120 min, AND door to needle time < 30 min OR PT not agreeable to PCI

When is DAPT used in ACS?

ALL patients get ASA plus P2Y12 inhibitor

Aspirin loading and maintenance dose

162-325 mg; 81 mg daily

Clopidogrel loading dose and maintenance dose

600 or 300 mg once; 75 mg daily

Prasugrel loading and maintenance dose

60 mg once, 10 mg daily; 5 mg daily if <60kg or over 75 yo

Ticagrelor loading and maintenance dose

180 mg once, 90 mg BID for 12 mo then 60 mg BID

First line P2Y12 for ACS + PCI

ticagrelor or prasugrel

First-line P2Y12 for non-invasive NSTEMI

ticagrelor only

Parenteral Anticoagulation in ACS: What and when

UFH only while in hospital

Parenteral anticoagulation PCI alternatives and when to stop

Enoxaparin/bivalirudin; stop after PCI

Parenteral anticoagulation non-PCI alternatives and when to stop

Enoxaparin/fondaparinux; stop after 2-8 days or at discharge

Which parenteral anticoagulations are IV

UFH and bivalirudin

How long is DAPT with ASA + P2Y12 continued after event?

1 year

IF DAPT score is what do you continue P2Y12 for more than 1 year?

greater than or equal to 2

When do we continue BB indefinitely after ACS?

if HFrEF (LVEF <40%)

What statins should a patient be initiated or increased to after ACS?

HI-statin; Atorva 40/80, Rosuva 20/40

Should ACEi or ARB be initiated or continued after ACS?

Yes, to reduce risk of all-cause death and MACE

Should aldosterone antagonist be initiated/continued after ACS?

Yes for those whose LVEF <40% and symptomatic HF or DM

Non-pharm lifestyle modifications after ACS

Improved diet- less fatty things, fruits, veggies; exercise- up to 150 min/week, will work up to that