Ischemic Heart Disease & Acute Coronary Syndrome PDF

REVIEW THE HEART BY: STEPHANIE JOYCE HOKSON, RPH, CPH HEART SESSION 18 HEART WALL SESSION 18 HEART SESSION 18 SESSION 18 & 22 ISCHEMIC HEART DISEASE & ACUTE CORONARY SYNDROME BY: STEPHANIE JOYCE HOKSON, RPH, CPH ISCHEMIC HEAR...

REVIEW THE HEART BY: STEPHANIE JOYCE HOKSON, RPH, CPH HEART SESSION 18 HEART WALL SESSION 18 HEART SESSION 18 SESSION 18 & 22 ISCHEMIC HEART DISEASE & ACUTE CORONARY SYNDROME BY: STEPHANIE JOYCE HOKSON, RPH, CPH ISCHEMIC HEART DISEASE SESSION 22 a condition in which there is an inadequate supply of blood and oxygen to a portion of the myocardium ACUTE CORONARY SYNDROME SESSION 18 used to describe a group of potentially life- threatening conditions that result from a thrombus formation in the coronary arteries following rupture of an atherosclerotic plaque CAUSES & PATHOPHYSIOLOGY SESSION 22 RISK FACTORS FOR PLAQUE FORMATION SESSION 22 Hypertension BMI>30 EtOH Age>65 An increase in LDL DM Relatives with CAD Tobacco use ACUTE CORONARY SYNDROME SESSION 18 CATEGORIES OF ISCHEMIC HEART DISEASE SESSION 22 Clinical Features Substernal chest pain characterized as “squeezing, tight choking” Chest pain occurs with exertion and can disappear with rest CATEGORIES OF ISCHEMIC HEART DISEASE:ACS SESSION 18 Clinical Features Chest pain occurs at rest and worsens with exertion CATEGORIES OF ISCHEMIC HEART DISEASE:ACS SESSION 18 Clinical Features Chest pain occurs at rest and worsens with exertion CATEGORIES OF ISCHEMIC HEART DISEASE:ACS SESSION 18 Clinical Features Chest pain occurs at rest Severe chest pain with exertion ACUTE CORONARY SYNDROME SESSION 18 ACUTE CORONARY SYNDROME SESSION 18 CATEGORIES OF ISCHEMIC HEART DISEASE SESSION 22 CATEGORIES OF ISH SESSION 18-22 CLINICAL FEATURE SESSION 18-22 CLINICAL FEATURE SESSION 18-22 RIGHT VENTRICULAR MYOCARDIAL INFARCTION SESSION 18-22 LEFT VENTRICULAR MYOCARDIAL INFARCTION SESSION 18-22 RIGHT VENTRICULAR MI VS LEFT VENTRICULAR MI SESSION 18-22 COMPLICATIONS: FIRST 24HRS SESSION 18-22 COMPLICATIONS: 24HRS-3 DAYS SESSION 18-22 COMPLICATIONS: 24HRS-3 DAYS SESSION 18-22 COMPLICATIONS: 3 DAYS-14 DAYS SESSION 18-22 COMPLICATIONS: 14 DAYS – 1 MONTH SESSION 18-22 DIAGNOSIS:EKG & BIOMARKER SESSION 18-22 DIAGNOSIS:EKG & BIOMARKER SESSION 18-22 DIAGNOSIS: BIOMARKERS SESSION 18-22 DIAGNOSTIC FEATURE SESSION 18-22 DIAGNOSTIC FEATURE SESSION 18-22 DIAGNOSTIC FEATURE SESSION 18 CARDIAC TROPONIN I >99%: abnormal CBC & Rise from 2-4 hours COAGULATION Peak:12-48 hours TEST Remain elevated for 4-15 days FASTING LIPID POTASSIUM & MAGNESIUM PANEL Arrhythmia Serum Createnine High risk of morbidity & mortality DIAGNOSTIC FEATURE SESSION 18 Coronary Angiography Echocardiogram DIAGNOSTIC APPROACH SESSION 18-22 TIMI Score Restratifies patients with NSTEMI or unstable angina and determines the need for catheterization based on the risk of mortality STRESS TESTING SESSION 18-22 PHARMACOLOGIC STRESS TESTING SESSION 18-22 SESSION 18 ACUTE CORONARY SYNDROME BY: STEPHANIE JOYCE HOKSON, RPH, CPH EPIDEMIOLOGY SESSION 18 Results showed that ACS occurred predominantly in males (67%), and patients had a median age of 61 years Hypertension (77.1%), diabetes (39%) and smoking history (33.4%) were the common risk factors for ACS Non-ST elevation myocardial infarction was the most common spectrum of ACS (49%), followed by ST elevation myocardial infarction (36%) and unstable angina (14.5%) RISK FACTORS FOR ACS SESSION 18 Non-modifiable risk Modifiable Risk Factors Smoking factors Hypertension Aging Poor Diet Male sex Dyslipidemia Obesity Family History Sedentary Lifestyle Caucasians Diabetes GOAL OF TREATMENT SESSION 18 Short-term desired outcomes early restoration of blood flow to the infarct-related artery to prevent infarct expansion (in the case of MI) or prevent complete occlusion and MI (in UA); prevention of death and other MI complications; prevention of coronary artery reocclusion; relief of ischemic chest discomfort. Long-term desired outcomes control of CAD risk factors, prevention of additional MACE, including reinfarction, stroke, and HF improvement in quality of life GENERAL APPROACH TO TXT SESSION 18 Patients with STEMI need urgent PCI to restore blood flow, while patients with NSTE-ACS may need PCI or medical management based on their risk level. All patients with ACS should receive antithrombotic therapy, pain relief, and other medications to prevent MACE and complications ACUTE SUPPORTIVE CARE SESSION 18 MONA 1. Morphine 4 mg IV stat and PRN q 30 min up to 3 doses defer for SBP< 90 mm Hg 2. Oxygen at 2-4 liters/min via nasal cannula x 24 hours 3. Nitrate: Nitrostat 0.4 mg SL up to 3 doses stat q 5min and PRN for chest pains then start Isosorbide Dinitrate (Isoket) Drip x 24-48 hours until chest pain subsides then shift to Transderm patch 5-10 mg OD to anterior chest wall or Isosorbide mononitrate (Imdur) 60 mg OD AM or Isosorbide dinitrate (Isordil) 10-20 mg TID (6 am-12-6 pm) 4. Aspirin 160-325 mg tab stat dose then 80 mg tab BID PC indefinitely ACUTE SUPPORTIVE CARE SESSION 18 THROMBINS2 Thienopyridine Heparin RAAS Oxygen Morphine Beta-blocker Intervention (PCI) NTG Statin/Salicylate ACUTE SUPPORTIVE CARE SESSION 18 BETA BLOCKERS CCB β-Blockers are recommended CCBs reduce myocardial oxygen demand for all patients with ACS without by dilating the arteries and lowering blood contraindications, as they have pressure and afterload. Non-DHP CCBs anti-ischemic effects and lower also slow down the heart rate. the risk of MACE, such as CCBs have anti-ischemic effects, but they reinfarction and death. do not improve survival or prevent MACE in patients with ACS. They are recommended β-Blockers work by blocking for patients with angina who are intolerant the β1 -adrenergic receptors, or refractory to β-blockers, or patients with which decreases heart rate, vasospasm. contractility, blood pressure, Immediate release nifedipine should be and coronary shunting. avoided as it can cause harm ACUTE SUPPORTIVE CARE SESSION 18 BETA BLOCKERS Metoprolol: 5 mg by slow (over 1 to 2 minutes) IV bolus, repeated every 5 minutes for a total initial dose of 15 mg. If a conservative regimen is desired, initial doses can be reduced to 1 to 2 mg. This is followed in 15 to 30 minutes by 25 to 50 mg orally every 6 hours. If appropriate, initial IV therapy may be omitted. Propranolol: 0.5 to 1 mg slow IV push, followed in 1 to 2 hours by 40 to 80 mg orally every 6 to 8 hours. If appropriate, the initial IV therapy may be omitted. ACUTE SUPPORTIVE CARE SESSION 18 BETA BLOCKERS Atenolol: 5 mg IV dose, followed 5 minutes later by a second 5-mg IV dose; then 50 to 100 mg orally every day beginning 1 to 2 hours after the IV dose. The initial IV therapy may be omitted. Esmolol: Starting maintenance dose of 0.1 mg/kg/min IV, with titration in increments of 0.05 mg/kg/min every 10 to 15 minutes as tolerated by BP until the desired therapeutic response is obtained, limiting symptoms develop, or a dose of 0.2 mg/kg/min is reached. An optional loading dose of 0.5 mg/kg may be given by slow IV administration (2 to 5 minutes) for more rapid onset of action. Alternatively, the initial IV therapy may be omitted MANAGEMENT STRATEGIES: STEMI SESSION 18 PRIMARY PERCUTANEOUS CORONARY INTERVENTION (PCI) PREFERRED: cardiogenic shock is present bleeding risk is increased symptoms have been present for at least 2–3 h when the clot is more mature and less easily lysed by fibrinolytic drugs STEMI SESSION 18 STEMI SESSION 18 FIBRINOLYTIC THERAPY ✓ Alteplase: 15-mg IV bolus followed by 0.75-mg/kg infusion (maximum 50 mg) over 30 minutes, followed by 0.5-mg/kg infusion (maximum 35 mg) over 60 minutes (maximum dose 100 mg). ✓ Reteplase: 10 units IV over 2 minutes, followed 30 minutes later with another 10 units IV over 2 minutes. ✓ Tenecteplase: A single IV bolus dose given over 5 seconds based on patient weight: 30 mg if