STEMI

Also known as BBB [bundle branch block]Caused by occlusive thrombus

NSTEMI

Also known as unstable angina Ischemic episodes caused by reversible, non-occlusive thrombus

treatment

STEMI → "MONA-GAP-BA" + PCI/fibrinolyticsBefore hospital arrival:Morphine IV 2-5mg PRNOxygenNitroglycerin SL/spray followed by IVASA 325mg [CHEWED]At the hospital:PCI preferred [within 2 hours symptom onset]PCI [door-to-balloon time] 90 minutesBefore PCI → clopidogrel 300-600mg or prasugrel 60mgFibrinolytics [door-to-needle time] 30 minutes↓GPIIB/IIIA antagonists [antithrombotics]AnticoagulantsP2Y12 inhibitors [antiplatelets]↓Beta-blockersACEiNSTEMI → "MONA-GAP-BA" ± PCI

secondary prevention for STEMI + NSTEMI

DAPT [1 year] → ASA 81mg QD + clopidogrel/ticagrelor [prasugrel also an option for DAPT if PCI] DAPT + warfarin for persistent atrial fibrillationASA 81 mg QD + nitroglycerin SL/spray PRN indefinitelyPantoprazole or H2RA [except cimetidine] for upper GI bleed Within 24 hours:Beta-blockers [3 years or indefinitely: HF, HTN] ACEi/ARBs [based on risk factors: LVEF < 40%, HTN]"-statins" [based on risk factors: LDL > 100mg/dL]

fibrinolytics

CI w/ pregnancy, ↑ BPFor STEMI alteplase [Activase; max = 100mg for ACS, 90mg for stroke]reteplase [Retavase]tenecteplase [TNK-tPA]streptokinase [Streptase]urokinase [Abbokinase]

GPIIB/IIIA antagonists

For STEMI, NSTEMI ADE = thrombocytopenia, bleeding, hypotensionMonitor = PTT/aPTTFiltered prior to administration

abciximab

Reopro for PCIBefore PCI → 0.25mg/kg bolus After PCI → 0.125mcg/kg/min [12 hours]

tirofiban

Aggrastat for ACS0.4mcg/kg/min [30 minutes], then 0.1mcg/kg/min [24 hours]

eptifibatide

Integrilin for ACS + PCI 180mcg/kg bolus, then 2mcg/kg/min [24 hours]

anticoagulants

ADE = bleeding [NOT for long-term → use antiplatelets instead]

UFH

STEMI treatment → 60u/kg bolus [max = 4000u], then 12u/kg/hr [max = 1000u]

LMWH

STEMI treatment < 75 years → 30mg IV bolus, then 1mg/kg SQ, then 1mg/kg SQ Q12HCrCl < 30 → 30mg IV bolus, then 1mg/kg SQ, then 1mg/kg SQ QDSTEMI treatment ≥ 75 years → 0.75mg/kg SQ Q12HCrCl < 30 → 1mg/kg SQ QD NSTEMI treatment→ 1mg/kg SQ Q12HCrCl < 30 → 1mg/kg SQ QD

bivalirudin

Angiomax [direct thrombin inhibitor] preferred for STEMI

P2Y12 inhibitors

CI w/ stroke, TIA for prasugrelADE = bleeding, bruising, TTP [clopidogrel, prasugrel], neutropenia + anemia [ticlopidine], dyspnea [cangrelor, ticagrelor] DDI = clopidogrel w/ omeprazole, esomeprazole, cimetidineDiscontinue 5-7 days prior to surgery

cangrelor

Kengreal 30mcg/kg bolus, then 4mcg/kg/minFor during PCI, then switch to PO P2Y12 inhibitors after

prasugrel

Effient 10mg< 60kg or ≥ 75 years → 5mg For PCI

clopidogrel

Plavix 75mg For ACS, MI, stroke, PAD

ticagrelor

Brilinta 180mg once, then 90mg BID [1 year], then 60mg BIDFor ACS, VTE prophylaxis

ticlopidine

Ticlid 250mg BID w/ foodFor ACS, MI, stroke, PAD

PAR-1 antagonist [antiplatelet]

vorapaxar [Zontivity] 2.08mg = vorapaxar sulfate 2.5mg

safest NSAID post-MI

naproxen [Naprosyn, Aleve]