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    Myocardial Infarction - STEMI

    heart attack

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    Assessment & Plan (short)

    # Myocardial Infarction - STEMI
    Patient presented with chest discomfort with concern for STEMI given troponinemia and EKG with ***; now s/p cath lab with ***.
    - s/p ASA 325, P2Y12, heparin gtt, SL Nitro PRN
    - CBC, BMP, Lactate, Trop, EKG
    - CPO, Telemetry
    - Continue ASA 81 QD, P2Y12
    - Atorvastatin 80mg QD
    - BB and ACEi/ARB within 24 hours

    Educational

    #STEMI, Type I NSTEMI, or Unstable Angina

    Coronary evaluation:
    -EKG, trop, TTE WMA, Stress, LHC.

    Antithrombotic:
    -ASA: Cont. ASA 81mg PO QD x life.
    -P2Y12:-Clopidogrel (Plavix) load 600mg PO x 1 then 75mg qD (some resistance particular in East Asian and Pacific Islander).
    -Ticagrelor (Brilinta) load 180mg PO x 1 then 90mg BID (may cause bradycardia and/or SOB).
    -Prasugrel (Efient, Effient) load 60mg PO x 1 then 10mg PO qD (contraindicated if h/o CVA).
    -IIb/IIIa:
    --Eptifibatide (Integrilin): Can be given “up front” prior to cath.
    --Abciximab (ReoPro): Okay in ESRD, can be given only after cath

    Anticoagulation:
    -Heparin bolus and gtt.

    Demand reduction:
    -Nitrates: (SLNTG, nitro paste, nitro gtt).
    -BB: (within 24 hours of MI).
    -ACE/ARB: (within 24 hours of MI).
    -CCB: (if intolerant to BB).
    -Pain medication: (Morphine a/w increased mortality in retrospective studies, if possible maximize above and use fentanyl).
    -Advanced meds: Ranolazine (Renexa) for intractable UA, avoid in renal/liver failure and with long QTC.

    Antiinflammatory/Antilipid:
    -Start Atorva 80mg QHS.
    -If admitted for ACS on high intensity statin and LDL > 50, consider adding Zetia 10mg PO QHS.
    -If familial hyperlipidemia or cannot tolerate statin, consider PCSK9.
    -In acute MI, avoid NSAIDs & steroids if at all possible.
    -Defer screening and management of DM2 and inflammatory dz to PCP.

    Organ systems
    • Cardiovascular
    Medical field
    • Internal medicine
    Setting
    • Inpatient
    Author
    Eric Lee
    Page info

    Originally created: March 3, 2020 by Eric Lee

    [xyz-ips snippet="lastupdated"] [xyz-ips snippet="sectioneditor"] [post-views]

    Number of revisions: [xyz-ips snippet="numrevisions"]

    References
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