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2.1) My Cards > 2. MTB Step 3 - Acute Coronary Syndrome (ACS) > Flashcards

2. MTB Step 3 - Acute Coronary Syndrome (ACS) Flashcards

Card Complete: Day 1: 4/24/2019 * Day 2: 4/26/2019 * Day 3: 5/4/2019 * Day 4: 5/24/19 Day 5: 6/23/19

1
Q

ACUTE CORONARY SYNDROMES (ACS)

The Definition of Acute Coronary Syndrome (ACS) involves which (5) criteria?

A
  1. Chest Pain that is Acute
  2. Chest Pain with exertion or at rest
  3. ECG shows ST-segment Elevation, Depression, or Normal
  4. Not based on Cardiac Enzyme levels, Angiography, or “Stress” Test results
  5. Based on History of Chest Pain with features suggestive of Ischemic Disease
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2
Q

ACUTE CORONARY SYNDROMES (ACS)

What is the Best INITIAL Therapy for ALL cases of Acute Coronary Syndrome (ACS)?

A

Aspirin

*has an instant effect on Inhibiting Platelets*

**Reduces Mortality by 25% for Acute MI**

***Reduces Mortality by 50% for “Unstable Angina”***

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3
Q

ACUTE CORONARY SYNDROMES (ACS)

One of (2) Medications is added to Aspirin for ALL patients with Acute MI. What are these (2) Medications?

A
  1. Clopidogrel, or
  2. Ticagrelor

*Prasugrel** is given ONLY when Angioplasty is done***

**Clopidogrel, Ticagrelor,** or **Prasugrel** are given to EVERYONE getting Angioplasty or Stent****

***MOA** for these 3 drugs **= P2Y12 Antagonists -** Block aggregation of Platelets to each other by Inhibiting ADP-Induced activation of the P2Y12 Receptor*****

****Clopidogrel** and **Prasugrel** are in the Thienopyridine class******

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4
Q

ACUTE CORONARY SYNDROMES (ACS)

What are (2) Important Properties/Facts about Thrombolytics and Primary Angioplasty in patients with Acute Coronary Syndromes (ACS)?

A
  1. Both Lower Mortality in a patient with a STEMI
  2. Both are Dependent on Time (benefit markedly diminished with time)
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5
Q

​​ACUTE CORONARY SYNDROME (ACS)

  1. What is the Meaning of Primary Angioplasty?
  2. What is the Single Best evidence for Mortality Benefit with Angioplasty?
A
  1. Primary Angioplasty = Angioplasty during an Acute Episode of Chest Pain.
  2. The Single Best evidence = Infarction
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6
Q

ACUTE CORONARY SYNDROMES (ACS)

How much Time do you have to perform an Angioplasty in a patient diagnosed with STEMI?

A

Within 90-minutes of arrival at ED

*If Angioplasty cannot be performed within 90-mins of arrival in the ED, the patient should receive Thrombolytics*

**Angioplasty has NOT been shown to decrease mortality in stable angina any more than medical therapy with ASA, BB, and Statins**

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7
Q

ACUTE CORONARY SYNDROMES (ACS)

What (2) ECG Findings are considered Indications for Thrombolytics in a patient with Ischemic Chest Pain of < 12 hours?

A
  1. STEMI in 2 or more leads
  2. New LBBB

*Thrombolytics should be given within 30-mins of patient’s arrival in ED with pain*

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8
Q

ACUTE CORONARY SYNDROMES (ACS)

What Procedure has the Single Greatest Efficacy in Lowering Mortality in STEMI and is used in place of Thrombolytics in patients with a Contraindication?

A

Urgent Angioplasty

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9
Q

ACUTE CORONARY SYNDROMES (ACS)

What are (3) Steps in the Mechanism of Action (MOA) of Thrombolytics?

A
  1. Thrombolytics activate Plasminogen –> Plasmin.
  2. Plasmin then cleaves fresh or newly formed Fibrin strands–> D-dimers.
  3. After several hours, the Fibrin Clot has been Stabilized by Factor XIII (Plasmin cannot cleave fibrin once Stabilized)
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10
Q

ACUTE CORONARY SYNDROMES (ACS)

Explain the Mortality Benefits of Beta-Blockers, ACE Inhibitors (ACEIs), and Angiotensin Receptor Blockers (ARBs).

A
  1. Beta-Blockers Lower Mortality, but the timing of administration is not critical (eg, Metoprolol)
  2. ACEIs & ARBs should be given to ALL patients with ACS, but they only Lower Mortality if there is:
    • LV Dysfunction, or
    • Systolic Dysfunction

**Make sure to order a Lipid Profile & start the patient on an HMG CoA Reductase Inhibitors, if indicated (i.e., if LDL is not at goal)**

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11
Q

ACUTE CORONARY SYNDROMES (ACS)

  1. What is the Most Common Cause of Death in both CHF and MI?
  2. What is the (2) Mechanisms of Action (MOA) of Beta-Blockers in MI?
A
  1. The Most Common cause of Death in both CHF and MI is a VENTRICULAR ARRHYTHMIA brought on by Ischemia.
  2. BBs are both Antiarrhythmic and Anti-Ischemic. Slower HR means More Time for Coronary Artery Perfusion. Increased LV filling time Increases both SV and CO.
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12
Q

ACUTE CORONARY SYNDROMES (ACS)

What are (6) Therapies for ACS that ALWAYS Lower Mortality?

A
  1. Aspirin
  2. Clopidogrel, Prasugrel, Ticagrelor
  3. Metoprolol
  4. Statins
  5. Primary Angioplasty
  6. Thrombolytics
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13
Q

ACUTE CORONARY SYNDROMES (ACS)

What are (3) Therapies for ACS that Lower Mortality only in certain conditions?

A
  1. ACEIs if EF is Low
  2. ARBs if EF is Low
  3. Heparin if ST-depression
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14
Q

ACUTE CORONARY SYNDROMES (ACS)

What are (6) Therapies for ACS that do NOT Lower Mortality?

A
  1. Morphine
  2. Oxygen
  3. Nitrates
  4. CCBs
  5. Lidocaine
  6. Amiodarone
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15
Q

ACUTE CORONARY SYNDROMES (ACS)

Under what (3) Conditions is Prasugrel, Clopidogrel, or Ticagrelor the answer?

A
  1. Aspirin Allergy
  2. Undergoing Angioplasty
  3. Acute Infarction occurring

**Add one of them to ASA when there is an Acute MI**

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16
Q

ACUTE CORONARY SYNDROMES (ACS)

Under what (3) Conditions are Calcium Channel Blockers (eg, Verapamil, Diltiazem) the answer?

A
  1. Intolerant to Beta-Blockers (eg, severe reactive airway disease; asthma)
  2. Cocaine-induced Chest Pain
  3. Coronary Vasospasm/Prinzmetal Angina
17
Q

ACUTE CORONARY SYNDROMES (ACS)

Under what (5) Conditions is Pacemaker the answer for Acute MI?

A
  1. Symptomatic Bradycardia
  2. New LBBB
  3. Bifascicular Block
  4. Mobitz Type II, Second-degree AV Block
  5. Third-degree (complete) AV Block
18
Q

ACUTE CORONARY SYNDROMES (ACS)

Under what (2) Conditions are Lidocaine or Amiodarone the answer for Acute MI?

A
  1. Ventricular Tachycardia (V-Tach)
  2. Ventricular Fibrillation (V-Fib)
19
Q

ACUTE CORONARY SYNDROMES (ACS)

What are (7) Complications of Myocardial Infarction (MI)?

A

Complications of MI:

  1. Cardiogenic Shock
  2. Valve rupture
  3. Septal rupture
  4. Myocardial Wall rupture
  5. Sinus Bradycardia
  6. Third-degree (complete) Heart Block
  7. Right Ventricular Infarction
20
Q

ACUTE CORONARY SYNDROMES (ACS)

What Condition can ALL of the (7) Complications of MI cause?

A

HYPOTENSION

21
Q

ACUTE CORONARY SYNDROMES (ACS)

  1. What are (2) Diagnostic Methods for Cardiogenic Shock?
  2. What are (2) Treatments for Cardiogenic Shock?
A
  1. Echo, Swan-Ganz (right heart) catheter
  2. ACEI, Revascularization (urgently)
22
Q

ACUTE CORONARY SYNDROMES (ACS)

  1. What is the Best INITIAL Diagnostic Test for Valve Rupture?
  2. What are (3) Treatments for Valve Rupture?
A
  1. Echo
  2. ACEI, Nitroprusside, Intra-aortic Balloon pump as a bridge to surgery
23
Q

ACUTE CORONARY SYNDROMES (ACS)

  1. What are (2) Diagnostic Methods for Septal Rupture?
  2. What are (3) Treatments for Septal Rupture?
A
  1. Echo, Right Heart Catheter (shows ste-up in saturation from the RA to RV)
  2. ACEI, Nitroprusside, Urgent Surgery
24
Q

ACUTE CORONARY SYNDROMES (ACS)

  1. What are (1) Diagnostic Method for Myocardial Wall Rupture?
  2. What are (2) Treatments for Myocardial Wall Rupture?
A
  1. Echo
  2. Pericardiocentesis, Urgent Cardiac Repair
25
Q

ACUTE CORONARY SYNDROMES (ACS)

  1. What is (1) Diagnostic Method for Sinus Bradycardia?
  2. What are (2) Treatments for Sinus Bradycardia?
A
  1. ECG
  2. Atropine, followed by Pacemaker (if there are still symptoms)
26
Q

ACUTE CORONARY SYNDROMES (ACS)

  1. What is (1) Diagnostic Method for Third-degree (complete) Heart Block?
  2. What are (2) Treatments for Third-degree (complete) Heart Block?
A
  1. ECG (canon “a” waves)
  2. Atropine, followed by a Pacemaker (even if symptoms resolve)
27
Q

ACUTE CORONARY SYNDROMES (ACS)

  1. What is (1) Diagnostic Method for Right Ventricular Infarction?
  2. What is (1) Treatment for Right Ventricular Infarction?
A
  1. ECG showing RV leads
  2. Fluid Loading
28
Q

ACUTE CORONARY SYNDROMES (ACS)

What is the Mechanism of Septal Rupture Systolic Murmur?

A

Left Ventricular pressure is greater than Right Ventricular pressure. This causes Left-to-Right shunt of Oxygenated Blood. Oxygen saturation in the Right Ventricle is markedly increased compared with the Right Atrium.

29
Q

ACUTE CORONARY SYNDROMES (ACS)

What are (5) Medications ALL patients should go home on Post-MI?

A
  1. Aspirin
  2. Clopidogrel (or prasugrel)
  3. Beta-Blocker
  4. Statin
  5. ACEI
30
Q

ACUTE CORONARY SYNDROMES (ACS)

How long should a patient wait to have Sex Post-MI?

A

2 - 6 weeks

31
Q

ACUTE CORONARY SYNDROMES (ACS)

What are (3) Prominent Differences in the Management of Non-ST Segment Elevation MI (NSTEMI)?

A
  1. NO Thrombolytic use
  2. Heparin is used routinely (LMWH is superior to unfractionated)
  3. Glycoprotein IIb/IIIa Inhibitors LOWER MORTALITY (particularly in those undergoing angioplasty)
    • Eptifibatide
    • Tirofiban
    • Abciximab
32
Q

ACUTE CORONARY SYNDROMES (ACS)

The single Greatest Benefit from GP IIb/IIIa Inhibitors in patients with Acute Coronary Syndromes (ACS) come in combination with which Procedure?

A

Angioplasty w/ Stent placement

33
Q

ACUTE CORONARY SYNDROMES (ACS)

What is the Mechanism of Action (MOA) for Heparin?

A

Heparin potentiates the effect of Antithrombin. Antithrombin inhibits almost every step of the Coagulation Cascade. This is why it does NOT work with Antithrombin Deficiency.

Heparin only prevents NEW Clots from forming.

34
Q

ACUTE CORONARY SYNDROMES (ACS)

What are the ONLY (2) Indications for the use of Thrombolytics in a patient with an Acute Coronary Syndrome (ACS)?

A
  1. STEMI
  2. New LBBB

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