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Acute Myocardial Infarction  [Final](2)
 

Acute Myocardial Infarction [Final](2)

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  • Minnie starts-
  • Angela beginsNot an all-inclusive listing, presentation of an acute MI is patient specificWomen are likely to present with back painSilent heart attacks- are still serious and patients still should seek treatmentDyspnea (SOB)Diaphoresis (excessive sweating)
  • Use this as a guide when a patient is suspected of having an acute MI
  • Patient History- specifically anything to do with chest painSTEMI-above baseline- ST elevationNSTEMI- below baseline- often inverted T waveLook for cardiac enzymes- do a series of 3 draws at time 0, 12, and 24 hoursMyoglobin- first to be elevated- ~1 hourTroponin- most common lab value to see, longest lasting enzyme as last as 7-14 weeks laterAlso presents a challenge when assessing new myocardial damage within that time frame- levels are still elevated
  • Transition slide to treatment- Angela Jaime
  • Jaime start
  • Only if they didn’t take it at homeDaily dose dependant on oterh factors… stent placement… etc
  • Early contraindications may resolve w/I 24 hrs
  • Sonia Start-Took out- RASS reduces blood pressureMOA: Suppresses rennin-angotensinaldosterone system Block conversion of angiotensin I to angiotensin II by the angiotensin-converting enzyme (ACE).ContraindicationsHypersensitivity or angioedema related to previous ACE inhibitor treatmentPregnancy
  • Calcium channel blockers (CCBs) are used mainly for symptom relief and have little effect on mortality. 4
  • CCBs should not be used in combination with tolvaptan, topotecan, dofetilide, and disopyramide. Therapy changes should be considered when using CCBs in combination with amifostine, amiodarona, antifungal agents, atorvastatin, benzodiazepines, buspirone, carbamazepine, cardiac glycosides, cimetidine, colchicines, conivaptan, cyclosporine, CYP3A4 inhibitors, dabigatran, dronedarone, everolimus, halofantrine, lovastatin, macrolides, nafcillin, protease inhibitors, ranolazine, rifamycin, rituximab, and simvastatin.
  • Percutaneous coronary intervention (PCI)neointimal proliferation  specific for DES … others are have BMS too
  • Prasugrel (Effient) also approved for PCI with a 60 mg loading dose followed by 10 mg daily dosePrasugrel is more potent, more consistent at platelet inhibition, and has faster onset of action than clopidogrelAlthough prasugrel has proven to be superior to clopidogrel, it has increased chance of bleeding
  • Preferred method if:Early presentation 3 hours or less from sx onset & delay to PCIPCI not an option Catheterization lab occupied/not available Vascular access difficulties Loss of access to a skilled PCI lab
  • care should be taken in patients with severe uncontrolled hypertension, history of stroke, concurrent anticoagulant therapy, known bleeding disorders, recent trauma, traumatic or prolonged cardiopulmonary resuscitation, recent surgery, non-compressible vascular punctures, recent internal bleeding, pregnancy, active peptic ulcers, or prior exposure to streptokinase when it is considered for use. 4 
  • Cory starts  end
  • Includes all our paper references--

Acute Myocardial Infarction  [Final](2) Acute Myocardial Infarction [Final](2) Presentation Transcript

  • Pharmacodynamics IV
    Spring 2011
    Acute Myocardial Infarction
    Kyoungmin Lee
    Angela Paul
    Cory Phillips
    Jaime Tausend
    Sonia Tadjalli
  • Introduction
    Occlusion of a coronary artery
    Death of cardiac myocyte
    Wide range of clinical sequelae
    Result in cardiogenic shock and death
    About 1.5 million people experience MI
  • Risk Factors
    Age
    Gender (male)
    Dyslipidemia
    Diabetes
    Hypertension
    Obesity
    Lack of physical activity
    Alcohol overconsumption
    Tobacco use
    Family history of atherosclerotic disease
  • Pathophysiology
    Atherosclerosis
    Plaque rupturing
    Thrombus formation
    Adhesion
    Activation
    Aggregation
  • Presentation
    • Common symptoms:
    • Chest pain associated with tightness or squeezing
    • Pain in the arms and/or upper back
    • Upper abdominal discomfort
    • Jaw pain, toothache, and/or headache
    • Dyspnea
    • Diaphoresis
    • Malaise
    • Women are more likely to experience an atypical MI
    • Some patients may not experience any symptoms are known as a silent heart attack
  • Assessment
    PQRST:
    P- Precipitation factors
    P- Palliative measures
    Q- Quality of pain
    R- Region of pain
    R- Radiation of pain
    S- Severity of pain
    T- Temporal pattern
  • Diagnosis
    Patient History
    Perform an electrocardiogram (EKG)
    STEMI vs NSTEMI
    Cardiac Enzymes
    Series of blood draws
    Myoglobin
    Creatine phosphokinase (CK-MB)
    Troponin
  • Treatment Overview
    MONA- B
    Morphine
    Oxygen
    Nitroglycerin
    Aspirin / Clopidogrel
    Beta-Blockers
    Other Early Hospital Therapies for MI
    ACE Inhibitors/ ARBs
    Calcium Channel Blockers
    Mechanical Reperfusion
    Fibrinolytics
  • Morphine
    • Analgesic of choice
    • 2-4mg IV bolus, with 2-8mg Q5-15minutes
    • All patients should receive
    • relieves pain, anxiety and is a vasodilator
    • Common adverse effects:
    • Bradycardia, hypotension, drowsiness, dizziness, confusion, constipation
    • Contraindications:
    • Asthma, hypotension, CNS depression, airway obstruction and abdominal surgery
  • Oxygen
    All patients with SaO2 <90%
    • Maybe all patients in first 6 hours
  • Nitroglycerin
    • All should receive sublingually
    • 0.4 mg Q5min x3 doses
    • Evaluate for IV nitroglycerin after 3 doses
    • Discomfort, HTN, pulmonary congestion
    • Common adverse effects:
    • Flushing, hypotension, headache
    • Monitor patients new to therapy
    • Contraindications:
    • PDE5 inhibitors, ergot derivatives, increased ICP, hypotension, sever anemia
  • Aspirin
    All patients should chew 162-325mg upon presentation
    Higher doses have equal effectiveness, but increased bleeding risks
    Daily aspirin 81-325mg continued indefinitely
    Common adverse effects:
    Bleeding, dysrhythmias, confusion, headache, rash ulcers, glycemic changes, renal impairment
    Contraindications:
    Asthma, rhinitis, nasal polyps, bleeding disorders and pregnancy
  • Clopidogrel
    Alternative to aspirin is contraindication exists
    75mg on presentation and indefinitely is aspirin is contraindicated
    Dual therapy after stent: 12-15 months
    Common adverse reactions:
    Rash, pruritis, bleeding and epistaxis
    Contraindications:
    Pathological bleeding, liver disease and caution with PPIs
  • Beta-Blockers
    All STEMI patients should receive
    Evaluate at admission and 24hrs for contraindications
    Decreases HR, BP and contractility
    Common adverse reactions:
    Bradycardia, dizziness, hypotension, edema, glycemic changes, lowered HDL, elevated triglycerides and fatigue
    Contraindications:
    HF, low Co, risk of cardiogenic shock, bradycardia,
  • Angiotensin-Converting Enzyme (ACE) Inhibitors
    Indicated within 24hrs if patient has:
    Heart failure
    LVEF < 40%
    Type 2 diabetes
    Chronic kidney disease
    CI to IV therapy
    CAD
    Reductions in death, heart failure, and stroke
    Common adverse reactions:
    Hyperkalemia
    Increased SCr
    Andioedema
    Cough
    If pt intolerant to ACEi, switch to ARB
  • Non- Dihydropyridine Calcium Channel Blockers (CCBs)
    Recommended in pts with:
    Frequent ischemia and CI to BBs
    Recurrent ischemia after BB and nitrates are used
    Two drugs:
    Verapamil
    Diltiazem
    MOA:
    Selectively block calcium channels and prevent influx of calcium ions into cells
    Prevents constriction of arterial smooth muscles and lowers blood pressure
  • Non-CCB
    Use is primarily for symptom relief and has no real benefit or detriment to mortality
    Adverse effects:
    Peripheral edema
    Gastroesophageal reflux
    Constipation
    ED
    Gynecomastia
  • Mechanical Reperfusion
    Balloon angioplasty
    Bare metal stent (BMS)
    Drug- eluting intracoronary stent (DES)
  • DES
    Coated with antiproliferative agents
    Paclitaxel
    Sirolimus
    Beneficial in preventing restonosis after PCI:
    Prevent elastic recoil
    Negative remodeling
    Neointimal proliferation
    Restenosis rates from DESs are 5-10% in comparison to 15-20% that is achieved with BMSs
  • Antiplatelet Therapy with DES
    Prior to PCI
    Loading dose of clopidogrel (Plavix) of up to 900 mg
    Post PCI
    Aspirin 325 mg for 3-6 months along with clopidogrel 75 mg daily for at least 12 months
    Following this time period, maintenance therapy with aspirin 81 mg continued indefinitely
    2009
    Prasugrel (Effient) also approved for PCI with a 60 mg loading dose followed by 10 mg daily dose
    Prasugrel is more potent, more consistent at platelet inhibition, and has faster onset of action than clopidogrel
    Although prasugrel has proven to be superior to clopidogrel, it has increased chance of bleeding
  • Pharmacologic Reperfusion: Fibrinolytics
    Only indicated for STEMI within 12hrs of symptoms onset and for patients <75 y.o.
    MOA:
    Converts plasminogen to plasmin, resulting in thrombus breakdown
    Opens arteries in 60-90% of patients
    decreases mortality by 20%
    Greatest benefit when administered early
    Preferred method of reperfusion if:
    (“door-to-balloon” – “door-to-needle”) > 1 hr
  • Fibrinolytics
    In order of specificity: Greater specificity = less chance of bleeding
    Tenecteplase (TNK)
    Alteplase (t-PA)
    Reteplase (r-PA)
    Streptokinase (SK)
    Anistreplase (APSAC)
    Absolute Contraindications:
    Active internal bleeding
    Previous hemorrhagic stroke at any time
    Any other stroke within the previous year
  • Supportive Treatment
    Supportive care
    Bed rest
    Correction of precipitating factors
    Hypoxia
    Give oxygen
    Anemia
    Give blood
    Hypertension
    Patient education
  • Supportive Treatment
  • Non-Pharmacological Therapies
    Balloon angioplasty
    Catheter with balloon is placed into artery
    Balloon is inflated
    Balloon crushes plaque
    Balloon is deflated and removed
    Nothing stays inside the patient
    Bare metal stents (BMS)
    Involves a balloon catheter with a mesh stent
    Mesh stent stays in the patient after balloon deflation
    Prevents elastic recoil and negative remodeling
  • Conclusion
    Most MIs are caused by a disruption in the vascular endothelium associated with a fibrous atherosclerotic plaque
    Leads to thrombus formation and occlusion of coronary artery
    About 1.5 million people experience a MI in the United States each year
    There are many modifiable risk factors associated with MIs
    Can be treated pharmacologically and non-pharmacologically
    Main goals of therapy
    Reperfusion of the occluded artery
    Salvaging as much myocardial tissue as possible
  • Questions?
  • References
    Boyle JA, Jaffe SA. Acute myocardial infarction. Current Diagnosis & Treatment Cardiology. 2010;3. http://online.statref.com/document.aspx?fxid=19&docid=33.
    Berger BP, Orford LJ. Acute myocardial infarction. ACP Medicine. 2010. http://online.statref.com/document.aspx?fxid=48&docid=208.
    Acute Myocardial Infarction. Cleveland Clinic Center for Continuing Education website. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/acute-myocardial-infarction/. Accessed April 8, 2011.
    Booziotis, K. IHD & ACS. Pathophysiology/Therapeutics II. Belmont University, McWhorter Hall. March 31, 2011.
    Heart Attack (Myocardial Infarction). MedicineNet. Available at: http://www.medicinenet.com/heart_attack/article.htm#tocb. Accessed: April 7, 2011.
    ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction- Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. American Heart Association. 2004. Accessed April 10, 2011.
    Nitroglycerin. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.
    Morphine. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.
  • References continued…
    Aspirin. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.
    Clopidogrel. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.
    Williams, M. Lecture on Chronic Heart Failure. Pathophysiology & Therapeutics II. Belmont School of Pharmacy. March 28, 2011.
    Thompson-Odom, M. Lecture on Hypertension. Pharmacodynamics IV. Belmont School of Pharmacy. February 2, 2011.
    Atenolol. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.
    Captopril. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.
    Irbesartan. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.
    Thompson-Odom, M. Lecture on Vasopressin/Renin-Angiotensin-Aldosterone System. Pharmacodynamics IV. Belmont School of Pharmacy. January 21, 2011.
    Thompson-Odom, M. Lecture on Myocardial Ischemia 2. Pharmacodynamics IV. Belmont School of Pharmacy. January 28, 2011.
    Verapamil. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.
    Alteplase. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.
  • Picture References
    Cover:
    http://www.whenguide.com/what-happens-when-someone-has-a-heart-attack.html
    Slide 6:
    http://www.ehsancenter.org/2011/02/a-note-from-the-heart/
    Slide 8:
    http://www.beltina.org/health-dictionary/oxygen-therapy-treatment-types-side-effects.html
    Slide 24:
    http://www.crmsocialmedia.com/2009/07/what-kind-of-customer-support-can-crm-help-my-business-achieve/