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Year 3 - Clinical > 20 - STEMI > Flashcards

20 - STEMI Flashcards

1
Q

Describe the differences between stable angina, unstable angina, NSTEMI, and STEMI in regards to what happens in the arteries

A
  • Stable angina = stable, fixed atherosclerotic plaque
  • Unstable angina = unstable plaque (plaque disruption & platelet aggregation)
  • NSTEMI = unstable plaque + thrombus; doesn’t fully occlude artery
  • STEMI = unstable plaque + thrombus; large vessel will be completely or near-completely occluded, medium vessel will be completely occluded
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2
Q

Which conditions are considered ACS?

A

Unstable angina, NSTEMI, and STEMI

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3
Q

What are some differences w/ STEMI compared to NSTE ACS?

A
  • STEMI = ~1/3 of ACS events
  • Mortality higher for STEMI (~2x)
  • Px w/ STEMI on average are younger, less likely to have significant multi-vessel CAD (tend to create faster growing plaques that are more likely to rupture)
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4
Q

What did STEMI used to be called?

A

Q-wave MI

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5
Q

ECG features of a STEMI

A
  • New left bundle branch block (LBBB) or ST-segment elevation (2 or more contiguous leads)
  • ST segment elevation is localizing (ie: indicates region, & often artery, involved)
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6
Q

How is STEMI diagnosed?

A
  • Same as NSTEMI, except 12-lead ECG shows ST-segment elevation or new LBBB
  • Troponin measured x 2 (possibly more) – b/c when vessel is still occluded, troponin will be slightly increased, but once vessel is opened troponin levels will skyrocket
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7
Q

Goals of therapy for acute management of STEMI

A
  • Increase myocardial O2 supply (reperfusion – must be done emergently)
  • Decrease myocardial O2 demand
  • Overall = minimize myocardial necrosis
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8
Q

Overview of initial tx for acute management of STEMI

A
  • ASA
  • Metoprolol IV prn
  • Nitroglycerin subling prn
  • O2 if O2 sat < 90%
  • Morphine or fentanyl prn for severe pain (**never use NSAIDs or COX-2 inhibitors)
  • BZD may be given to mitigate anxiety
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9
Q

What other medications are given if a px is undergoing a primary PCI?

A
  • P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel)

- Anticoagulant bolus (UFH, enoxaparin)

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10
Q

What other medications are given if a px is undergoing thrombolysis?

A
  • P2Y12 inhibitor (clopidogrel)

- Anticoagulant bolus (UFH, enoxaparin)

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11
Q

When is an MI considered a completed infarct?

A

> 12 h from onset of sx

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12
Q

Describe the antiplatelet therapy for initial tx of STEMI

A
  • ASA 160-325 mg po once (chew & swallow, non-enteric coated), then 81 mg po daily
  • P2Y12 inhibitor will be determined by choice of reperfusion (primary PCI or thrombolysis)
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13
Q

Describe beta-blocker therapy for initial tx of STEMI. What is the purpose?

A
  • Reduce ventricular arrhythmias (esp. w/ fibrinolysis)
  • May be beneficial if hypertensive &/or tachycardic w/ ischemia
  • Metoprolol 5 mg IV q5min prn x 3 IF:
    • No contraindications (bradycardia, 2nd/3rd degree heart block, acute heart failure, severe asthma)
    • SBP > 120 mmHg (infarct may cause hypotension)
    • Caution in age > 70 years & w/ inferior STEMI (would cause high level heart block)
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14
Q

Describe reperfusion

A
  • “Time is muscle” – most myocardial cell death happens w/in first 2 h
  • Choice of reperfusion – primary percutaneous coronary intervention (PCI) or thrombolysis
  • All px w/ ongoing sx of ischemia presenting w/in 12 h are eligible for emergent reperfusion
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15
Q

Describe primary percutaneous coronary intervention (PCI)

A
  • Preferred strategy if able to be performed in
    > 120 min (“door-to-balloon” time) from first medical contact (FMC)
    – Ideally PCI should open artery w/in 60-90 min of FMC
  • Early angiography (w/in 24 h) recommended if sx completely relieved & ST-segment elevation completely normalized spontaneously or after nitroglycerin – this is an “aborted STEMI”
  • Infarct-related artery is stented if possible, generally w/ drug-eluting stent (DES)
  • Non-infarct-related arteries w/ severe plaque may be stented prior to discharge, or post-discharge
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16
Q

When should a PCI be performed after more than 12 h?

A

If pt has ongoing sx of ischemia, hemodynamic instability, or life-threatening arrhythmias

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17
Q

What is the pre-PCI antiplatelet therapy?

A
  • ASA 160-325 mg po once
  • P2Y12 inhibitor
    • Clopidogrel 600 mg po once
    • Ticagrelor 180 mg po once (may be preferred b/c works faster)
    • Prasugrel 60 mg po once – only given after anatomy confirmed, so rarely used
  • Glycoprotein IIb/IIIa inhibitors (abciximab, eptifibatide, tirofiban) may be used as “bailout” during PCI
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18
Q

What is the pre-PCI anticoagulation therapy?

A
  • UFH bolus
  • Enoxaparin 0.5 mg/kg IV bolus (no weight cap)
  • Bivalirudin rarely used
  • Anticoagulation d/c post-PCI unless otherwise indicated
  • VTE prophylaxis should be given until discharge
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19
Q

What is another name for thrombolysis?

A

Fibrinolysis

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20
Q

When is thrombolysis used?

A

If time to PCI will be > 120 min (ex: pt presents to a rural hospital and must be transported to city for PCI)

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21
Q

Thrombolysis has limited benefit after __ h

A

3

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22
Q

What is the preferred agent for thrombolysis and why? How and when is it given?

A
  • Tenecteplase (TNK) preferred agent
  • Given as weight-based IV bolus (most favourable)
  • Very high fibrin specificity & highest 90 min success rate
  • Given ASAP after STEMI diagnosis (ideally less than 10 min; may be given pre-hospital by EMS)
23
Q

What dose of TNK should be given to px 75 years and older?

A

1/2 dose

24
Q

When is success of thrombolysis evaluated? What is considered a success?

A
  • Evaluated 60-90 min post-dose

- Success = resolution of pain and over 50% resolution of ST-elevation

25
Q

What should be done immediately after thrombolysis?

A

Pt should be transferred to PCI-capable centre (don’t wait to see if it works)

26
Q

Primary concern w/ thrombolysis is _____

A

Bleeding

27
Q

Which antiplatelets are used w/ TNK?

A
  • ASA 160-325 mg po once (if not already given), 81 mg po daily
  • Clopidogrel 300 mg po once, then 75 mg daily (if < 75 y/o); or 75 mg once, then 75 mg daily (if 75 years and older)
28
Q

Which anticoagulants are used w/ TNK?

A
  • Enoxaparin (preferred)
    • If < 75 y/o – 30 mg IV once, then 15 min later 1 mg/kg subcut q12h (max. 100 mg/dose for first 2 doses)
    • If 75 y/o or older – no bolus, 0.75 mg/kg subcut q12h (max 75 mg/dose for first 2 doses)
  • UFH (preferred if Clcr < 30 mL/min or if > 150-160 kg
  • Anticoagulants d/c following revascularization (successful PCI or CABG)
29
Q

When should CABG be done for STEMI?

A
  • If angiogram reveals anatomy not amenable to PCI, reperfusion w/ CABG must be considered
  • Not all px are candidates
30
Q

Which medications should be stopped prior to CABG?

A
  • P2Y12 inhibitors (clopidogrel and ticagrelor x 5 days)
  • Anticoagulants should be managed as follows (if possible):
    • UFH & bivalirudin – continue uninterrupted
    • Enoxaparin & fondaparinux – last dose 24 h pre-op
31
Q

What is the general approach to in-hospital therapies for STEMI?

A
  • Antithrombotics (antiplatelets, DAPT)
  • Beta-blockers & statins may be part of initial tx
  • ACE inhibitor or ARB
  • Rapid-acting nitroglycerin
  • Maybe MRAs
32
Q

Antiplatelet therapy for STEMI in-hospital

A
  • DAPT regardless if PCI or CABG
    • ASA 81 mg maintenance dose (especially in combo w/ ticagrelor)
    • Ticagrelor may be preferred P2Y12 inhibitor
  • Px w/ completed infarct who don’t undergo revascularization may receive only ASA
  • PPI indicated in combination w/ DAPT in px at risk of GI bleeds
33
Q

Which px are at risk of GI bleeds?

A
  • Hx of GI ulcer/hemorrhage
  • Anticoagulent therapy
  • Chronic NSAID/corticosteroid use
  • 2 or more of: age >/ 65 years, dyspepsia, gastroesophageal reflux disease, H. pylori infection, chronic alcohol use
34
Q

Anticoagulant therapy for STEMI in-hospital

A
  • D/C after revascularization in absence of another indication
  • Px w/ significant infarct & anterior STEMI should be assessed for LV thrombus (detectable 3-5 days post event) – if present, pt will require anticoagulation for at least 3 months (warfarin is standard)
35
Q

Beta-blocker therapy for STEMI in-hospital

A
  • Reduce early post-ACS mortality (reduce risk of ventricular arrhythmias)
  • Oral BBs recommended w/in 24 h of hospital admission for STEMI (may be part of initial tx) in absence of CI or risk factors for cardiogenic shock (age > 70, HR > 110 beats/min, SBP < 120 mmHg – avoid early beta-blockers in these px if LV function poor or unknown)
  • Preference for beta-1 selective agents (bisoprolol or metoprolol); carvedilol may be used if LVEF less than 40%)
36
Q

Statin therapy for STEMI in-hospital

A
  • Indicated in all px w/ CAD
  • Should be initiated early (may be part of initial tx)
  • High potency preferred, regardless of LDL
37
Q

ACEi/ARB therapy for STEMI in-hospital

A
  • ACEi strongly recommended in px w/:
    • Left ventricular systolic dysfunction (LVEF  40%) or anterior infarct
    • HTN
    • Diabetes mellitus
    • Chronic kidney disease
  • ARB recommended in px intolerant of ACEi
  • RAAS inhibition also used in absence of indications listed above for secondary prevention
  • Caution for acute kidney injury, hyperkalemia, hypotension
38
Q

Nitroglycerin therapy for STEMI in-hospital

A
  • Rapid-acting sublingual nitroglycerin may be used prn for ischemic pain, doesn’t change outcomes
  • Shouldn’t be required post-revascularization unless stable occlusive CAD remains
  • Long-acting may be used to reduce pulmonary congestion in px w/ heart failure
39
Q

MRA therapy for STEMI in-hospital

A
  • Recommended in px w/ LV dysfunction & symptomatic heart failure or diabetes
  • Eplerenone was agent studied for this indication, spironolactone likely has similar benefit
  • Benefit is long-term only
  • Caution for hyperkalemia & combination w/ ACEi or ARB
40
Q

What is another name for MRAs?

A

Aldosterone antagonists

41
Q

When can pericarditis occur?

A

Early infarct-related pericarditis may occur due to inflammation w/in pericardial sack

42
Q

Tx for pericarditis

A
  • ASA 650-975 mg po q6h (dose titrated down once sx controlled) w/ PPI; acetaminophen
  • Don’t use non-ASA NSAIDs or corticosteroids (impair myocardial repair)
  • Safety of colchicine unknown – may also interfere w/ myocardial repair
43
Q

What are the medications given at discharge for a STEMI?

A
  • Same as for NSTEMI
  • Mnemonic (AABCC) – ASA, ACE/ARB, beta-blocker, clopidogrel or alternative, cholesterol (statin) + rapid-acting nitroglycerin
44
Q

What is some general info to give px post-ACS?

A
  • Ensure px/caregivers understand nature of disease before proceeding w/ explanation of tx (plaques in arteries are sometimes “juicy” and can “pop,” causing blood to stick to them, which blocks the artery…)
  • Emphasize beneficial effects (purpose) of medications
  • When explaining AEs, put risk into context
  • Explain management
  • Keep regimen to minimum level of complexity
45
Q

Patient education - purpose of antiplatelets (DAPT)

A
  • Make blood less sticky, which prevents clots from forming inside of stents or plaques in arteries
  • Very important not to stop or interrupt taking clopidogrel, ticagrelor, or prasugrel early unless approved by a cardiologist
  • Ensure intended duration of DAPT is clear
  • Missing doses can result in second heart attack, especially if missed soon after 1st event
  • ASA will be a lifelong medication b/c will lower risk of other blockages leading to clots w/in arteries and another heart attack
46
Q

Patient education - adverse effects of antiplatelets (DAPT)

A
  • Px may be at risk for minor bleeding or bruising; often termed “nuisance bleeding” & doesn’t require drug discontinuation
  • Seek medical attention immediately if experiencing – severe stomach pain, bloody vomit, vomit that looks like coffee grounds, bloody/tarry black stools, bloody urine, excessive bruising (especially if unprovoked) – risk of this is low
  • Don’t take any other medications (including OTC or herbal) containing ASA or that have known or potential antiplatelet effect
  • Acetaminophen is analgesic of choice; NSAIDs should be avoided
  • 1% of developing rash after starting clopidogrel; can be treated effectively w/ steroids w/o stopping clopidogrel or clopidogrel could be changed w/ alternative agent
  • 13% chance of experiencing short episodes of dyspnea (shortness of breath) after starting ticagrelor; usually self-limiting & rarely require d/c
47
Q

Patient education - purpose of beta-blockers

A
  • Help prevent another heart attack
  • Block effect of stress hormones on heart muscle & slow HR to help heart relax
  • Protect against abnormal rhythms
  • Protect heart muscle if it has been weakened
  • If doses missed or drug is stopped w/o medical advice, HR may speed up or heart may flip into unhealthy rhythm
48
Q

Patient education - adverse effects of beta-blockers

A
  • May lower BP, sometimes causing dizziness, especially when going from lying or sitting to standing; usually gets better w/ time
  • Some people may feel more tired when first start taking beta-blocker; usually gets better w/ time
49
Q

Patient education - purpose of statins

A
  • Slows/stops formation of plaques in arteries (preventing another heart attack)
  • Should be taken life-long after a heart attack
50
Q

Patient education - adverse effects of statins and when to take

A
  • Large majority of people experience no side effects
  • Some people experience new muscle soreness, achiness, cramping or weakness (similar to next-day muscle discomfort after hard work or heavy lifting); often can be resolved by lowering dose or changing to different statin
  • Atorvastatin & rosuvastatin in morning; all others in evening
51
Q

Patient education - purpose of ACEi/ARB

A
  • Help prevent another heart attack
  • “Unloads” heart & makes it easier to pump blood, mostly by lowering BP
  • Strong protective heart that prevents heart muscle from weakening & helps a weakened heart muscle get stronger (other BP medications don’t have same protective effect)
52
Q

Patient education - adverse effects of ACEi/ARB

A
  • Will lower BP, can sometimes cause dizziness
  • Non-productive cough or “tickle in the throat” is common w/ ACE inhibitors; may start early after starting the drug, or may take several months to develop
  • May cause high potassium in blood
  • Kidney function should be checked w/in 1-2 weeks of starting one of these drugs
53
Q

Patient education - important info about nitroglycerin

A

Purpose is to buy time to get to the hospital – doesn’t fix the underlying problem if there is a new blockage in an artery

54
Q

What are the long-term therapies after STEMI?

A
  • Same as for NSTEMI
  • Same medications as given as discharge
    • DAPT continued preferably for 1 year regardless of tx approach; life-long ASA 81 mg daily continued following DAPT
    • Ezetimibe = optional add-on in high-risk px willing/able to take

Year 3 - Clinical (30 decks)

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