129 Management of Acute Coronary Syndromes

Question 1

ST segment elevation myocardial infarction

Answer 1

usually associated with: Total obstruction without good residual flow and a large degree of heart damage

Question 2

Spectrum of CAD

Answer 2

Question 3

Platelet activation in vascular injury/ACS

Answer 3

Question 4

Mechanisms of oral antiplatelet therapies

Answer 4

Question 5

Intersection of anti-platelet and anti-coagulation cascade drugs for ACS

Answer 5

Question 6

New Classification of MI

Answer 6

• 1 Spontaneous MI related to ischemia due to a primary coronary event, such as plaque erosion and/or rupture, fissuring, or dissection
• 2 MI secondary to ischemia due to an imbalance of O2 supply and demand, as from coronary spasm or embolism, anemia, arrhythmias, hypertension, or hypotension
• 3 Sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggesting ischemia with new ST-segment elevation; new left bundle branch block; or pathologic or angiographic evidence of fresh coronary thrombus—in the absence of reliable biomarker findings
• 4a MI associated with PCI
• 4b MI associated with documented in-stent thrombosis
• 5 MI associated with CABG surgery

Question 7

Time course of MI enzyme markers

Answer 7

Re-establishemnt of blood flow makes the enzyme markers peak earlier

Question 8

STEMI Guidelines:
Acute Medical Therapy

Answer 8

Question 9

“Wavefront” Phenomenon

Answer 9

Question 10

Fibrinolytic Reperfusion—Pros and Cons

Answer 10

Question 11

Currently Available Fibrinolytics

Answer 11

Question 12

Risk Score for UA/NSTEMI (7)

Answer 12

1. Age ≥65 y
2. ≥3 CAD risk factors (high cholesterol, family history, hypertension, diabetes, smoking)
3. Prior coronary stenosis ≥50%
4. Aspirin in last 7 days
5. ≥2 anginal events ≤24 h
6. ST-segment deviation

7.Elevated cardiac markers
(CK-MB or troponin)

N-STEMI:

• Reinfarction occurs more frequently than following STEMI
• There is less of an urgency to perform PTCA within 90 minutes of presentation
• Discharge medications are identical to patients with STEMI
• The incidence of mortality at one year is similar to patients with STEMI

Question 13

Risk Stratification
to Target Therapies in UA/NSTEMI

Answer 13

*Aspirin super effective*, clopidogrel on top of aspirin increased benefit, with or without PCI benefit of GP2b3a inhibitor FOR PATIENTS WITH POSITIVE TROPONINS

•Four classes of anticoagulants are available

–Unfractionated heparin (UFH)

–Low-molecular-weight heparins (LMWH)

–Direct thrombin inhibitors

–Factor Xa inhibitors

• Current guidelines support use of UFH and LMWH with enoxaparin preferred over UFH (Class IIa)
• Recent studies suggest direct thrombin inhibitors (bivalirudin) and factor Xa inhibitors (fondaparinux) may be appropriate new options for anticoagulation but in limited patient populations

Question 14

Medications at Discharge for NSTEMI

Answer 14

• •Antiplatelet therapy (aspirin/ADP antagonist such as clopidogrel/prasugrel/ticagrelor and for some—vorapaxar)
• •Beta blocker
• •Angiotensin converting enzyme inhibitor/angiotensin receptor blocker
• •Statin
• •Reduction of cardiac risk
  
  • –Control BP: 130/80
  • –Stop smoking
  • –Increase activity

Question 15

In-hospital mortality rate for ACS

Answer 15

4.8%

Hospitals that follow guidelines for therapy better have lower rates of mortality (5.95%–>4.16%)