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Acute Coronary Syndrome - Coggle Diagram

- - - - Will peak within 24-48 hours of an MI and then decrease steadily
- - - - mechanical reperfusion: performed by using intracoronary balloons, stents, and other devices.
      - Goal: to achieve reperfusion within 90-120mins of first medical contact.
    - - Indication: sx of ACS with onset within 12 hours of first medical contact, ST elevation of 1 mm or greater, anticipated that PCI cannot be performed within 120 mins of first medical contact
      - Absolute CI: any prior hemorrhagic storke, Ischemic stroke within past 3 months (except in past 4.5 hours), intracranial neoplasm or AV malformation, active internal bleeding, aortic dissection, considerable facial/head trauma, intracranaial or intraspinal surgery within past 2 months, sever, uncontrolled HTN that is unresponsive to emergency surgery,
      - Relative CI: BP > 180/110 on presentation or hx of chronic poorly controlled HTN, hx of AIS > 3 mo ago, recent major surgery less than 3 wks ago, traumatic or prolonged CPR > 10 min, recent internal bleeding, active peptic ulcer, non compressible vascular punctures, pregnancy, demential, oral anticoagulant therapy
      - Treatment
        
        Alteplase - 15 mg IVP over 1-2 mins then 0.75 mg/kg max 50mg IV over 30 min then 0.5 mg/kg max 35 mg IV over 60 mins - total dose do not exceed 100 mg
        
        Reteplase: 10 units IVP over 2 mins x 2 doses given 30 mins apart
        
        Tenecteplase: < 60 kg: 30 mg IVP, 60-69 kg: 35 mg IVP, 70-79 kg: 40 mg IVP, 80-89 kg: 45 mg IVP, >90 kg: 50 mg IVP administer push over 5 seconds
    - - ASA: 162-325 mg LD followed by 81 mg MD
      - Clopidogrel 600 mg LD followed by 300 mg daily - no loading dose given if age >75
      - Prasugrel, Cangrelor, Ticagrelor: no recommendation
  - - - clopidogrel: 600 mg loading dose 75 mg maintenance dose for STEMI and early invasive NSTEMI. Ischemia NSTEMI loading dose of 300 mg and maintenance dose of 75 mg
      - prasugrel: 60 mg loading dose and 10 mg maintenance dose in STEMI and early invasive NSTEMI
      - Ticagrelor: 180mg loading dose and 90 mg BID maintenance dose for STEMI, and NSTEMI
    - - Abciximab: 0.25 mg/kg IV bolus, followed by 0.125 mcg/kg/min (maximum 10 μg/min) IV infusion for 12 hours after PCI. Same for STEMI and NSTEMI.
      - Eptifibatide: 180 mcg/kg IV bolus x 2 given 10 minutes apart, followed by 2 mcg/kg/min IV infusion started after first bolus and continued for 18-24 hours after PCI. The same for STEMI and NSTEMI.
      - Tirofiban: 25 mcg/kg IV bolus, followed by 0.15 mcg/kg/min. The same for STEMI and NSTEMI.
      - MOA: inhibit the binding of fibrinogen to GP IIb/IIIa receptors to inhibit platelet aggregation.
  - - - Primary PCI
        
        Bivalruidn: 0.75 mg/kg IV bolus followed by 1.75 mg/kg/hr IV infusion until completion of PCI - if CrCl less than 30 reduce infusion to 1 mg/kg/hr
        
        Enoxaparin: 0.5 mg/kg one time IV bolus
        
        Fonduparinux: no recommendation
        
        UFH: No GP IIb/IIIa:: 70-100 unit/kg IV bolus, GP IIb/IIIa: 50-70 units/kg IV bolus
      - Fibrinolytic Reperufsion
        
        Bivalruidin: no recommendation
        
        Enoxaparin: 30 mg IV bolus followed by 1 mg/kg SC q12h for 8 days or d/c
        
        Fondaparinux: 2.5 mg IV x1 followed by 2.5 mg SC daily for 8 days or hospital d/c
        
        UFH: 60 units/kg max 4000 units IV bolus followed by 12 units/kg/hr max rate 1000 units/hr
    - - Early invasive Strategy
        
        Bivalrudin: 0.10 mg/kg IV bolus, followed by 0.25 mg/kg/hr IV infusion until completion of PCI
        
        Enoxaparin: 1 mg/kg SC q12h until completion of PCI
        
        Fonduparinux: 2.5 mg SC daily until PCI
        
        UFH: 60 units/kg max 4000 units followed by 12 units/kg/hr max 1000 units/hr
      - Ischemia Driven Strategy
        
        Bivalrudin: no recommendation
        
        Enoxapairn: 1 mg/kg SC q12h during hospitalization
        
        Fondaprinux: 2.5 mg SC daily for up to 8 days or duration of hospitalization
        
        UFH: 60 units/kg max 4000 units IV bolus, followed by 12 units/kg/hr max 1000 units/hr