Cardiovascular Medicine Book


Acute Coronary Syndrome Adjunctive Therapy

Aka: Acute Coronary Syndrome Adjunctive Therapy, MI Adjunctive Therapy
  1. See Also
    1. Acute Coronary Syndrome
    2. Acute Coronary Syndrome Immediate Management
    3. Acute Coronary Syndrome Adjunctive Therapy
    4. High Risk Acute Coronary Syndrome Management
    5. Moderate Risk Acute Coronary Syndrome Management
    6. Low Risk Acute Coronary Syndrome Management
    7. Chest Pain
    8. Cardiac Risk Factors
    9. Angina
    10. Angina Diagnosis
    11. Unstable Angina
    12. TIMI Risk Score
    13. Bosner Chest Pain Decision Rule
    14. Myocardial Infarction Stabilization
    15. Serum Cardiac Markers
    16. Electrocardiogram in Myocardial Infarction
    17. Echocardiogram in Myocardial Infarction
    18. Goldman Criteria for ICU Chest Pain Admission
  2. Indications: Based on Immediate MI Management Protocol
    1. High Risk: Myocardial Infarction Protocol
    2. Moderate Risk: Myocardial Ischemia Protocol
  3. Management
    1. Heparin
      1. Preparations
        1. Weight based Heparin Nomogram
          1. Standard management in Acute Coronary Syndrome
        2. Low Molecular Weight Heparin
          1. As effective as Heparin in non-ST Elevation ACS
          2. Do NOT use if acute Angioplasty (PCI) is planned (discuss with cardiology first)
          3. Petersen (2004) JAMA 292:89-96 [PubMed]
      2. Continue Heparin until... (usually 24-48 hours):
        1. Definitive evaluation procedure or
        2. Revascularization performed
      3. Efficacy
        1. Heparin does not decrease overall mortality in ACS
        2. Heparin decreases the short-term (first 7-10 days) Myocardial Infarction rate by 3% (NNT 33)
          1. No difference in Myocardial Infarction rate at 30, 60 and 90 days
          2. Heparin appears to delay Myocardial Infarction to the longterm in these 3% of patients
        3. Low Molecular Weight Heparin and Unfractionated Heparin both have a 4% risk of major bleeding
          1. Major bleeding includes serious complications (Intracranial Hemorrhage, transfusion required)
        4. References
          1. Magee (2008) Cochrane Database Syst Rev (2):CD003462 [PubMed]
          2. Petersen (2004) JAMA 292(1):89-96 [PubMed]
    2. Nitroglycerin Drip (IV)
      1. High efficacy circumstances
        1. Recurrent ischemia
        2. Large anterior Myocardial Infarction
        3. Congestive Heart Failure
        4. Labile Blood Pressure or Hypertension
      2. Switch after 24 hours symptom free period
        1. Oral Nitroglycerin
        2. Transdermal Nitroglycerin
          1. Allow 6-8 hour drug free period
    3. Beta Blocker
      1. Start within 24 hours of STEMI or NSTE-ACS onset if not contraindicated
      2. Continued for 3 years after Myocardial Infarction
      3. Contraindication
        1. Overt Congestive Heart Failure, Cardiogenic Shock or low output state
        2. Second or third degree AV Block
        3. Hypotension
      4. Metoprolol (Lopressor)
        1. Titrate: 2.5-5 mg IV every 5 minutes
          1. Max dose of 15 mg OR
          2. Pulse under 60 OR
          3. Systolic Blood Pressure under 100
        2. Convert to Oral dose
          1. Step 1: Metoprolol Tartrate (Lopressor) 25-50 mg orally every 6 hours for 48 hours
          2. Step 2: Metoprolol Succinate (Toprol XL) 50-100 mg orally once daily
      5. Carvedilol (Coreg)
        1. Start: 3.125 mg orally twice daily
        2. Increase: 6.25 mg twice daily
        3. Longterm plan to titrate up to 25 mg orally twice daily
    4. ACE Inhibitor
      1. Start when stable or 6 hours after event (within first 24 hours) if not contraindicated
      2. Specific Indications
        1. Heart Failure (esp. ejection fraction <40%)
        2. Anterior STEMI
      3. Lisinopril 2.5 to 5 mg orally daily (titrating up to 10 mg orally daily)
        1. Alternative: Valsartan (Diovan) 20 mg orally twice daily (titrating up to 160 mg orally twice daily)
      4. Contraindications
        1. Systolic Blood Pressure below 100 mmHg
      5. High efficacy circumstances
        1. Large anterior Myocardial Infarction
        2. Congestive Heart Failure
        3. Prior Myocardial Infarction
    5. Platelet ADP Receptor Antagonist (e.g. Clopidogrel or Ticagrelor) WITH Aspirin
      1. Start in all moderate to high risk patients
      2. Decreasing Aspirin dose to 81 mg lowers bleeding risk
      3. See Platelet ADP Receptor Antagonist for dosing
      4. Start at loading doses prior to PCI and continue at maintenance dose for 12 months after event or stenting
        1. Example: Load Plavix at 300-600 mg and then give 75 mg daily
      5. Avoid if CABG imminent (will delay procedure by days)
      6. Boden (2004) Am J Cardiol 93:69-72 [PubMed]
    6. Statin
      1. Atorvastatin (Lipitor) 40-80 mg orally daily
      2. High dose Statin dosing is recommended in all ACS patients (even those with LDL Cholesterol <70 mg/dl)
  4. Management: Other medications
    1. Glycoprotein IIB/IIIA Inhibitor Indications
      1. Consider in Moderate Risk Acute Coronary Syndrome Management
      2. Evolving Acute Coronary Syndrome
      3. Following coronary stent placement
  5. Management: Limited use medications (use with caution)
    1. Lidocaine IV
      1. Indication: For specific Arrhythmias only
      2. Amiodarone replaces for Ventricular Tachycardia
    2. Magnesium IV (if indicated for Hypomagnesemia, esp. <1.2 mg/dl)
      1. Goal Magnesium 2.0 or higher
      2. Magnesium 1-2 g IV
    3. Transfusion (pRBC)
      1. Transfusion increased mortality if Hematocrit >25%
        1. ACS patients developing Anemia while hospitalized
        2. Rao (2004) JAMA 292:1555-62 [PubMed]
      2. Initial study suggested benefit if Hematocrit <33%
        1. Transfusion decreased 30 day mortality
        2. Wu (2001) N Engl J Med 345:1230-6 [PubMed]
  6. Management: Avoid Medications that decrease survival
    1. Avoid Calcium Channel Blockers (esp. Dihydropyridines)
    2. Avoid Antiarrhythmics
  7. References
    1. (2000) Circulation 102(suppl I):I172-203 [PubMed]
    2. Stenestrand (2001) JAMA 285:430-6 [PubMed]

Myocardial Infarction (C0027051)

Definition (MEDLINEPLUS)

Each year over a million people in the U.S. have a heart attack. About half of them die. Many people have permanent heart damage or die because they don't get help immediately. It's important to know the symptoms of a heart attack and call 9-1-1 if someone is having them. Those symptoms include

  • Chest discomfort - pressure, squeezing, or pain
  • Shortness of breath
  • Discomfort in the upper body - arms, shoulder, neck, back
  • Nausea, vomiting, dizziness, lightheadedness, sweating

These symptoms can sometimes be different in women.

What exactly is a heart attack? Most heart attacks happen when a clot in the coronary artery blocks the supply of blood and oxygen to the heart. Often this leads to an irregular heartbeat - called an arrhythmia - that causes a severe decrease in the pumping function of the heart. A blockage that is not treated within a few hours causes the affected heart muscle to die.

NIH: National Heart, Lung, and Blood Institute

Definition (NCI_FDA) Gross necrosis of the myocardium, as a result of interruption of the blood supply to the area, as in coronary thrombosis.
Definition (NCI_CTCAE) A disorder characterized by gross necrosis of the myocardium; this is due to an interruption of blood supply to the area.
Definition (NCI) Gross necrosis of the myocardium, as a result of interruption of the blood supply to the area, as in coronary thrombosis.
Definition (CSP) gross necrosis of the myocardium, as a result of interruption of the blood supply to the area.
Definition (MSH) NECROSIS of the MYOCARDIUM caused by an obstruction of the blood supply to the heart (CORONARY CIRCULATION).
Concepts Disease or Syndrome (T047)
MSH D009203
ICD10 I22, I21
SnomedCT 66514008, 266288001, 155304006, 194796000, 233824008, 22298006
LNC LP98884-7, MTHU035551, LA14274-7, LA10558-7
English Myocardial Infarct, Infarctions, Myocardial, Myocardial Infarction, Myocardial Infarctions, Infarcts, Myocardial, Myocardial Infarcts, HEART ATTACK, Infarct, Myocardial, Infarction, Myocardial, MI, Myocardial infarction (MI), Attack heart (NOS), Infarct myocardial, cardiac infarction, Myocardial Infarction [Disease/Finding], attacking heart, heart attacks, attack hearts, infarctions myocardial, infarcts myocardial, myocardial infarctions, Infarction;heart, myocardial infarcts, Infarction;myocardial, AMI, attacks coronary, attacks hearts, coronary attack, disorder infarction myocardial, myocardial necrosis, syndrome myocardial infarction, heart attack, mies, Heart Attack, Attack - heart, Cardiac infarct, myocardial infarction, myocardial infarction (diagnosis), MI, MYOCARDIAL INFARCTION, MYOCARDIAL INFARCTION, MYOCARDIAL INFARCTION, (MI), INFARCTION (MI), MYOCARDIAL, -- Heart Attack, Cardiovascular Stroke, Cardiovascular Strokes, Stroke, Cardiovascular, Strokes, Cardiovascular, Myocardial infarct, Myocardial infarction, Heart attack, MI - Myocardial infarction, Cardiac infarction, Infarction of heart, Myocardial infarction (disorder), cardiac; infarction, infarction; myocardial, Cardiac infarction, NOS, Heart attack, NOS, Infarction of heart, NOS, Myocardial infarction, NOS, Heart Attacks, Infarctions (Myocardial), Myocardial infarction NOS, Attack coronary, heart infarction
German MYOKARDINFARKT, Koronarattacke, Herzanfall, MI, Herzanfall (NNB), HERZANFALL, Herzinfarkt, Myokardinfarkt
Dutch hartaanval, hartinfarct, hartaanval (NAO), MI, cardiaal; infarct, infarct; myocard, myocardinfarct, Hartinfarct, Infarct, myocard-, Myocardinfarct
French Crise coronaire, IM, Crise cardiaque SAI, Crise cardiaque, CRISE CARDIAQUE, INFARCTUS DU MYOCARDE, IDM (Infarctus Du Myocarde), Infarctus du myocarde, Infarctus myocardique
Italian MI, Attacco cardiaco, Attacco coronarico, Attacco cardiaco (NAS), Infarto del miocardio, Infarto miocardico
Portuguese Ataque coronário, Ataque do coração, Ataque cardíaco NE, EM, ATAQUE CARDIACO, ENFARTO DO MIOCARDIO, Enfarte do miocárdio, Infarto do Miocárdio
Spanish IM, Crisis coronaria, Ataque al corazón, Ataque al corazón (NEOM), Infarto miocárdico, ATAQUE CARDIACO, INFARTO DE MIOCARDIO, Infarto al Miocardio, ataque al corazón, infarto cardíaco, infarto de corazón, infarto de miocardio (trastorno), infarto de miocardio, Infarto de miocardio, Infarto del Miocardio
Japanese 心臓発作(NOS), 冠発作, 心臓発作, カンホッサ, シンゾウホッサNOS, シンゾウホッサ, シンキンコウソク, 冠状動脈梗塞, 心筋梗塞, 冠動脈梗塞, 心筋梗塞症
Swedish Hjärtinfarkt
Czech infarkt myokardu, Srdeční záchvat, Srdeční záchvat (NOS), IM, Koronární záchvat, Infarkt myokardu
Finnish Sydäninfarkti
Polish Świeży zawał serca, Zawał serca świeży, Zawał mięśnia sercowego, Zawał serca
Hungarian Coronaria roham, Szívroham (k.m.n.), Szívroham, Infarctus myocardii, Szívizom infarctus, MI
Norwegian Hjerteinfarkt, Hjerteattakk, Myokardinfarkt
Derived from the NIH UMLS (Unified Medical Language System)

Acute Coronary Syndrome (C0948089)

Definition (MSH) An episode of MYOCARDIAL ISCHEMIA that generally lasts longer than a transient anginal episode that ultimately may lead to MYOCARDIAL INFARCTION.
Definition (NCI_CTCAE) A disorder characterized by signs and symptoms related to acute ischemia of the myocardium secondary to coronary artery disease. The clinical presentation covers a spectrum of heart diseases from unstable angina to myocardial infarction.
Definition (NCI) Signs and symptoms related to acute ischemia of the myocardium secondary to coronary artery disease. The clinical presentation covers a spectrum of heart diseases from unstable angina to myocardial infarction.
Concepts Disease or Syndrome (T047)
MSH D054058
SnomedCT 393587009, 394659003
Japanese 急性冠動脈症候群, キュウセイカンドウミャクショウコウグン
English Coronary Syndromes, Acute, Syndromes, Acute Coronary, Acute Coronary Syndromes, Acute Coronary Syndrome, Syndrome, Acute Coronary, Coronary Syndrome, Acute, Acute Coronary Syndrome [Disease/Finding], acute coronary syndromes, syndrome acute coronary, acute coronary syndrome (diagnosis), acute coronary syndrome, Acute coronary syndrome, Acute coronary syndrome (disorder), ACS - Acute coronary syndrome
Portuguese Síndrome Coronariana Aguda, Síndrome coronário agudo
Spanish Síndrome Coronario Agudo, síndrome coronario agudo (trastorno), síndrome coronario agudo, Síndrome coronario agudo
Finnish Akuutti sepelvaltimo-oireyhtymä
German Akutes Koronarsyndrom, akutes Koronarsyndrom
Italian Sindrome coronarica acuta
Swedish Akut koronarsyndrom
Czech Akutní koronární syndrom, akutní koronární syndrom
French Syndrome coronaire aigu, SCA (Syndrome Coronarien Aigu), Syndrome coronarien aigu
Polish Zespół wieńcowy ostry
Hungarian Acut coronaria syndroma
Norwegian Akutt koronarsyndrom, Koronarsyndrom, akutt, AKS
Dutch acuut coronairsyndroom
Derived from the NIH UMLS (Unified Medical Language System)

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