Cardiology Board Review

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Cardiology Board Review

  1. 1. <ul><li>A 63-yo non-English-speaking woman comes to the ED b/c of severe, steady precordial discomfort that began 14 hours ago. She thought that the CP may have been indigestion, but she had no relief with an antacid. She has a h/o HTN. She is taking no medication. Her HR is 92/min, and her BP is 150/90. Her chest and cardiac exam is normal. Her EKG shows 3-mm STE in V2-V6. She is given a chewable ASA, morphine 4mg IV, metoprolol 5mg IV, and NTG 20mcg/min IV w/ a decrease in her CP intensity from severe to moderate. A hospital in the next county (1.5h away by ambulance) recently established a program that provides 24h angioplasty services. </li></ul>
  2. 2. Which of the following should be considered in the decision of whether to refer this patient for treatment? <ul><li>Angioplasty (with or without stenting) has a better outcome than thrombolysis in this patient </li></ul><ul><li>Thrombolysis has a better outcome than angioplasty (with or without stenting) in this patient </li></ul><ul><li>Thrombolysis and angioplasty (with or without stenting) are equivalent in outcome for this patient </li></ul><ul><li>Neither thrombolysis nor angioplasty (with or without stenting) should be performed in this patient </li></ul>
  3. 3. <ul><li>74yo female is admitted w/ 3h of crushing substernal CP. She has a h/o L carotid occlusion w/ hemiparesis occurring 3 months ago. She also has a h/o mild HTN, hyperlipidemia, and DM complicated by neuropathy and retinopathy. Her meds include coumadin, atenolol, and pravastatin. In the ED, she has a Vfib arrest and is successfully converted to NSR after receiving 2 min of CPR. Her EKG shows SR w/ 3-mm STE in V2-V6. The results of initial laboratory tests are within normal limits, except for an elevated PT w/ and INR of 1.8. </li></ul>
  4. 4. Which of the following represent an absolute contraindication to the use of a thrombolytic agent in this patient? <ul><li>L carotid occlusion w/ hemiparesis 3 months ago </li></ul><ul><li>CPR for 2 minutes </li></ul><ul><li>Patient age>70 years </li></ul><ul><li>Patient on coumadin with an INR of 1.8 </li></ul><ul><li>Diabetic retinopathy </li></ul>
  5. 5. Fibrinolytic Therapy in STEMI June 6, 2007
  6. 6. <ul><li>90% of patients w/ acute STEMI have complete occlusion of culprit artery </li></ul><ul><li>PCI preferred if performed w/in 90 minutes of presentation or if transfer to neighboring institution for PCI can occur w/in 30-60 min. </li></ul><ul><li>Thombolytic therapy is the alternative treatment </li></ul><ul><li>Not as effective in non-STEMI as the infarct-related artery is not totally occluded in 60-85% of cases </li></ul>
  7. 7. EFFICACY <ul><li>Benefit first demonstrated w/ streptokinase (GISSI-2 and ISIS-2 trials). ISIS-2 showed combination of ASA and streptokinase reduced mortality from 10.2% (placebo) to 7.2%. </li></ul><ul><li>GUSTO-I: alteplase superior to streptokinase (although more expensive) </li></ul><ul><li>ASSENT-2 and GUSTO-III: newer agents like tenecteplase , reteplase , lanoteplase as effective as alteplase but have significantly lower incidence of noncerebral bleeding complications and need for transfusion. </li></ul>
  8. 8. Time to presentation… <ul><li>Survival benefit greatest when lytics administered within first 4 hours after onset of symptoms, particularly within the first 70 minutes. </li></ul><ul><li>Mortality benefit less likely at 13-18 hours. </li></ul><ul><li>There MAY be benefit in patients presenting >12hours if patient has on-going stuttering chest pain. </li></ul><ul><li>AHA recommendations (2004): administer lytics if no contraindications w/in 12 hr of symptom onset; reasonable to administer at 12-24 hr if continuing symptoms or persistent ST elevation on EKG. </li></ul>
  9. 9. Long-term survival… <ul><li>Long-term benefit primarily seen in patients who achieved TIMI 3 flow w/ lytic administration. Vessel opening (TIMI 2 or 3) reported in 60-87% of patients receiving lytics, but normalization (TIMI 3) in only 50-60% of arteries. Only TIMI 3 flow associated w/ improved LV function and survival. </li></ul><ul><li>***Note: TIMI 3 flow is achieved in ~90% of patients treated with primary PCI. </li></ul>
  10. 10. Other prognostic indicators…positive predictors of one-year mortality <ul><li>Demographics: older age (>55), lower weight (<80kg), previous MI, previous CABG </li></ul><ul><li>Larger infarctions, anterior wall infarct, hypotension, tachycardia (>115), longer QRS (>125), lower EF/heart failure, cardiogenic shock </li></ul><ul><li>Presence of cardiac risk factors such as smoking, HTN, prior CVA </li></ul>
  11. 11. CONTRAINDICATIONS <ul><li>It is estimated that 20-30% of patients ineligible for thrombolytic therapy… </li></ul><ul><li>This is what we missed on the in-service!! </li></ul>
  12. 12. ABSOLUTE contraindications <ul><li>Previous ICH </li></ul><ul><li>Known structural cerebral vascular lesion </li></ul><ul><li>Known malignant intracranial neoplasm </li></ul><ul><li>Ischemic CVA within 3 months prior </li></ul><ul><li>Suspected aortic dissection </li></ul><ul><li>Active bleeding or bleeding diathesis </li></ul><ul><li>Significant closed-head or facial trauma within 3 months prior </li></ul><ul><li>ADVANCED AGE IS NOT A MAJOR CONTRAINDICATION FOR THROMBOLYTICS! </li></ul><ul><li>… although pts >75y/o may get less overall benefit. </li></ul>
  13. 13. RELATIVE contraindications <ul><li>Poorly controlled or chronic sustained HTN </li></ul><ul><li>Ischemic CVA >3 months prior </li></ul><ul><li>Dementia </li></ul><ul><li>Traumatic or prolonged CPR or major surgery within <3 wk prior </li></ul><ul><li>Recent (within 2-4 wk) internal bleeding </li></ul><ul><li>Noncompressible vascular puncture </li></ul><ul><li>Allergy to lytic agents </li></ul><ul><li>Pregnancy </li></ul><ul><li>Active peptic ulcer </li></ul><ul><li>Current use of anti-coagulants </li></ul>
  14. 14. Adjunctive anti-coagulation… <ul><li>Thrombin inhibition enhances coronary thrombolysis and limits reocclusion; therefore anti-coagulation is administered to most patients receiving lytics. </li></ul><ul><li>Alteplase, reteplase, tenecteplase : UFH at 60units/kg bolus followed by 12u/kg/hr gtt; maintain PTT b/w 50-70 sec for 48hr. </li></ul><ul><li>LMWH also effective w/ tenecteplase , although don’t use it in pts>75 y/o (increased risk of ICH) or those w/ Cr>2.5 in men or Cr>2.0 in women. </li></ul><ul><li>? benefit of UFH or LMWH in streptokinase, anistreplase, urokinase . </li></ul>
  15. 15. Plavix… <ul><li>CLARITY-TIMI 28 and COMMIT/CCS-2 demonstrated improved outcomes when plavix given before thrombolytic therapy. </li></ul><ul><li>300mg loading dose followed by 75mg daily </li></ul><ul><li>In patients>75, risk of ICH not clear with 300mg loading dose vs 75mg loading dose… </li></ul>
  16. 16. GP IIb/IIIa inhibitors… <ul><li>Two large trials failed to shows survival benefit with combination therapy (GP IIb/IIIa with thrombolytics) compared to conventional thrombolytic therapy, and bleeding was increased. </li></ul><ul><li>DO NOT administer concurrent GP IIb/IIIa inhibitors with thrombolytics! </li></ul>
  17. 17. Assessment of response… <ul><li>Relief of symptoms </li></ul><ul><li>Maintenance or restoration of hemodynamic and/or electrical stability </li></ul><ul><li>Reduction of at least 50% of initial ST segment injury pattern on a follow-up EKG 60-90 min after initiation of therapy </li></ul><ul><li>Serial measurements of cardiac biomarkers </li></ul>
  18. 18. PCI after thrombolytics??? <ul><li>This issue remains unresolved… </li></ul><ul><li>3 possible scenarios… </li></ul><ul><li>*Facilitated PCI—lytic drug given prior to planned PCI in attempt to achieve an open infarct-related artery before arrival of cath lab </li></ul><ul><li>*Adjunctive PCI—PCI performed within hours after thrombolysis </li></ul><ul><li>*Early elective PCI—PCI performed within a few days after thrombolysis </li></ul>
  19. 19. <ul><li>A 63-yo non-English-speaking woman comes to the ED b/c of severe, steady precordial discomfort that began 14 hours ago. She thought that the CP may have been indigestion, but she had no relief with an antacid. She has a h/o HTN. She is taking no medication. Her HR is 92/min, and her BP is 150/90. Her chest and cardiac exam is normal. Her EKG shows 3-mm STE in V2-V6. She is given a chewable ASA, morphine 4mg IV, metoprolol 5mg IV, and NTG 20mcg/min IV w/ a decrease in her CP intensity from severe to moderate. A hospital in the next county (1.5h away by ambulance) recently established a program that provides 24h angioplasty services. </li></ul>
  20. 20. Which of the following should be considered in the decision of whether to refer this patient for treatment? <ul><li>Angioplasty (with or without stenting) has a better outcome than thrombolysis in this patient </li></ul><ul><li>Thrombolysis has a better outcome than angioplasty (with or without stenting) in this patient </li></ul><ul><li>Thrombolysis and angioplasty (with or without stenting) are equivalent in outcome for this patient </li></ul><ul><li>Neither thrombolysis nor angioplasty (with or without stenting) should be performed in this patient </li></ul>
  21. 21. Which of the following should be considered in the decision of whether to refer this patient for treatment? <ul><li>Angioplasty (with or without stenting) has a better outcome than thrombolysis in this patient </li></ul>
  22. 22. <ul><li>74yo female is admitted w/ 3h of crushing substernal CP. She has a h/o L carotid occlusion w/ hemiparesis occurring 3 months ago. She also has a h/o mild HTN, hyperlipidemia, and DM complicated by neuropathy and retinopathy. Her meds include coumadin, atenolol, and pravastatin. In the ED, she has a Vfib arrest and is successfully converted to NSR after receiving 2 min of CPR. Her EKG shows SR w/ 3-mm STE in V2-V6. The results of initial laboratory tests are within normal limits, except for an elevated PT w/ and INR of 1.8. </li></ul>
  23. 23. Which of the following represent an absolute contraindication to the use of a thrombolytic agent in this patient? <ul><li>L carotid occlusion w/ hemiparesis 3 months ago </li></ul><ul><li>CPR for 2 minutes </li></ul><ul><li>Patient age>70 years </li></ul><ul><li>Patient on coumadin with an INR of 1.8 </li></ul><ul><li>Diabetic retinopathy </li></ul>
  24. 24. Which of the following represent an absolute contraindication to the use of a thrombolytic agent in this patient? <ul><li>L carotid occlusion w/ hemiparesis 3 months ago </li></ul>

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