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Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
Acute Myocardial Infarction  [Final](2)
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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--
  • Transcript

    • 1. Pharmacodynamics IV <br />Spring 2011<br />Acute Myocardial Infarction<br />Kyoungmin Lee<br />Angela Paul<br />Cory Phillips<br />Jaime Tausend<br />Sonia Tadjalli<br />
    • 2. Introduction<br />Occlusion of a coronary artery <br />Death of cardiac myocyte<br />Wide range of clinical sequelae<br />Result in cardiogenic shock and death<br />About 1.5 million people experience MI<br />
    • 3. Risk Factors<br />Age<br />Gender (male)<br />Dyslipidemia<br />Diabetes<br />Hypertension<br />Obesity<br />Lack of physical activity<br />Alcohol overconsumption<br />Tobacco use<br />Family history of atherosclerotic disease<br />
    • 4. Pathophysiology<br />Atherosclerosis<br />Plaque rupturing<br />Thrombus formation<br />Adhesion<br />Activation<br />Aggregation<br />
    • 5. Presentation<br /><ul><li>Common symptoms:
    • 6. Chest pain associated with tightness or squeezing
    • 7. Pain in the arms and/or upper back
    • 8. Upper abdominal discomfort
    • 9. Jaw pain, toothache, and/or headache
    • 10. Dyspnea
    • 11. Diaphoresis
    • 12. Malaise
    • 13. Women are more likely to experience an atypical MI
    • 14. Some patients may not experience any symptoms are known as a silent heart attack</li></li></ul><li>Assessment<br />PQRST:<br />P- Precipitation factors<br />P- Palliative measures<br />Q- Quality of pain<br />R- Region of pain<br />R- Radiation of pain<br />S- Severity of pain<br />T- Temporal pattern<br />
    • 15. Diagnosis<br />Patient History<br />Perform an electrocardiogram (EKG)<br />STEMI vs NSTEMI<br />Cardiac Enzymes<br />Series of blood draws<br />Myoglobin<br />Creatine phosphokinase (CK-MB)<br />Troponin<br />
    • 16. Treatment Overview<br />MONA- B<br />Morphine<br />Oxygen<br />Nitroglycerin<br />Aspirin / Clopidogrel <br />Beta-Blockers<br />Other Early Hospital Therapies for MI<br />ACE Inhibitors/ ARBs<br />Calcium Channel Blockers<br />Mechanical Reperfusion<br />Fibrinolytics<br />
    • 17. Morphine<br /><ul><li>Analgesic of choice
    • 18. 2-4mg IV bolus, with 2-8mg Q5-15minutes
    • 19. All patients should receive
    • 20. relieves pain, anxiety and is a vasodilator
    • 21. Common adverse effects:
    • 22. Bradycardia, hypotension, drowsiness, dizziness, confusion, constipation
    • 23. Contraindications:
    • 24. Asthma, hypotension, CNS depression, airway obstruction and abdominal surgery</li></li></ul><li>Oxygen<br />All patients with SaO2 &lt;90%<br /><ul><li>Maybe all patients in first 6 hours</li></li></ul><li>Nitroglycerin<br /><ul><li>All should receive sublingually
    • 25. 0.4 mg Q5min x3 doses
    • 26. Evaluate for IV nitroglycerin after 3 doses
    • 27. Discomfort, HTN, pulmonary congestion
    • 28. Common adverse effects:
    • 29. Flushing, hypotension, headache
    • 30. Monitor patients new to therapy
    • 31. Contraindications:
    • 32. PDE5 inhibitors, ergot derivatives, increased ICP, hypotension, sever anemia</li></li></ul><li>Aspirin<br />All patients should chew 162-325mg upon presentation<br />Higher doses have equal effectiveness, but increased bleeding risks<br />Daily aspirin 81-325mg continued indefinitely<br />Common adverse effects:<br />Bleeding, dysrhythmias, confusion, headache, rash ulcers, glycemic changes, renal impairment<br />Contraindications:<br />Asthma, rhinitis, nasal polyps, bleeding disorders and pregnancy<br />
    • 33. Clopidogrel<br />Alternative to aspirin is contraindication exists<br />75mg on presentation and indefinitely is aspirin is contraindicated<br />Dual therapy after stent: 12-15 months<br />Common adverse reactions:<br />Rash, pruritis, bleeding and epistaxis<br />Contraindications:<br />Pathological bleeding, liver disease and caution with PPIs<br />
    • 34. Beta-Blockers<br />All STEMI patients should receive<br />Evaluate at admission and 24hrs for contraindications<br />Decreases HR, BP and contractility<br />Common adverse reactions:<br />Bradycardia, dizziness, hypotension, edema, glycemic changes, lowered HDL, elevated triglycerides and fatigue<br />Contraindications:<br />HF, low Co, risk of cardiogenic shock, bradycardia, <br />
    • 35. Angiotensin-Converting Enzyme (ACE) Inhibitors<br />Indicated within 24hrs if patient has:<br />Heart failure<br />LVEF &lt; 40%<br />Type 2 diabetes<br />Chronic kidney disease<br />CI to IV therapy<br />CAD<br />Reductions in death, heart failure, and stroke<br />Common adverse reactions:<br />Hyperkalemia<br />Increased SCr<br />Andioedema<br />Cough<br />If pt intolerant to ACEi, switch to ARB<br />
    • 36. Non- Dihydropyridine Calcium Channel Blockers (CCBs)<br />Recommended in pts with:<br /> Frequent ischemia and CI to BBs<br />Recurrent ischemia after BB and nitrates are used<br />Two drugs: <br />Verapamil<br />Diltiazem<br />MOA: <br />Selectively block calcium channels and prevent influx of calcium ions into cells<br />Prevents constriction of arterial smooth muscles and lowers blood pressure<br />
    • 37. Non-CCB<br />Use is primarily for symptom relief and has no real benefit or detriment to mortality<br />Adverse effects:<br />Peripheral edema<br />Gastroesophageal reflux<br />Constipation<br />ED<br />Gynecomastia<br />
    • 38. Mechanical Reperfusion<br />Balloon angioplasty<br />Bare metal stent (BMS)<br />Drug- eluting intracoronary stent (DES)<br />
    • 39. DES<br />Coated with antiproliferative agents<br />Paclitaxel<br />Sirolimus<br />Beneficial in preventing restonosis after PCI:<br />Prevent elastic recoil<br />Negative remodeling<br />Neointimal proliferation <br />Restenosis rates from DESs are 5-10% in comparison to 15-20% that is achieved with BMSs<br />
    • 40. Antiplatelet Therapy with DES<br />Prior to PCI<br />Loading dose of clopidogrel (Plavix) of up to 900 mg<br />Post PCI<br /> Aspirin 325 mg for 3-6 months along with clopidogrel 75 mg daily for at least 12 months<br />Following this time period, maintenance therapy with aspirin 81 mg continued indefinitely<br />2009<br />Prasugrel (Effient) also approved for PCI with a 60 mg loading dose followed by 10 mg daily dose<br />Prasugrel is more potent, more consistent at platelet inhibition, and has faster onset of action than clopidogrel<br />Although prasugrel has proven to be superior to clopidogrel, it has increased chance of bleeding<br />
    • 41. Pharmacologic Reperfusion: Fibrinolytics<br />Only indicated for STEMI within 12hrs of symptoms onset and for patients &lt;75 y.o.<br />MOA: <br />Converts plasminogen to plasmin, resulting in thrombus breakdown<br />Opens arteries in 60-90% of patients<br />decreases mortality by 20%<br /> Greatest benefit when administered early<br />Preferred method of reperfusion if: <br /> (“door-to-balloon” – “door-to-needle”) &gt; 1 hr<br />
    • 42. Fibrinolytics<br />In order of specificity: Greater specificity = less chance of bleeding<br />Tenecteplase (TNK)<br />Alteplase (t-PA)<br />Reteplase (r-PA)<br />Streptokinase (SK)<br />Anistreplase (APSAC)<br />Absolute Contraindications: <br />Active internal bleeding <br />Previous hemorrhagic stroke at any time <br />Any other stroke within the previous year<br />
    • 43. Supportive Treatment<br />Supportive care<br />Bed rest<br />Correction of precipitating factors<br />Hypoxia<br />Give oxygen<br />Anemia<br />Give blood<br />Hypertension<br />Patient education<br />
    • 44. Supportive Treatment<br />
    • 45. Non-Pharmacological Therapies<br />Balloon angioplasty<br />Catheter with balloon is placed into artery<br />Balloon is inflated<br />Balloon crushes plaque<br />Balloon is deflated and removed<br />Nothing stays inside the patient<br />Bare metal stents (BMS)<br />Involves a balloon catheter with a mesh stent<br />Mesh stent stays in the patient after balloon deflation<br />Prevents elastic recoil and negative remodeling <br />
    • 46. Conclusion<br />Most MIs are caused by a disruption in the vascular endothelium associated with a fibrous atherosclerotic plaque <br />Leads to thrombus formation and occlusion of coronary artery<br />About 1.5 million people experience a MI in the United States each year<br />There are many modifiable risk factors associated with MIs<br />Can be treated pharmacologically and non-pharmacologically<br />Main goals of therapy <br />Reperfusion of the occluded artery <br />Salvaging as much myocardial tissue as possible<br />
    • 47. Questions?<br />
    • 48. References<br />Boyle JA, Jaffe SA. Acute myocardial infarction. Current Diagnosis &amp; Treatment Cardiology. 2010;3. http://online.statref.com/document.aspx?fxid=19&amp;docid=33.<br />Berger BP, Orford LJ. Acute myocardial infarction. ACP Medicine. 2010. http://online.statref.com/document.aspx?fxid=48&amp;docid=208.<br />Acute Myocardial Infarction. Cleveland Clinic Center for Continuing Education website. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/acute-myocardial-infarction/. Accessed April 8, 2011. <br />Booziotis, K. IHD &amp; ACS. Pathophysiology/Therapeutics II. Belmont University, McWhorter Hall. March 31, 2011. <br />Heart Attack (Myocardial Infarction). MedicineNet. Available at: http://www.medicinenet.com/heart_attack/article.htm#tocb. Accessed: April 7, 2011.<br />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.<br />Nitroglycerin. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.<br />Morphine. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.<br />
    • 49. References continued…<br />Aspirin. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.<br />Clopidogrel. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.<br />Williams, M. Lecture on Chronic Heart Failure. Pathophysiology &amp; Therapeutics II. Belmont School of Pharmacy. March 28, 2011.<br />Thompson-Odom, M. Lecture on Hypertension. Pharmacodynamics IV. Belmont School of Pharmacy. February 2, 2011.<br />Atenolol. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.<br />Captopril. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.<br />Irbesartan. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.<br />Thompson-Odom, M. Lecture on Vasopressin/Renin-Angiotensin-Aldosterone System. Pharmacodynamics IV. Belmont School of Pharmacy. January 21, 2011.<br />Thompson-Odom, M. Lecture on Myocardial Ischemia 2. Pharmacodynamics IV. Belmont School of Pharmacy. January 28, 2011.<br />Verapamil. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.<br />Alteplase. Lexi-Comp ONLINE [database online]. Hudson, OH: Lexi-Comp, Inc.; 2010. Available at: http://www.lexi.com. Accessed April 13, 2011.<br />
    • 50. Picture References<br />Cover: <br />http://www.whenguide.com/what-happens-when-someone-has-a-heart-attack.html<br />Slide 6: <br />http://www.ehsancenter.org/2011/02/a-note-from-the-heart/<br />Slide 8: <br />http://www.beltina.org/health-dictionary/oxygen-therapy-treatment-types-side-effects.html<br />Slide 24:<br />http://www.crmsocialmedia.com/2009/07/what-kind-of-customer-support-can-crm-help-my-business-achieve/<br />

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