Acute Coronary Syndrome PDF

Acute Coronary Syndrome C. Mateo Garcia Drugs ● ● ● ● ● Oxygen Aspirin ASA Nitroglycerin Morphine Sulfate Beta Blockers ○ Metoprolol ○ Atenolol ○ Esmolol ○ Labetalol (Normodyne, Trandate) ● ● ● ● ● ● ● Clopidogrel (Plavix) Heparin (unfractionated heparin) Enoxaparin (lovenox) Bivalirudin (angio...

Acute Coronary Syndrome C. Mateo Garcia Drugs ● ● ● ● ● Oxygen Aspirin ASA Nitroglycerin Morphine Sulfate Beta Blockers ○ Metoprolol ○ Atenolol ○ Esmolol ○ Labetalol (Normodyne, Trandate) ● ● ● ● ● ● ● Clopidogrel (Plavix) Heparin (unfractionated heparin) Enoxaparin (lovenox) Bivalirudin (angiomax) Abciximab (ReoPro) Tirofiban (Aggrastat) ACE - Inhibitors: ○ CAptopril ○ Enalapril ○ Lisinopril ○ ramipril ● ● HMG coenzyme A statins ○ Atorvastatin (Lipitor) ○ Fluvastatin (Lescol) ○ Lovastatin (Mevacor) ○ Pravastatin (pravachol) ○ Rosuvastatin (Crestor) ○ Simvastatin (Zocor Fibrinolytic: ○ Tissue Plasminogen activator (tPA) Aunt Angi Angina ● ● ● ● ● ● Chest discomfort, pressure, and or pain that is provoked. Occurs when oxygen demand > oxygen supply. Resolves typically within 5-10 minutes after rest and or O2 supplementation. Rarely ever lasts longer than 20 minutes. Resolves with rest or oxygen supplementation Indicates underlying stenosis of one or more coronary arteries. Unstable Angina ● ● ● ● Chest pain, pressure, or discomfort that is unrelated to exertion. Results from partial thrombus Chest pain is > in duration than typical angina. Typically viewed as a precursor or warning sign to NSTEMI or STEMI. Medications for UA/NSTEMI Nitroglycerin Beta Blockers Clopidogrel Heparin/LMWH Glycoprotein IIb/IIIa inhibitor ACE inhibitor/ ARB Statin NSTEMI (non ST Elevation MI) ● Acute Cardiac ischemia affecting the myocardium. ● Indicated by elevated cardiac enzymes (CK-MB, or Troponin~i). ● NO ST Elevation on EKG ● Treated similar to STEMI however less emergent time frame to cath Lab. STEMI ● ● ● ● ● ST Elevation on EKG Indicates transmural Ischemia This is a TIME SENSITIVE emergency. Many systems have a STEMI Alert system. This allows transmission of EKG, preparation of receiving facilities CAth Lab Etc. Time is TISSUE. STEMI Medications Reperfusion strategy Beta Blockers Clopidogrel Heparin ACE Inhibitors/ ARB Statin Oxygen ● ● ● ● Odorless, tasteless gas 21% in atmosphere Give if hypoxemic Some studies have shown that may not be beneficial or recommended in ACS without hypoxia. Aspirin (ASA) ● ● ● ● ● Acetylsalicylic Acid Cox - 1 and Cox 2 inhibitor Considered an anti-platelet aggregation drug. Makes platelets essentially more slippery. Lasting effect for life of the platelet 710 days. Nitroglycerin ● ● ● ● ● ● Nitroglycerin breaks down to Nitric Oxide (NO) Results in smooth muscle relaxation Dilates peripheral veins and arteries Reduces preload and LV systolic wall tension, reducing afterload Also has effect on platelet aggregation and can inhibit further platelet adhesion. Contraindications: sildenafil (Viagra) or tadalafil (Cialis). Inferior/Right sided infarct PLEASE no NITRO for Inferior STEMI - Very PRELOAD dependent. Morphine Sulfate ● ● ● ● ● Opioid analgesic Typically given for Refractory Angina if non-responsive to Nitro per your book Considered a AHA Class - 1 Recommendation for STEMI related pain. Class - IIa recommendation for UA/ NSTEMI. USe with caution in INferior or Right sided MI 2/2 preload reduction. Contraindications: Respiratory depression, shock, allergy, relative contraindications, hypotension, RV dysfunction, respiratory insufficiency. Morphine Vs Fentanyl ● Fentanyl is a safe and appropriate first line alternative to ongoing chest pain Beta Blockers Beta Blockers: ○ ○ ○ ○ ● ● ● Metoprolol Atenolol Esmolol Labetalol (Normodyne, Trandate) Works by reducing sympathetic drive on B1 receptors reducing chronotropy and inotropy This reduction decreases oxygen demand. B-Blockers administered within first few hours of ischemia have in some studies shown decreased myocardial damage. Contraindications: Cardiogenic shock, RV infarcts, prolonged PR interval > 0.24 sec. Second or third degree heart block. Asthma, COPD Clopidogrel (Plavix) ● ● ● Antiplatelet drug Blocks platelet aggregation of GP IIB/IIIA receptors. Used in ACS, CAD, PVD, Prior Ischemic strokes. Contraindications: History of intracranial hemorrhage, GI bleed, trauma Heparin (unfractionated Heparin) ● ● ● Anticoagulant MOA: acts on antithrombin III to reduce ability of blood to form clots, thus preventing clot deposition in the coronary arteries. Used in many clotting related disease processes such as ACS, Pulmonary embolism, and DVT. Contraindications: predisposition to bleeding, aortic aneurysm, GI bleeding, peptic ulcers, heparin induced thrombocytopenia. Enoxaparin (Lovenox) ● ● ● Class: Anticoagulant Acts on antithrombin III, reducing ability to form blood clots and also inhibits factor Xa. Onset of action 3-5 hours, lasts ~12 hours Contraindications: predisposition to bleeding, Aortic aneurysm, GI bleeds and peptic ulcers, sulfite sensitivity. Bivalirudin (angiomax) ● ● ● ● Anticoagulant and Direct thrombin inhibitor. Binds with thrombin to inhibit various clotting pathways. Serves as alternative to heparin ACS and cardiac surgeries Contraindications: predisposition to bleeding, Aortic aneurysm, GI bleeds and peptic ulcers, sulfite sensitivity. ABCIXIMAB (Reopro), Tirofiban (aggrastat) Eptifibatide (Integrilin) ● ● ● GP IIb/IIIa inhibitor. Prevents aggregation of platelets by inhibiting the integrin GP IIb/IIIa receptor. Used in UA/NSTEMI/STEMI patients undergoing planned or emergent percutaneous coronary interventions. Contraindications: predisposition to bleeding, Aortic aneurysm, GI bleeds and peptic ulcers, sulfite sensitivity. ACE- I’s (-pril), Captopril, Lisinopril, Ramipril Enalapril ● ● ● ● ACE inhibitors block enzyme responsible for production of Angiotensinogen II. This inhibition results in decreased blood pressure. Indications: CHF, hypertension, and post- MI. Believed to reduce risk of future NSTEMI and STEMI as well as associated morbidity and mortality. Contraindications: Angioedema from Ace I, aortic stenosis, bilateral renal artery stenosis HOCM, hyperkalemia HMG CoA reductase inhibitors (Statins): Atorvastatin, Fluvastatin, Lovastatin Pravastatin, Rosuvastatin, Simvastatin ● ● ● ● HMG-CoA reductase Inhibitors Reduces level of total cholesterol, LDL and triglycerides. Reduces incidence of reinfarction, recurrent angina, rehospitalizations and strokes. Given in ACS, AMI prophylaxis in CAD, hypercholesterolemia. Contraindications: Class X for pregnancy, Active hepatitis, breastfeeding and rhabdomyolysis. Reperfusion therapy Two Types: 1. 2. Pharmacologic reperfusion (fibrinolytics) a. Preferred when: i. Invasive strategy is not an option (I.e not available at facility ii. Door to balloon time of > 120 minutes. iii. (Door-to-Balloon time) - (Door-to-Needle time) is >1 hour PCI (percutaneous intervention) a. Preferred When: i. The diagnosis of STEMI is in doubt. ii. A skilled PCI facility is available with surgical backup iii. Door to balloon time <120 minutes iv. Contraindications to fibrinolysis including bleeding risk, intracranial hemorrhage. v. High risk from STEMI to include Congestive heart failure Pharmacological reperfusion: Fibrinolytics TPA ● ● ● Thrombolytic agent Dissolves Thrombi plug and reestablishes blood flow. ST Segment Elevation MI (>1mm in tow or more contiguous leads) ADVERSE Effects: Bleeding, intracranial hemorrhage, stroke, cardiac arrhythmias hypotension Contraindications: ST-segment depression, cardiogenic shock, recent surgery within 10 days, BI bleeding, recent trauma, severe hypertension systolic > 180 or Diastolic >110. Septic thrombophlebitis, Advanced age, patients on warfarin. Citations/ resources to check out! ● https://tmedweb.tulane.edu/pharmwiki/doku.php/treatment_of_angina ● https://www.mdpi.com/1301510 ● https://www.nejm.org/doi/full/10.1056/nejmoa0904327