Cardiovascular Critical Care I
Predominant interventions on presentation/onset for stabilization – Any ACS
Nitrates
| • | Can facilitate coronary vasodilation and may also be helpful in scenarios of severe |
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cardiogenic pulmonary edema caused by increased venous capacitance
| • | Nitroglycerin (NTG) 0.4 mg sublingually every 5 minutes for total of THREE doses; |
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afterward, assess need for IV NTG
| • | IV NTG is indicated in the first 48 hr after onset of ischemia, HF, or hypertension but |
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should not preclude therapy such as β-blockers or ACE inhibitors when indicated
Should NOT be administered:
| • | If SBP < 90 mm Hg OR if SBP is > 30 mm Hg below baseline |
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| • | If severe bradycardia (including heart block) with HR ≤ 50 beats/min |
| • | If tachycardia (HR ≥ 100 beats/min) in the absence of symptomatic HF |
| • | RV infarction, as evidenced by ischemic changes in inferior leads on ECG |
| • | If patient has received an oral phosphodiesterase inhibitor or riociguat within the past |
24–48 hr
Aspirin
| • | Inhibits platelet activation |
|---|---|
| • | Four aspirin 81 mg each (324 mg total) or one 325 mg tablet (non–enteric coated) should be |
chewed and swallowed immediately
β-Blockade
| • | Decreases risk of ventricular arrhythmias and sudden cardiac death in early post-MI period |
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| • | Decreases HR and myocardial oxygen demand and increases diastolic filling time of |
ventricles, thereby improving oxygen flow through the coronary arteries
β-Blockade should be initiated within the first 24 hr of an ACS unless:
| • | There are signs of HF |
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| • | Active evidence of other shock states |
| • | If at increased risk of cardiogenic shock (SBP < 120 mm Hg, HR > 110 beats/min or < 60 |
beats/min, age > 70, and increased time since onset of symptoms)
Relative contraindications to β-blockade include:
| • | PR interval > 0.24 s, second- or third-degree heart block, and active asthma/reactive |
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airway disease
*Note: Intravenous β-blockers may be particularly harmful in patients with risk factors for
shock.
Other
precautions
| • | Any NSAID other than aspirin should be avoided and/or discontinued for reasons beyond |
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GI bleeding and nephrotoxicity, which may include reinfarction, hypertension, HF
exacerbation, myocardial rupture, and overall increased risk of mortality associated with
their use
ACS = acute coronary syndrome(s); GI = gastrointestinal; HF = heart failure; IV = intravenous; LMNOP = lasix-morphine-nitro-oxygen-position/positive pressure
ventilation; NSAID = nonsteroidal anti-inflammatory drug; RV = right ventricular; Sao2 = arterial oxygen saturation.
426; Circulation 2013;127:e362-425) (continued)