Perfusion/ACS-Chapter 26
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| Acute Coronary Syndromes | NSTEM or STEM
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| Non-ST-segment Elevation ACS | Unstable Angina or NTE acute MI
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| ST segment elevation ACS | STE Acute MI
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| Systoms of ACS | Anginal chest pain at rest, new onset, may radiate or increasing angina. May be associated with diaphoresis, dyspnea, N/V
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| EKG STE-ACS | Must have 2 or more ST elevations in 2 contigous leads AND either >0.2mV (mm) in leads V1, V2, V3 or >0.1mV in other leads
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| EKG NSTE-ACS | ST segment depression>0.1mV in 2 or more contiguous leads or T-wave inversion> 0.1mV
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| EKG Anterior Infarct | Q in V1, V2, V3, or V4
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| EKG Posterior Infarct | Large R in V1, V2, Maybe Q in V6
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| EKG Laterial Infarct | Q in I, AVL
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| EKG Inferior Infarct | Q in II, III, AVF
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| Troponin I and T | Draw lab after 6 hours (then every 8) and need only 1 value within 24 hrs to confirm DX
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| CK-MB | Draw lab after 6 hours (then every 8) and need 2 values above upper limit wiithin 24 hrs to confirm DX
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| AGE65-74 -TIMI RISK for STEMI ACS | 2 points
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| Age > 75y/o TIMI RISK for STEMI ACS | 3 points
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| SBP,100mmHgTIMI RISK for STEMI ACS | 3 points
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| HR>100 bpm TIMI RISK for STEMI ACS | 2 points
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| HF class II-IV TIMI RISK for STEMI ACS | 2 points
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| Anterior ST segment or Left ventricular bundle branch block TIMI RISK for STEMI ACS | 1points
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| DM or HTN or Angina TIMI RISK for STEMI ACS | 1 points
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| Time to TX > 4hrs TIMI RISK for STEMI ACS | 1 points
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| Weight <67 kg TIMI RISK for STEMI ACS | 1 point
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| Age >65 y/o TIMI RISK for NSTEMI ACS | 1 point
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| > 3 or more risk for CAD TIMI RISK for NSTEMI ACS | 1 point
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| Prior Hx of CAD TIMI RISK for NSTEMI ACS | 1 point
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| ASA within the past 7 days TIMI RISK for NSTEMI ACS | 1 point
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| > 2 anginal events w/in last 24 hrs TIMI RISK for NSTEMI ACS | 1 point
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| St-segment deviation TIMI RISK for NSTEMI ACS | 1 point
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| Elevation of Biochemical markers TIMI RISK for NSTEMI ACS | 1 point
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| Non-STEMI High risk | 5-7 points
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| Non-STEMI medium risk | 3-4 points
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| Non-STEMI low risk | 0-2 points
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| STEMI mortality Risk 2% vs points | 0 points
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| STEMI mortality Risk 7% vs points | 7 points
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| STEMI mortality Risk 35% vs points | >8 points
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| EKG STEMI treatment-All | IV Line, O2, ASA, Plavix, SL NTG, IV NTG, BB, Statin, ACE if anterior, previous MI Heparin, PCI or fibrinlysis
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| STEMI or NSTEMI ASA dose acute | 162-325mg PO chew or 300mg PR(only STEMI)
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| Plavix dose acute | 300mg PO
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| IV NTG dose STEMI or NSTEMI | 5-10mcg/kg/min titrate up 5mcg/kg/min to max 200 mcg/Kg/min
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| Metoprolol dose acute | 5mg IV push over two minutes, 3 doses, then 50mg PO Q6-8hr
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| Statin dose | high dose Atorvostatin 80mg QD
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| ACE dose | lisinopril 2.5-5.0 then 10-200mg if anterior infarction, or previous MI
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| Aldosterone Antagonist | Use if LVEF<40%, HF, or DM within the first 24 hours
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| Aldalactone | 25-100 mg PO QD
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| Inspra | 25-50 mg PO QD
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| Heparin dose acute STEMI | 60U/kg bolus then 12U/Kg/Hr check aPTT 1.5-2.5 above normal (50-70)
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| enoxaparin STEMI | 30mg IV bolus then 1mg/kg/ SC
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| STEMI <12 hours Reprofusion therapy | PCI (stent) ,Abciximab,ASA, Heparin, Plavix
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| Abciximab dose STEMI (PCI) | 0.25mg/kg bolus 10-60min before PCI then 0.125mcg/kg/min for 12 hours
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| ASA dose acute STEMI (PCI) | 300-325mg 2-24 hours before procedure
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| Heparin dose STEMI (PCI) | 70-100U/Kg
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| Plavis dose acute STEMI (PCI) | 300-600mg PO at least 6 hours prior to PCI and/or IIb/IIIa inhibitor
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| ASA chronic dose | 75-162mg PO indefintely
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| Plavix chronic dose | 75 mg PO indefintely
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| Within 30 minutes of presenting to Hospital | Abciximab + plavix
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| STEMI Within 90 minutes of presenting to the hospital | PCI
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| STEMI >12 hours | Stress test, PCI, or CABG, or fibrinlysis
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| Primary PCI-STEMI | 90% of occluded infarct opened
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| Fibrinlysisis-STEMI | 60% occulded infarct opened
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| NSTEMI acute | IV line, O2, ASA, PLavix, SL, NTG, IV NTG, IV BB, Statin, UFH or enoxaparin
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| NSTEMI NO PCI | no further treatment
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| NSTEMI <12 hours PCI | ASA, Abiciximab, plavix
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| Bare metal stent | Can lead ro restenosis (scab) 1 month325mg ASA, , 75mg Paxil
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| Drug eluting stent | 3 month 325 mg ASA, 75 mg paxil
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| Brachytherapy | 6 months 325 mg ASA, 75 mg paxil
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| Canidates for fibrinolytic Therapy Contraindications: | Prior ICH, cerebral vascular lesions, malignant intracranial neoplasm, ischemic stroke w/in 3 months, severe facial trauma w/in 3 months, active bleed
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| Fibrinolysis Prefereed if | Early presentation (<3 hrs), invasive strategy not an option(Operater ,75 per y, or team ,36 per y), Delay to invasive strategy
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| Highest risk of bleed | Age, female, low body weight
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| ISIS-2 | value of ASA, 160mg acute (chew)
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| ISG | Alteplace (more stroke) and stroptokinase (more bleed)
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| ISIS-3 | Duteplace (more stroke) Heparin (more bleed)
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| Gusto | Flawed study, Combination Alteplace + strepotkinase (more stroke)
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| Gusto III | No different between Alteplace (tPA) and Recteplace (rPA) for stroke
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| Assent -2 | Tecnecteplace (TNK) fewer bleed, less specificity, more intracrainal and stroke
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| Gusto V | Retecplace (rPA) +abciximab +heparin had higher risk of bleeding complications
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| Asscent 3 | Tececteplace and enoxaparin increased benefit less reinfarct, refractory ischemia with combination product
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| EPIC | Abciximab 13% reduction at 3 years, overall 60% reduction in mortality
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| EPILOG | Abciximab +low dose weight heparin Decrease bleed
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| PRISM | Combo of Heparin, Tirofibran reduced death, But Tirofibran alone increased mortality
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| PURSUIT | Eptifibatide better than placebo
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| EPSIRIT | Eptifibatide + IIb/IIIa inhibitor reduced mortality 47%
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| Gusto IV | Abciximab infusion 24hr highest decrease in death or reinfaction
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