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  • 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’s Angiotensin 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

  • 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

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