Posts Tagged STEMI

Cardiology- Day 19

June 17, 2010 at 11:53 pm · Filed under Articles and Clinical Tools, Clinical Interventions ·Tagged , ,

BB in CHF

  • bb counteracts mechanism of catecholamine by decreasing preload (RAAS) and decreasing afterload (vasoconstriction)
  • -antagonize the effects of SNS
  • antiarrhythmic effect
  • attenuating or reversing ventricular remodeling
  • decrease myocyte death from catecholamine induced necrosis or apoptosis
  • decrease hr and ventricular wall stres thereby reducing myocardial oxygen demand and inhibiting plasma renin release

Detrimental effects of NE

  • tachycardia, vasoconstriction, increased contractility
  • NE contributes to ventricular hypertrophy and remdoelling

Candasartan and BP

  • CHARM- PRESERVE
    • candasartan 32 mg daily vs placebo
    • By 6 months, blood pressure was lowered from baseline by 6·9 mm Hg systolic and 2·9 mm Hg diastolic more in the candesartan group than in the placebo group (p<0·0001

AF Target

Criteria for rate control vary with patient age but usually involve achieving ventricular  rates between 60 and 80 beats per minute at rest and between 90 and 115 beats per minute during moderate exercise. For the AFFIRM trial, adequate control was defined as an average heart rate up to 80 beats per minute at rest and either an average rate up to 100 beats per minute over at least 18-h ambulatory Holter monitoring with no rate above 100% of the maximum age-adjusted predicted exercise heart rate or a maximum heart rate of 110 beats per minute during a 6-min walk test . In the RACE trial, rate control was defined as less than 100 beats per minute at rest. Only about 5% of patients from these large clinical trials required AV ablation to achieve heart rate control within these limits.

Lone AF with CHADS2

  • CLASS IIa-For patients with nonvalvular AF who have 1 or more of the following less well-validated risk factors, antithrombotic therapy with either aspirin or a vitamin K antagonist is reasonable for prevention of thromboembolism: age 65 to 74 y, female gender, or CAD. The choice of agent should be based upon the risk of bleeding complications, ability to safely sustain adjusted chronic anticoagulation, and patient preferences. (Level of Evidence: B)
  • ClassIIb- In patients with AF younger than 60 y without heart disease or risk factors for thromboembolism (lone AF), the risk of thromboembolism is low without treatment and the effectiveness of aspirin for primary prevention of stroke relative to the risk of bleeding has not been established. (Level of Evidence: C)
  • The estimated prevalence of AF is 0.4% to 1% in the general population, increasing with age (18,19). Cross-sectional studies have found a lower prevalence in those below the age of 60 y, increasing to 8% in those older than 80 y
  • CHADS2=0
    • 1.9% without treatment= annual stroke risk
    • 1% with ASA= annual stroke risk
    • 0.25% with ASA= major bleed (all)

STEMI Evidence

Clopidogrel

  • DAP
    • CLARITY- TIMI
      • COMMIT
        • CURE
          • 14 days clopidogrel therapy is an exptrapolation of CURE, CLARITY and commit ( 8-30 days)

        ACEI

        • HOPE
        • EUROPA
        • PEACE
        • TRACE
        • AIRE
        • SAVE
        • CCS1
        • ISIS-4
        • GISSI-3

        ARB

        • ON-TARGET
        • VALIANT

        CCB

          • INVEST

        BB

        • CCS
        • TIMI2-B
        • ISIS-1
        • MIAMI

        Statin

        • MIRACLE
        • PROVE IT TIMI 22
        • A TO Z
        • CAGE
        • LIPID

        COOPERATIVE-Japan study

        ASTRODE

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        Cardiology- Day 3

        May 27, 2010 at 7:48 pm · Filed under Articles and Clinical Tools, Drug Information Requests & Literature Searches, Uncategorized ·Tagged , , ,

        STEMI

        • strongest evidence for ACEI in STEMI with LVEF less than 40%
        • simva 40= atorva 20
        • high risk pt: LDL less than 2 or decrease of 50% ( Lipid guidelines 2009)

        Verapamil vs diltazem

        • Diltiazem hydrochloride is a slow calcium channel blocker that blocks calcium ion influx during depolarization of cardiac and vascular smooth muscle. It decreases peripheral vascular resistance and causes relaxation of the vascular smooth muscle resulting in a decrease of both systolic and diastolic blood pressure .
          • indicated in atrial arrhythmia, htn, stable angina
          • ADE
            • Cardiovascular: Atrioventricular block, Bradyarrhythmia, Congestive heart failure, Exacerbation (rare), Peripheral edema, Syncope
            • Gastrointestinal: Drug-induced gingival hyperplasia
            • Neurologic: Dizziness, Headache
        • Verapamil hydrochloride is slow-channel blocker that selectively blocks the transmembrane influx of calcium ions into arterial smooth muscles including conductile and contractile myocardial cells, without affecting the concentration of serum calcium. Its hypertensive effect is attributed to the reduction of systemic vascular resistance and selective vasodilation of peripheral arteries. Its antianginal effect is related to inhibition of coronary spasm, and relaxation of main coronary artery and coronary arterioles .
          • Indicated in atrial arrhythmia,htn, angina
          • ADE
            • Cardiovascular: Edema, Hypotension
            • Gastrointestinal: Constipation, Nausea
            • Neurologic: Dizziness, Headache
        • Nifedipine, a slow-calcium channel antagonist, selectively inhibits the transmembrane influx of calcium ions into cardiac muscle and vascular smooth muscle which is dependent upon for the contractile process. The mechanism by which it relieves angina remains undetermined but it is thought to be related to the relaxation and prevention of coronary artery spasm and reduction of myocardial oxygen demand .
          • indication: htn, angina
          • ADE
            • Cardiovascular: Palpitations (7%), Peripheral edema (10-30%)
            • Dermatologic: Flushing
            • Gastrointestinal: Constipation, Drug-induced gingival hyperplasia (up to 40% ), Heartburn (10% ), Nausea (10% )
            • Neurologic: Dizziness, Headache, More frequent with immediate-release formulation (23-27%)

        FMI

        • calcium in HD as a phosphate bindign agent
        • stop ACEI if greater than 30% serum creatinine rise from baseline
        • no bleed difference between UFH and LMWH
        • if HIT concern, use LMWH
        • CKmb is specific to cardiac
        • ARCHIVE- BB may reduce mortality and risk of exacerbation in patients with COPD
          • arch intern med. 2010; 170(10):880-7. by Rutten FH
          • 30% reduction in mortality and hospit admission
          • decrease number of exacerbation
          • bb unregulate b receptor and has potential benefit in COPD
        • wedge pressure greater than 18~ pulmonary edema
        • MI–> ischemic heart is stillf; therefore, increase wedge pressure needed; therefore use volume to treat hypotension
        • dopamine: increase VT/VG and arrhymia; therefore, can extend infarction ( AVOID)
        • contrast nephropathy pk @ 2-4 days
        • av block can be cause by:
          • ischemia
          • rv infarction ( dead cell release calcium and blocks av node)
          • dead cell release adenosin and can block av
        • RV infarction
          • clear lung b/c blood can’t get to lung)
          • increase JVP
          • hypotensive ( can’t get blood to left side of heart)
          • tx with fluids (1-2 L); but too much fluid can be bad
          • no nitro in rv infarction
        • dobutamine causes pulmonary vasodilation
        • long term nitro can cause tachyphylaxis
        • Heparin indications:
          • anticoagulant tx in transfusion of blood product
          • afib
          • operation of heart
          • pe
          • vte
          • venous cather occlusion
          • acs (stemi)
          • hd
          • ibd
          • percutaneous coronary intervention
          • phlebitis prophylaxis
          • prosthetic valve endocarditis
          • unstable angina
          • prosthetic valve endocarditis

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        Cardiology- Day 1

        May 25, 2010 at 5:42 pm · Filed under Reflections on Residency & Learning, Topics Discussed ·Tagged , ,

        FMI

        • Lupus –> 2-3x increase in ACS
        • Drug causes for cardiac blockade: CCB,BB, digoxin, amiodarone
        • tx of angina: dihydropyridine ( nifidipine LA –> decrease PCI and CABG secondary to decrease s/s; no change in mortality) or BB ( no mortality benefit)
        • 3 things to look for after a heart attack: HF, arrhymias, recurrent chest pain
        • source of clots: afib, valve abnorm
        • mitral valve has a greater chance of clot formation than aortic valve
        • hep + warfarin (2.5-3.5) if strong indication of clot
        • poor LV: increase risk of HF and arrhymias
        • ALLHAT:doxazosin arm stopped early, increase CHF
        • q wave ~sign of infarction
        • TIMI 0 = no flow; 3= normal flow ( decrease mortality with higher TIMI score)
        • Takotsubo cardiomyopathy, also called transient left ventricular apical ballooning or “broken heart syndrome”, is a cardiac condition that mimics the clinical presentation of acute coronary syndrome but without any evidence of obstructive atherosclerotic coronary artery disease. An episode of intense emotional or physiologic stress, serving as the nidus for a catecholamine surge, has been reported prior to presentation and is presumed to be the triggering factor playing the pathogenic role.
        • alcohol withdrawal period:
          • Withdrawal is defined as the development of predictable signs and symptoms following the abrupt discontinuation of, or rapid decrease in, alcohol intake beginning 4-12h after the last drink and peaking at 48-72h. Some symptoms related to autonomic dysregulation (anxiety, insomnia) can persist on a low level for several months
          • thiamine 100mg daily x 3 days, prevents Korsakoff’s psychosis
        • sternal pericardial rub:A pericardial friction rub, also pericardial rub, is an audible medical sign used in the diagnosis of pericarditis.[1] Upon auscultation, this sign is an extra heart sound of to-and-fro character, typically with three components, one systolic and two diastolic. It resembles the sound of squeaky leather and often is described as grating, scratching, or rasping. The sound seems very close to the ear and may seem louder than or may even mask the other heart sounds. The sound usually is best heard between the apex and sternum but may be widespread.
        • Different types of rub:
          • pericardial friction rub
          • pericardial rub
          • pleural friction rub
          • pleuritic rub
          • pleuropericardial rub
        • morphine in MONA used if patient is symptomatic despite nitro, not for patients who are experiencing n/v

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