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ACS - Sorry haba ha. Kung wala ng time, basahin nio na lang Sample order chart, CSAP part, STEMI part, basically lahat. HAHAHA. Loko lang. Alam nio naman na to. Reviewer ko kasi talaga to inayos ko lang hehe.

CORONARY ARTERY DISEASE (CAD)

- obstruction of the coronary arteries usually the epicardial arteries by atheromatous plaque.

- Risk factors: family history of premature coronary artery disease, cigarette smoking, diabetes mellitus, hypertension, hyperlipidemia, a sedentary lifestyle, and obesity.

- Anginal “equivalents” (i.e.,dyspnea, faintness, fatigue, and eructations) are common particularly in the elderly.

Patients with chronic coronary artery disease commonly present with Chronic Stable Angina Pectoris (CSAP)

CHRONIC STABLE ANGINA PECTORIS (CSAP)

Clinical manifestations:

Angina in a man > 50 years old or woman >60 years of age who complains of episodes of chest discomfort - Described as heaviness, pressure, squeezing, smothering or choking

- Cresecendo-decrescendo in nature

- Usually lasts 2-5 minutes

- Associated with physical exertion or stress

- Radiation to either or both shoulders/arms (especially

the ulnar surfaces of the forearm and hand)

- Can also arise in or radiate to the back, interscapular

region, root of neck, jaw or teeth, or epigastrum, and does not radiate to the trapezius muscles; - Exertional angina typically is relieved in 1-5 min by slowing or ceasing activities and even more rapidly by rest and sublingual nitroglycerin

Physical Examination:

often normal in a patient with stable angina; may reveal other conditions associated with angina, such as valvular heart disease or hypertrophic obstructive cardiomyopathy Other key findings to look for are: xanthelasma, xanthomas, earlobe crease, arcus senilis, retinal exudates, femoral bruit

Canadian

Cardiovascular

Society

Classification

of

Angina

I

Angina occurs with GREATER THAN ordinary physical activity

II

With ORDINARY physical activity

III

With LESS THAN ordinary physical activity

IV

AT REST

Differentials:

 
 

Rule Out

GERD

Burning character of pain Not related to food intake yung ACS

Costochondritis

 

Localized tenderness

-

Aortic Dissection

 

Tearing type of pain, radiating to the back

Pulmonary Embolism

Sudden onset

-

Hypotension? (unless inferior wall

STEMI) History of DVT before?

-

-

Pneumonia

Cough, fever

(Worsening

Pneumonia

as

they

always say…)

 

Pneumothorax

Decreased

breath

sounds,

vocal

fremitus

Pericarditis

Pain is relieved by leaning forward or sitting up Pericardial friction rub on PE

Psychological

History of panic attacks, alam na alam nio na to from psych rotation, hallucinations, delusions, or recent traumatic events

Diagnosis:

Laboratory Exams:

- Urinalysis (for evidence of DM and renal disease)

- Lipid Profile

- HbA1C

- Crea, Hematocrit

- Thyroid function test (if there’s indication)

Chest xray

- May show cardiac enlargement, ventricular aneurysm, signs of HF. These support diagnosis of IHD

ECG

- May be normal at rest or show ST-T wave changes, LV hypertrophy (S in V1 + R in V5/6 = >35 mm or R in aVL> 11 mm based on Sokolow-Lyon Criteria),

Stress Testing

- Involves recording the 12 L ECG before, during and after exercise; the treadmill exercise test (TET) is recommended as the initial test of choice to diagnose CAD and evaluate prognosis

- Stress imaging test (stress myocardial radionuclide perfusion imaging) are strongly recommended as the diagnostic and prognostic tests of choice in patients with resting ECG abnormalities, patients unable to exercise, and patients with previous revascularization (PCI or CABG).

2D echo

- Recommended in patients with clinically detected murmurs, history and ECG changes of prior MI and signs or symptoms of heart failure; assess for chest wall motion abnormalities, EF, presence of thrombus

Coronary angiography indications:

- Patients with chest discomfort suggestive of angina pectoris but a negative or nondiagnostic stress test who require a definitive diagnosis

- Patients who have been admitted repeatedly to the hospital for a suspected acute coronary syndrome

- Patients with careers that involve the safety of others (e.g. pilots, police) who have questionable symptoms or suspicious or positive noninvasive tests

- Patients with aortic stenosis or hypertrophic cardiomyopathy and angina in whom the chest pain could be due to IH

- Male patients >45 years and females >55 years who are to undergo a cardiac operation such as valve replacement or repair and who may or may not have clinical evidence of myocardial ischemia.

- Patients after MI

- Patients with angina pectoris , regardless of severity in whom noninvasive testing indicates a high risk of coronary events (poor exercise performance or severe ischemia)

- Patients in whom coronarγ spasm or another nonatherosclerotic cause of myocardial ischemia

UNSTABLE ANGINA/NSTEMI

- Subtotal occlusive thrombus formation

Subendochardial ischemia

Clinical manifestations

- Angina pain which occurs at rest or with minimal exertion usually lasting >20 minutes

- Severe and new onset (within prior 4-6 weeks)

- Occurs with a crescendo pattern

Recommendations: initial triage of patients with chest pain

- Should be instructed to call the hospital and brought by ambulance - Administer ASA 162-135 mg chewed if suspecting ACS unless there’s CI

- Do not take more than 1 SL NTG

7 Variables of TIMI (1 point lahat) if more than 3 points, 13% mortality rate

1. Age 65 or older

2. At least 3 risk factors for CAD

3. Prior coronary stenosis of 50% or mor;

4. ST-segment deviation on ECG presentation;

5. At least 2 anginal events in prior 24h

6. Use of ASA in prior 7D

7. Elevated serum biomarkers

Diagnostics:

ECG

- If the initial ECG is not diagnostic but the patient remains symptomatic; serial ECGs should be done at 15 to 30 minute intervals

- ST depression ≥0.1 mV (1 mm) deep from J point or NSSTWC

Biomarkers

- Cardiac biomarkers should be measured in all patients who

present with chest discomfort consistent wit ACS

- Patients with negative biomarkers within 6 hours of onset

- More rapid (~30minutes) and potent plt inhibitor c/w clopidogrel

- 180mg OD or 90mg BID

4. GP IIb/IIIa Inhibitors

- Inhibit platelet aggregation by blocking the GP IIb/IIIa

receptors

- Indicated for patients in whom invasive management is

planned, in conjunction with aspirin and clopidogrel - - Abciximab if no delay> others

Anticoagulant

1. Heparin

- Inhibit thrombin formation

- PTT should be maintained at 1.5-2 times the control value

- Minimum of 48 hours up to 5 days

Unfractionated

60

U/kg bolus (maximum 4000 U)

Heparin

12

U/kg/hour (maximum 1000 U/hour)

Low Molecular

30

mg IV bolus

Weight

1 mg/kg SC Q12 (OD if creatinine clearance

Heparin

<30)

2. Fondaparinux

- Factor Xa inhbitor

- Given 2.5mg SC qD

Anti-ischemic and others

should have biomarkers remeasured in the time frame of 8-

1.

Nitrates

 

12 hours after symptom onset

-

Preload unloader and coronary vasodilator

 

-

Contraindicated

in

patients

with

hypotension,

Trop I/T

- Most specific and sensitive markers of myocardial necrosis

- Values slightly above the upper reference limit (99th percentile of enzyme levels in a reference population) are already considered diagnostic of myocardial necrosis

- Peaks at 24-48 hours up to 20-50 times the upper

reference limit, returns to normal after 7-10 days post-infarct

- Direct relationship between troponin levels and mortality

CKMB/CK TOTAL

- Less specific for myocardial infarction

- Ratio of CKMB mass to CK activity ≥2.5 is suggestive of a myocardial source of the CK MB elevation

- Peaks at 12-24 hours up to 2-5 times the upper reference limit, returns to normal after 3-5 days post-infarct

- Shorter half-life allows for better detection of early reinfarction

Other labs to order:

CBC Urinalysis Serum electrolytes Serum fasting glucose / HbA1c Lipid profile Chest X-ray

bradycardia,

phosphodiesterase-5 inhibitors

tachycardia

or

or

patients

receiving

Nitroglycerin

0.4 mg SL every 5 minutes for 3 doses 5-10 μg/min, uptitrated until relief of symptoms o hypotension is reached

ISMN

60-240 mg OD

ISDN

5 mg SL every 5 minutes for 3 doses 10 mg TID

2. Beta Blockers

- Negative inotropic and chronotropic effects, reduce risk of

reinfarction and ventricular fibrillation - Contraindicated in patients with hyperreactive airways, bradycardia, hypotension, conduction disturbances, signs of CHF, or increased risk of cardiogenic shock (age >70, HR >110 or <60, SBP <120, increased time since onset of symptoms)

Metoprolol

5 mg SIVP every 5 minutes for 3 doses 25-50 mg Q6 for 48 hours, start 15 mins after IV bolus 100 mg Q12 TITRATE to HR 50-60

Therapeutics

3.

Calcium Channel Blockers

Antiplatelets

- Afterload unloader and coronary vasodilator

1. Aspirin

- irreversible cyclooxygenase inhibitor

-

contraindications should be continued indefinitely on a daily basis thereafter

be given on day 1 in the absence of

should

- Initial dose of chewed 162-325 mg; 75-162 mg OD

2. Clopidogrel

- blocks ADP receptor-mediated platelet aggregation

- If aspirin intolerant

- Patient who will undergo diagnostic cath and PCI

(DOC: prasugrel)

- 300-600 mg loading dose ; 75 mg OD maintenance

3. Ticagrelor

- ADP receptor blocker

- Indicated when β-blockers are contraindicated or ineffective

- Contraindicated in patients with CHF or left ventricular dysfunction

Verapamil

Immediate release: 80-160 mg TID Slow release: 120-480 mg OD

Diltiazem

Immediate release: 30-80 mg QID Slow release: 120-130 mg OD

4. RAAS inhibition

- Reduces ventricular remodelling after myocardial infarction and subsequent development of CHF

- Contributes to long-term plaque stabilization

- Strongly indicated for patients with CHF, LV dysfunction, hypertension, or diabetes mellitus ARBs indicated for patients intolerant to ACE inhibitors

- Aldosterone antagonists indicated for patients with creatinine clearance >30, no hyperkalemia

Captopril

6.25 mg TID

Enalapril

5

mg OD

Valsartan

20

mg BID

Candesartan

8

mg OD

Spironolactone

50

mg OD

5. HMG-CoA Reductase Inhibitor

- Long-term plaque stabilization

- LDL goal of <100 mg/dL for patients post-ACS, further reduction to 70 mg/dL is reasonable

Simvastatin

80

mg OD

Atorvastatin

80

mg OD

6. Proton Pump Inhibitors

- Indicated in conjunction with aspirin/clopidogrel to decrease risk of GI bleeding

- Omeprazole has been shown to inhibit CYP450 2C19,

preventing conversion of clopidogrel to its active form

- No reported decrease in clopidogrel activity with pantoprazole or esomeprazole

Esomeprazole

40

mg OD

Pantoprazole

40

mg OD

7. Oxygen Support

- Indicated for patients with arterial desaturation <90%,

respiratory distress, or other high-risk features for hypoxemia

- May be given to all patients during the first 6 hours after the event, then reassess after

- O2 via nasal cannula or face mask at 2-4 LPM

Diet

- NPO or clear liquids only by mouth for the first 4-12 hours

- Complex carbohydrates compose 50-55% of total caloric requirement -Fat composes ≤30% of total calories

- Cholesterol content ≤200 mg/day

- Enriched with foods high in potassium, magnesium, and fiber

- Low sodium, low simple sugars

Cardiac Rehabilitation

- Complete bed rest during the first 12 hours post-ACS

- If with no complications, patients are encouraged to sit up

on bed and dangle legs down the side within the first 24 hours -Can ambulate by the 2nd or 3rd day -By day 3, ambulation goals are 185 m at least 3 times a day or ambulate inside the room or near their bed

STEMI

Pain is not uniformly present in patients with STEMI

- Painless STEMI in DM and elderly patients

- May present as sudden onset breathlessness, LOC,

profound weakness,

- PE: unexplained drop in arterial pressure, appearance of

an arrhythmia, anxiety and restlessness, pallor, substernal chest pain >30 mins + diaphoresis (Highly suggestive of STEMI); Tachycardia + hypertension (anterior infarction); Bradycardia + hypotension (inferior infarction); Heart sounds (3rd and 4th heart sounds, decreased intensity of first heart sound

Killip Scoring for STEMI (basta higher class higher risk of mortality)

Class 1

No

rales

or

signs

of

pulmonary

or

vebous

congestion

 

Class 2

Moderate HF, bibasal rales Normal BP S3 gallop Tachypnea or sogns of right sided CHF

 

Class 3

Severe heart failure Mid basal rales and pulmo edema S3 S4 Normal BP

 

Class 4

Shock with SBP <90 Peripheral cyanosis Mental confusion and oliguria

 

Diagnostics (similar lang sa NSTE-ACS) 12 L ECG –New Q waves preceded by hyperacute T waves/ST elevations and followed by T wave inversions

Cardiac biomarkers

2D Echocardiography

- Abnormalities of wall motion

- Useful for cases where ECG is not diagnostic of STEMI

Myocardial perfusion scan

-Cannot distinguish acute from old infarcts

ER Management

- Initial management (aspirin 162 to 325 mg chewed and

swallowed!)

- Control chest discomfort by giving:

Sublingual nitroglycerin 0.4 mg x 3 doses Q5 mins Contraindicated in low SBP, inferior infarction or previous intake of sildenafil Morphine 2-4 mg Q5 mins Metoprolol 5 mg Q2-5 mins within 24 hrs ; contraindicated if with signs of heart failure, 2nd or 3rd degree block, active asthma, SBP <100, symptomatic bradycardia

- O2 support via NC (2-4 L/min) only if hypoxemic

Reperfusion

- All STEMI patients should undergo rapid evaluation for reperfusion therapy

Fibrinolysis

- Door-to-needle time of 30 minutes

- Reduction of mortality greatest when administered within

the 1st 2 hours of presentation of chest pain, benefit seen in up to 12h after presentation

- Preferred if patient cannot be immediately transported to a suitable PCI center

- tPA 15 mg bolus IV, 50 mg over 1st 30 mins, 35 mg over next 60 mins

- Streptokinase 1.5 million U IV over 1 hour

Primary Percutaneous Coronary Intervention

- Door-to-balloon time of 90 minutes

- Generally preferred over fibrinolysis especially in the setting of cardiogenic shock, increased bleeding risk, symptoms present for >2-3 hours , contraindication to fibrinolysis is present

Antiplatelets (Aspirin, Thienopyridines if with aspirin allergy)

Anticoagulants

- Direct antithrombins: Bivalirudin bolus of 0.25 mg/kg followed by infusion of 0.5 mg/kg/hr for 1st 12 hours, 0.25 mg/kg/hr for next 36 hours

Nitroglycerin

- IV nitroglycerin is indicated in the 1st 48 hours after STEMI for treatment of persistent ischemia, CHF or hypertension

- Dose should not preclude therapy with beta blockers or ACE inhibitors

RAAS Inhibitor (ACE and ARBs) BB or CCBs (If there’s contraindication to beta blockers) PPIs

Diet and Cardiac Rehabilitation/activity: same lang sa NSTEMI

Some points:

Fibrinolysis and coronary angiography not for NSTE-ACS

PCI or CABG is also recommended for UA/NSTEMI patients with 1-2 vessel CAD with or without significant proximal left anterior descending CAD but with a large area of viable myocardium and high risk criteria on non invasive testing

Assess for possible fibrinolysis or PCI if STEMI

SAMPLE ORDER CHART ADMITTING ORDERS

Admit at Medical Intensive Care Unit Bed Diet: Low salt, low fat diet, (depends kung ano co-morbids) with SAP IVF: Heplock O2 support via nasal cannula 2-4 lpm as need if desaturated Monitor VSQ1, I and O shift Diagnostics:

- 12 L ECG (usually repeat 6 hours)

- Trop I (usually repeat 6 hours) or CK MB/CK total

- CBC

- PT/PTT? (PTT if you’re going to use heparin)

- BUN, Crea, AST, ALT, Na, K, Cl, Ca, Mg

- Urinalysis

- FBS, LP

- CXR PA

- 2d echo with DS

Treatment:

- Aspirin (initial dose of 160 mg/tab) then 80 mg/tab 1 tab OD after lunch

- Clopidogrel 300-600 mg LD then 75 mg/tab 1 tab OD (strongly recommended in patients in whom an early noninterventional approach is planned in addition to ASA based on guidelines)

- ISMN 80 mg/tab 1 tab OD

- ISDN 5 mg/tab 1 tab SL PRN for chest pain

- Enoxaparin 30 mg IV LD then 1 mg/kg SC q12 for the duration of hospitalization or until PCI is performed)

- Enalapril 10 mg/tab 1 tab BID

- Atorvastatin 40 mg/tab 1 tab ODHS

- Lactulose 30 cc ODHS (to prevent straining)

- Carvedilol 6.25 mg/tab ½ tab BID

- Omeprazole 40 mg OD pre breakfast Cardiac rehabilitation Refer as needed

Labas tayo after ng orals. Sana pumasa tayong lahat. J Maraming salamat ulit sa tatlong beses na pagsulat ng

pangalan ko sa alam nio na…

Dama ko yung concern niyo. Hehe

ako grabe slow clap para sainyong lahat. J

kahit

di ko naman hinihingi. Mahal na mahal niyo

Sorry haba ah. Basahin nio na lang ung sample order chart tapos ung STEMI part.

Block E for Edi WOW!