Myocardial Infarction

The time it takes a patient to go from the door of the ED to recieving a PCI or thrombolytic

You want to open the coronary artery as soon as possible. If opened within an hour, there is a 47% reduction in death. If opened within 4 hours, that drops to 17%.

Revascularization therapy, PPCI or thrombolytic to break up / remove clot
DAPT (dual antiplatelet therapy) to ensure that once the clot is broken up, it doesn't reform
Anticoagulant for the same reason
Beta-blocker (given IV loading dose if patient not already taking PO, in order to reduce risk of arrythmia and preserve myocardial viability to reduce HF after MI cleared)
IV NTG or NTG paste along with IV morphine for pain relief

Anticoagulant continued for 48 hours to up to 8 days, run risk of HIT if using heparin for over 6 days
Discontinue NTG or swap to oral nitrate after 24 hours
Beta-blockers continued indefinitely
DAPT continued for 12 months, then single antiplatelet indefinitely
ACE I or ARB PO started within 24 hours and continued indefinitely (ACE I are the prils, lisinopril, enalapril, ect) (ARBs are the sartans, losartan, olmesartan, ect.)

PPCI prefered over thrombolytic unless the wait time from arrival to the ED to surgery will be greater than 2 hours, in this case it is better to get thrombolytics started earlier.

Thrombolytics should not be used if it has been more than 12 hours since the onset of STEMI, PPCI can still be performed for up to 24 hours if there is still evidence of ischemia.

They should be initiated within the first 24 hours as long as there are no signs of HF, evidence of a low output state, at an increased risk for cardiogenic shock, or there are other contraindications to beta blocker use, such as first, second, or third degree heart (AV) block, active asthma, or reactive airway disease.

ACE inhibitors are reasonable for all STEMI patients.

ARBS should be given to patients with STEMI who are intolerant to ACE I.

the prils, enalapril, lisinopril, ect.

the sartans, losartan, olmesartan, ect.

Aldosterone antagonists (diuretics, eplerenone, spironolactone) should be given to patients who have already recieved an ACE I and a beta blocker, who have an ejection fraction of <0.4 and either symptomatic HF or diabetes mellitus.

Potassium sparing diuretics, eplerenone and spironolactone

High intensity statins can be given to all STEMI patients unless there is a contraindication, regardless of immediate LDL levels, then ezetimibe or PCSK9 inhibitors can be added if LDL levels are still too high, or dose can be decreased if LDL levels too low later on.

Aspirin is recommended therapy and should already be given to all STEMI patients as part of DAPT therapy.

Acetaminophen, colchicine (anti-inflammitory primarily used for gout), or narcotic analgesics may be given if a higher dose aspirin is not effective.

DO NOT give glucocorticoids or NSAIDS (taking away beneficial effects of aspirin), as they are potentially harmful.

Avoid use when APAP, nonacetylated salicylates, or nonselective NSAIDs can provide relief, use lowest dose of any NSAIDs and combine with APAP or aspirin therapy.

Avoid use of:
Sulindac
Diclofenac
Celecoxib
Meloxicam
Etodolac
(drugs ending in ac plus celecoxib and meloxicam)

Metoprolol tartrate 100mg BID
Atenolol 50mg BID

HR<45 BPM
severe 1st (PR interval above 240ms), type 1 second, or third degree AV block
Symptomatic hypotension BP<90/50 with confusion, chest pain, or unconciousness
Reynaud's phenomenon with hypertension (caused by cold, hypertension in fingers, ok to use if no hypertension)

Diabetes mellitus, can supress most of the signs of hypoglycemia, aside from sweating. Important to counsel on this risk and have a home blood glucose monitor
Asthma or reactive airway disease, should not use nonselective beta blockers (metoprolol and atenolol are both cardioselective). Even with cardioselective, patient should have a beta-2 agonist inhaler for emergencies, and should not use any beta blocker in patients with moderate to severe persistent asthma.
Hypotension
low grade 1st degree AV block

Carvedilol
*Metoprolol*
Nebivolol
Timolol
Propranolol

Eliminated by the liver

Quinidine (antiarrythmic)
paroxetine (SSRI)
propefenone (antiarrythmic)
propoxyphene (opioid)
dronedarone (antiarrythmic)
amiodarone (antiarrythmic)
diphenhydramine (antihistamine)
mirabegron (beta-3 adrenoceptor agonist, for urinary retension)

Renally

In patients who have hepatorenal syndrome (poor liver and renal function) who need beta blocker treatment during the peri-infarction period. Afterwards, they would not take a maintinence beta blocker.

Beta blockers: reduced excercise tolerance
Nitrates: headache
ACE Inhibitors: Cough
CCB: ankle swelling

You don't, risk of hypotension is too high.

pregnancy
previous angioedema (fluid swelling under the skin)
bilateral (both sides) renal artery stenosis

Dry nagging cough (no colored sputum)
May cause large drop in blood pressure for patients who are hypovolemic or hyponatremic (use a small test dose if suspected)
May cause hyperkalemia, less likely when combined with loop or thiazide diuretics. Avoid use with potasium sparing diuretics (spironolactone, eplerenone) if potassium is too high.

monopril

Captopril, lisinopril, enalaprilat, safter in severe liver disease

captopril 6.25mg one time

Check SCr after initiation
<30% reduction, no dose change
30-50% reduction, reduce dose by 50% and check again in 4 weeks
>50% reduction, half ACE inhibitor and check for reversable causes (hypovolemia or hyponatremia). In absence of these, check for bilateral renal artery stenosis.

Blood pressure should stay >90/60

Serum potassium should be 3.5-5.0mEq/L

Captopril, moexipril, benazepril, and quinipril

Nobody, more adverse events

pregnancy
use in caution with bilateral renal artery stenosis

losartan (has active metabolite)

Sulfamethoxazole
Amiodarone
Dronedarone
Metronizadole
Fluconazole
Voriconazole
(oles plus dronedarone and amiodarone which also inhibits 2D6 and 3A4)

losartan by 50%

Telmisartan

Losartan and valsartan, these 2 are also dosed BID

Reduce if K>4.7 mEq/L, hold if K>5 mEq/L