Author Archive for: srrezaie

The Death of MONA in ACS: Part IV – Aspirin

05 Nov
November 5, 2017

Background: Aspirin is the most widely used antiplatelet agent in acute coronary syndromes.  The bulk of the evidence for this came from the second international study of infarct survival (ISIS-2) published in the Lancet in 1988. Read more →

The Death of MONA in ACS: Part III – Nitroglycerin

05 Nov
November 5, 2017

Background: Nitroglycerin is a first line agent in the treatment of ACS. The physiologic basis for it’s use rests on it’s ability to promote coronary vasodilation resulting in increased blood flow to the coronary arteries . Nitroglycerin, is typically given as sublingual tablets or sublingual spray of 0.3 – 0.4mg q5min x3 for ischemic chest pain and only after this is IV NTG given for persistent pain. Read more →

The Death of MONA in ACS: Part II – Oxygen

05 Nov
November 5, 2017

Background: The first report for supplemental oxygen for angina was in 1900, and since then oxygen therapy has been a commonly used treatment of patients with ST-Elevation Myocardial Infarction (STEMI).  The reason for this is the belief that supplemental oxygen will increase oxygen delivery to ischemic myocardium and help reduce myocardial injury.  This belief is based off lab studies and older clinical trials, but there have been other studies that suggest potential adverse physiologic effects of supplemental oxygen in acute coronary syndromes (ACS) (i.e reduced coronary blood flow, increased coronary vascular resistance, and production of reactive oxygen species) causing vasoconstriction and reperfusion injury. Read more →

The Death of MONA in ACS: Part I – Morphine

05 Nov
November 5, 2017

Background: Morphine is a commonly used medication in acute coronary syndromes (ACS) to help relieve pain which in turn can help reduce sympathetic tone.  Over the past few years however, there has been some concern raised about the drug-drug interactions with antiplatelet agents causing impaired platelet inhibition as well as an association with worsened clinical outcomes.  P2Y12 receptor antagonists (i.e. Clopidogrel, Pasugrel, Ticagrelor) are typically administered with aspirin (dual anti-platelet therapy) as one of the cornerstones of treatment for ACS.  This drug-to-drug interaction can cause delayed inhibition of platelet activation and potentially worsen clinical outcomes. Read more →

NSTEMIs Are Not All the Same

30 Oct
October 30, 2017

Background: Acute coronary syndrome (ACS) is a true spectrum of disease: STEMI, NSTEMI, Unstable Angina (UA), and Stable Angina (SA).  The history and physical plus ECG help us to differentiate patients with STEMI from NSTEMI.  Classically, STEMI represents complete occlusion of a culprit artery and this finding requires immediate coronary angiography and revascularization.  It turns out that there is a subset of NSTEMI patients that also have complete total occlusion (TO) of culprit arteries despite not having true ST elevation on ECG, which unfortunately causes delays in definitive treatment. Read more →

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