Medications: Calcium Channel Blockers

Blocks the movement of calcium ions into heart cells and blood vessels widening the coronary arteries

Thereby increasing the supply of oxygen rich blood into the heart

Lowers blood pressure, reduces the hearts workload

Use cautiously in patients with moderate to severe left ventricular dysfunction

This class of drugs can also be used to treat coronary artery spasms associated with variant or Prinzmetal angina.

Acute Coronary Syndrome – Part II

Management

Sandra Keavey, DHSc, DFAAPA, PA-C

Immediate Treatment of ACS

ASA- Prevent platelet aggregation Inhibits thromboxane A2 mediated platelet aggregation 160-325 mg nonenteric coated crushed or chewed Use cautiously with h/o PUD, bleeding diathesis, ASA allergy

Oxygen – Limit injury Limit ischemic injury 4 L/min then titrated correct hypoxemia (SA O2 >90%)

NTG – Relieve discomfort Relieves ischemic symptoms through arterial and venous dilatation– SL: 0.4 mg x 2 in 3-5 minute intervals

Immediate Treatment of ACS

NTG (continued)

IV: 12.5-25 ug bolus followed by10 ug/min infusion titrated every 5 minutes to a maximum dose of 200 ug/min

Use IV therapy in patients with ongoing symptoms, pulmonary congestion or hypertension

Goals of therapy: Relief of ischemic symptoms

Reduction of SBP of up to 25% or 110 mm Hg in patients who were previously normotensive

Contraindicated in hypotension (SBP < 90 mm Hg), severe bradycardia (HR < 50 bpm) or tachcardia, recent use of PDE5 inhibitors (Cialis, Levitra, Viagra)

Caution in patients with RV infarction or borderline bradycardia (HR 50-60 bpm)

Immediate Treatment of ACS

Morphine

Dilates arteries and veins Anxiolysis and analgesia Used in patients with ongoing ischemic symptoms

unrelieved by NTG or those with pulmonary congestion Goals of therapy: Relief of ischemic symptoms Contraindicated in hypotension (SBP < 90 mm Hg ) STEMI: 2-4 mg IV with up to 2 repeat doses of up to 2-8 mg

every 5-15 minutes UA/NSTEMI: 1-5 mg IV In one registry an increase risk of death has been noted in

patients treated with MS

ED Medications

Aspirin (325 mg)

Beta Blocker

Nitroglycerin (SL, IV or Paste)

Morphine

Heparin (IV can be quickly reversed)

Thrombolytics (if criteria met)

Absolute Thrombolytic Contraindications

• Any prior intracranial hemorrhage

• Known structural cerebral vascular lesion (e.g., arteriovenous malformation)

• Known malignant intracranial neoplasm (primary or metastatic)

• Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours

• Suspected aortic dissection

• Active bleeding or bleeding diathesis (excluding menses)

• Significant closed-head or facial trauma within 3 months

Relative Thrombolytic Contraindications

• History of chronic, severe, poorly controlled hypertension

• Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg or DBP > 110 mm Hg)

• History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in contraindications

• Traumatic or prolonged (> 10 minutes) CPR or major surgery (< 3 weeks)

Relative Thrombolytic Contraindications

• Recent (< 2 to 4 weeks) internal bleeding

• Noncompressible vascular punctures

• For streptokinase/anistreplase: prior exposure (> 5 days ago) or prior allergic reaction to these agents

• Pregnancy

• Active peptic ulcer

• Current use of anticoagulants: the higher the INR, the higher the risk of bleeding

Primary PCI for STEMI

Patient with STEMI (including posterior MI) or MI with new or presumably new LBBB

PCI of infarct artery within 12 hours of symptom onset

Balloon inflation within 90 minutes of presentation

Skilled personnel available (individual performs > 75 procedures per year)

Appropriate lab environment (lab performs > 200 PCIs/year of which at least 36 are primary PCI for STEMI)

Cardiac surgical backup available

Primary PCI for STEMI

Medical contact–to-balloon or door-to-balloon should be within 90 minutes.

PCI preferred if > 3 hours from symptom onset.

Primary PCI should be performed in patients with severe congestive heart failure (CHF) and/or pulmonary edema (Killip class 3) and onset of symptoms within 12 hours.

Inpatient Treatment Options

Aspirin

Nitrates (PO)

Morphine

Oxygen

Anti-platelet

Calcium channel blockers

ACE

Beta Blockers

Reperfusion

Revascularization

Integrillin

Heparin

Medications: Nitrates

Relaxes the smooth muscles of the heart

Lowers blood pressure

Improves blood flow to the heart

Reduces the oxygen demand of the heart.

Medications: ACEI’sAngiotensin Converting Enzyme Inhibitors

Dilates blood vessels

Lowers blood pressure

Reduces the workload of the heart

Reduces the force of the heart muscle contraction

Avoid in the pregnant patient

Medications: Beta Blockers

Lowers blood pressure

Reduce the workload of the heart

Slows the heart

Reduces the force of the heart muscle contraction

Cardioselective: atenolol or metoprolol.

Inhibit the stress response of the sympathetic nervous system.

Selective B1 blockers only inhibit the beta receptors of the heart

Medications: Beta Blockers

Contraindications: heart failure

low cardiac output (tachycardia, cool clammy skin, obtundation)

risk factors for cardiogenic shock (age > 70, SBP < 120 mm Hg, heart rate > 110 bpm or < 60 bpm )

COPD or asthma

PR interval > 0.24 second, second degree AV block or greater

In the absence of contraindications oral beta blockers should be started within 24 hrs

IV beta blockers can be administered early in patients with hypertension

Patients with early contraindications should be reevaluated for beta blocker treatment later

Medications: Anti-platelet

Aspirin is the most common

Prevent aggregation of platelets the blocking the formation of blood clots

Reduces the stickiness of platelets

Also clopidogrel (Plavix) and ticlopidine (Ticlid)

GPIIb/IIIa (Integrillin) inhibitors for patients with planned PCI or high risk patients

Medications: Anti-platelet

Heparin

STEMI, NSTEMI or UA with high risk features UFH 60U/kg (max 4000 U) bolus followed by an infusion of 12 U/kg/hr

(maximum 1000 U/hr)

Enoxaparin 1mg/kg every 12 hours

Clopidogrel (Plavix)

STEMI 75 mg daily for at least 14 days (I) and up to a year (II)

A loading dose of 300 mg can be given in patients <75 years (II)

Can be used in place of ASA for ASA allergic patients (II)

UA/NSTEMI 75 mg daily for at least 1 month to up to a year (I)

Can be used in place of ASA for ASA allergic patients (I)

Medications: Vitamin D

• Vitamin D is able to block the action of cCFU-Fs (Colony-forming units

- fibroblast (CFU-Fs), thereby preventing the buildup of scar tissue

and potentially stopping a blockage from developing.

Published this year in the journal Heart Lung and Circulation.

vitamin D could prove to be an exciting, low-cost addition to current

treatments, and we hope to progress these findings into clinical trials

for humans."

So, although research into vitamin D and its cardioprotective powers

is in its infancy, the results are encouraging.

More research required on indications, dosing, et cetera.

Thrombolytics

Fibrinolysis vs Early Intervention

Fibrinolysis

Early presentation Immediate PCI is not an option (door to balloon time > 90

minutes or door to balloon minus door to needle > 1 hour No contraindications

Invasive therapy

Presentation > 3 hrs Contraindications to thrombolysis High risk features such as CHF Questionable diagnosis Timely PCI available

Management-Conservative

Medical therapy

Stress test prior to discharge

Angiography for recurrent ischemia, positive sub-maximal stress test, or markedly positive full level stress test

Invasive Therapy

Angiography in 24-48 hours

~ 25% decrease in death

Indicated in high risk patient

High Risk Patient?

Recurrent ischemia

Positive troponin

CHF

ST changes on ECG

Recent PCI or CABG

Low EF

TIMI risk score >3

Common Management Errors

Failure to consider ACS

Not initiating chest pain protocol

Using less than optimal medication doses

Not obtaining consult when indicated

Not addressing performance measures

Does the Patient Have CADHigh Likelihood Intermediate Risk Low Likelihood

(At least 1 feature present) (No high risk features and at least 1 feature present)

History Chest or left arm discomfort plus

-symptoms similar to prior episodes of ischemia

-history of known CAD

Chest or left arm discomfort, Age > 70, male sex, DM

Probable ischemic symptoms, recent cocaine

use

Clinical Findings

Transient MR, hypotension, pulmonary congestion, diaphoresis

Findings suggestive of extra cardiac vascular disease

Reproducible chest pain

ECG New ST segment changes > (0.05 mm) or T wave inversion (>2mm)

with symptoms

T wave inversion >0.2 mV or pathologic Q waves

ECG normal or nonspecific T wave abnormalities

Cardiac Markers

Elevated troponins or CKMB Between MDL and CDL Normal

Risk StratificationHigh Risk Intermediate Risk Low Risk

History Accelerating ischemic symptoms in past 48 hrs.

Known CAD, PVD or prior ASA use

Character of Pain Prolonged (>20 min.) ongoing angina.

Prolonged (>20 min.) rest angina with moderate -

high likelihood of CAD or rest angina <20 min. or relieved with rest or

nitroglycerine

New onset or CCS III or IV angina in the past 2

weeks without prolonged (>20 min.) chest pain and

with moderate – high likelihood of CAD.

Clinical Findings CHF, new or worsening MR, S3, hypotension,

brady- or tachcardia, age > 75 years

Age >70 years, findings suggestive of PVD

ECG Transient ST segment changes > 0.05 mV, new or presumed new bundle branch block, sustained ventricular tachycardia

T wave inversion >0.2 mV or pathologic Q waves

ECG normal or unchanged during chest discomfort

Cardiac Markers Elevated troponins or CKMB

Between MDL and CDL Normal

TIMI Risk Factors

Variable

Age > 65

3 CAD risk factors Family history of CAD

Hypertension

DM

Hypercholesterolemia

Current smoker

ASA use in the past 7 days

Recent severe symptoms 2 anginal episodes in the past 24 hrs.

Elevated markers

ST deviation 0.5 mm

Prior CAD stenosis 50%

TIMI Scale

Score Risk of MI/death Risk Status

0-1 5% Low

2 8%

3 13% Intermediate

4 20%

5 25% High

6 or 7 41%

What’s The Good News?

Since the time when the only treatment for angina was nitroglycerin and limitation of activity, the 30-day mortality from ACS has decreased significantly………..

• From 1987 to 2000 there has been a statistically significant 47% relative decrease in 30-day mortality among newly diagnosed ACS.

• This decrease is attributed to aspirin, glycoprotein (GP) IIb/IIIa blockers, and coronary revascularization via medical intervention or procedures.

Performance Measures

Aspirin at arrival

Beta blocker on arrival

Time to Fibrinolysis

Time to PCI

Reprofusion therapy

LDL-cholesterol assessment

Smoking cessation advice/counseling during admission.

At discharge

Aspirin Rx

Beta blocker

Lipid lowering therapy

And Zetimibe (Zetia) in DM patients

ACEI or ARB for LVSD at discharge

Long Term Management

Eating a heart healthy diet

Improving cholesterol ratio-start Ezetimibe (Zetia) in DM patients

Exercising regularly

Controlling diabetes

Controlling hypertension

Achieving and maintaining a healthy weight

Managing stress

Quitting smoking

Controlling depression and emotional factors

Recent Updates-Zetimibe (Zetia)

In the study IMPROVE-IT. Zetimibe (Zetia) added to the regimen of DM patients lowers primary cardiovascular events (death,MI, stroke) by 5% (0.7%)

The largest relative reductions in DM patients were in MI (24%) and ischemic stroke (39%).

Patients ≥75 years had a 20% relative reduction in the primary endpoint regardless of DM

Non-diabetics, patients with a high risk score experienced a significant 18% relative reduction in the composite of cardiovascular death, MI, and ischemic stroke

Non-diabetics at low or moderate risk demonstrated no benefit with the addition of ezetimibe to simvastatin

Recent Updates- Influenza

Chances of a heart attack are increased six-fold during the first seven

days after detection of laboratory-confirmed influenza infection,

according to a new study by researchers at the Institute for Clinical

Evaluative Sciences (ICES) and Public Health Ontario (PHO).

"Our findings are important because an association between influenza

and acute myocardial infarction reinforces the importance of

vaccination," says Jeff Kwong, MD, a scientist at ICES and PHO and

lead author of the study.

Recent Updates-

When To Order What-Outpatient

Everybody gets an EKG

If they need a stress test they need a baseline EKG

If you think they need a heart cath they will be referred to a cardiologist first who will decide whether or not to perform one

When To Order What-Outpatient

Complaints of fatigue, chest pain, dyspnea, surgical clearance and turning 40 require an EKG

An abnormal EKG does not necessarily indicate the need for a stress test if you have a prior EKG indicating the abnormality is not new.

When To Order What-Outpaitent

A new murmur should prompt an EKG and an echocardiogram

Significant surgery (requiring general anesthesia or invading the thorax, abdominal cavity or structures of the neck) should prompt an EKG and if older and a known history of CAD, a stress test.

When To Order What-Inpatient

EKG for---

Chest pain

Abdominal pain

Arrhythmia

Dyspnea

Weakness

Confusion

Syncope

When To Order What-Inpatient

Echo for---

?? of tamponade

New murmur

New arrhythmia

Dyspnea

Valvular disease

Confusion

Syncope

When To Order What-Inpatient

Labs-

Troponin series

A1C

Lipid Panel

Chemistry

CBC

If Uncertain………. Ask.

For changes in status get an EKG while pondering what else you would like to do and getting a hold of your supervisor or colleagues.

If staff asks if you want an EKG the answer is yes unless you absolutely know you don’t.