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Cardiology > 268 NSTEMI > Flashcards

268 NSTEMI Flashcards

1
Q

Topical or oral nitrates can be used when the pain has resolved or they may replace intravenous nitroglycerin when patient has been symptom free for how long?

A

12-24 hours

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2
Q

Most common etiology of coronary thrombosis

A

Plaque rupture

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3
Q

Vulnerable plaques

A

Eccentric stenosis with scalloped or overhanging edges and a narrow neck
Lipid core with thin fibrous cap

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4
Q

Genetic variant related to Inadequate response to clopidogrel

A

CYP450 involving 2C19

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5
Q

Demonstrates the transient coronary spasm in Prinzmetal variant angina

A

Coronary angiography

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6
Q

Main therapeutic agents in Prinzmetal Variant Angina

A

Nitrates and calcium channel blockers

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7
Q

Most dangerous manifestation of ischemic heart disease

A

Acute coronary syndrome

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8
Q

Mode of action of nitrates

A

Venous vasodilation with concomitant reduction in LV end diastolic volume

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9
Q 
A 50M complains of chest heaviness associated with shortness of breath and diaphoresis 5 hours PTC. He lost consciousness and pronounced dead at the ER. Which type of myocardial infarction will you classify the patient?
A. Type 1
B. Type 2
C. Type 3
D> Type 4
A

Type 3

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10
Q

pathophysiology of NSTE-ACS

A

disruption of an unstable coronary plaque due to plaque rupture, erosion or a calcified protruding nodule tat leads to intracoronary arterial vasoconstriction, 2. coronary arterial vasoconstriction, 3. gradual intraluminal narrowing, 4. increased myocardial oxygen demand

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11
Q

most common etiology of coronary thrombosis

A

Plaque rupture

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12
Q

description of the vulnerable plaque

A

eccentric stenosis with scalloped or overhanging edge and narrow neck on coronary angiogrpahy

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13
Q

True or false. Vulnerable plaques are composed of lipid rich core with thin fibrous cap

A

True.

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14
Q

True or false. NSTE-ACS is based largely on clinical presentation.

A

True.

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15
Q

Typical chest discomfort.

A

one of three features: 1. occurrence at rest or with minimal exertion lasting more than 10 mins 2. of relatively recent onset within the prior 2 week and 3. a crescendo pattern, distinctly more severe, prolonged or frequent than previous episodes

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16
Q

Location of chest discomfort

A

substernal region, radiates to left arm, left shoulder, and/or superiorly to the neck and jaw

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17
Q

anginal equivalents

A

dyspnea, epigastric discomfort, nausea or weakness

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18
Q

subset of patients who may present with anginal equivalent

A

women, elderly, patients with diabetes

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19
Q

ECG findings of NSTE ACS

A

deep t wave inversion of more than 0.3 mV;

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20
Q

True or false. New ST segment depression occurs in one third of patient with NSTE-ACS

A

True.

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21
Q

minor elevations in cTn in patients without clinical history of myocardial ischemia

A

seen in patients with heart failure, myocarditis, pulmonary embolism

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22
Q

characteristic temporal rise and fall post onset of symptoms

A

Peaking 12-24 hrs post onset of symptoms

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23
Q

Non cardiac or systemic causes of elevated cTn

A

pulmonary embolism, trauma, hypo or hyperthyroidism, renal failure, sepsis, shock, stroke, rhabdomyolysis

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24
Q

when to take or repeat cardiac biomarkers

A

obtained at baseline and at 4-6 hour and 12 hours after presentation

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25
Q

True or false. Patients with NSTE ACS should be placed at bed rest with continuous ECG monitoring for ST segment deviation and cardiac arrhytmias, preferably a specialized cardiac unit

A

True.

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26
Q

when is ambulation permitted in the patient with NSTE ACS

A

no recurrence of ischemia and does not develop an elevation of biomarker of necrosis for 12-24 hours

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27
Q

when is oxygen supplementation given

A

O2 sat less than 90% and or in those with heart failure and rales

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28
Q

absolute contraindication to nitrates

A

hypotension and recent use of PDE5 inhibitor within the 24 hr

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29
Q

how should nitrates be given

A

Nitroglycerin 03.-0.6 mg q 5mins apart

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30
Q

how to give nitroglycerin IV

A

10 ug/min every 3-5 mins until symptoms are relieved, or SBP falls to less than 90 mmHg or dose reaches 200 ug/min

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31
Q

max dose of nitroglycerin

A

200 ug/min

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32
Q

when is IV nitrate be shifted to oral

A

patient has been symptom free for 12-24 hrs

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33
Q

mainstay of anti ischemic treatment

A

beta blockers

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34
Q

target heart rate

A

50-60 bpm

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35
Q

when is beta blocker avoided

A

severe heart failure, low cardiac output, hypotension, active bronchospasm, high degree AV block

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36
Q

recommended for patients who have persistent symptoms or ECG signs of ischemia after treatment with full dose nitrates and beta blockers and in patients with contraindications to either drug class

A

calcium channel blockers like verapamil

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37
Q

add on medication if LDL C is not on target with statin

A

Ezetimibe 10 mg OD

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38
Q

drug that causes irreversible blockade of the platelet PY212 receptor

A

clopidogrel

39
Q

loading and maintenance dose of clopidogrel

A

600 or 300 mg loading dose then 75 mg OD maintenance dose

40
Q

relative reduction in cardiovascular death, MI, stroke compared to aspirin alone vs DAPT

A

20.00%

41
Q

Drugs commonly used in intensive medical management of patients with UA and NSTE ACS

A

nitrates, beta blockers, calcium channel blockers, morphine sulfate

42
Q

dose of metoprolol

A

25-50 mg q6hrs

43
Q

dose of morphine

A

2-5 mg IV every 5- 30mins as needed

44
Q

initial treatment for NSTE ACS

A
  1. aspirin, 2. P2Y12 inhibitor: clopidogrel or ticagrelor; 3. anticoagulant: enoxaparin, fondaparinoux, bivalirudin, 4. GP Iib/IIIa receptor inhibitor in high risk patient fot early invasive strategy: epitifibatide or tirofiban
45
Q

During hospitalization. Medically treated.

A

aspirin, P2Y12 inhibitor, anticoagulant.

46
Q

During hospitalization. PCI treated

A

aspirin, P2Y12 inhibitor, anticoagulant, GP Iib/IIIa inhibitor

47
Q

Long term. Medically treated

A

aspirin and clopidogrel for 12 months

48
Q

long term. PCI treated

A

aspirin and clopidogrel for 12 months

49
Q

oral antiplatelets

A

aspirin, clopidogrel, prasugrel, ticagrelor

50
Q

intravenous antiplatelet

A

abciximab, eptifibatide, trifiban, cangrelor

51
Q

anticoagulants

A

UFH, enoxaparin, fondaparinaux, bivalirudin

52
Q

Dose prasugrel

A

loading pre PCI: 60 mg then 10 mg OD

53
Q

Dose ticagrelor

A

Loading 180 mg then 90 mg BID

54
Q

dose aspirin

A

325 mg nonenteric formulation then 75-100 mg OD

55
Q

dose clopidogrel

A

300-600 mg loading dose then 75 mg OD

56
Q

dose abciximab

A

0.25 mg/kg bolus then 0.125 ug/kg per min for 12-24 hr

57
Q

max dose of abciximab

A

10 ug/min

58
Q

dose of eptifibatide

A

180 ug/k bolus then 10 min later second bolus of 180 ug/kg then 2 ug/kg per min for 72-96 hr following first bolus

59
Q

dose of tirofiban

A

25 ug/k per min then 0.15 ug/kg per min for 48-96 hrs

60
Q

dose of cangrelor

A

30 ug/kg followed by 4 ug/kg per min

61
Q

dose of enoxaparin

A

1 mg/kg SQ q12hrs

62
Q

when to dose adjust enoxaparin

A

CrCl less than 30 ml/min

63
Q

renal dose of enoxaparin

A

1 mg/kg SQ OD

64
Q

dose of fondaparinaux

A

2.5 mg SC OD

65
Q

dose of bivalirudin

A

0.75 mg/kg bolus then 1.75 mg/kg per hour

66
Q

dose of UFH

A

Bolus 70-100 U/Kg followed by infusion of 12-15 U/Kg per hour titrated to ACT250-300 s

67
Q

max bolus of UFH

A

5000 U

68
Q

target ATC in UFH

A

250-300 s

69
Q

potent reversible P2Y12 inhibitor

A

ticagrelor

70
Q

genetic variant that leads to inadequate response to clopidogrel

A

P450 2C19

71
Q

intravenous direct and rapidly activing P2Y12 inhibitor

A

cangrelor

72
Q

indirect factor Xa inhibitor

A

fondaparinux

73
Q

most important adverse effect of all antithrombotic agents

A

excessive bleeding

74
Q

when to do immediate invasive strategy for patients with NSTE ACS

A

refractory angina, signs or symptoms of heart failure or new or worsening mitral regurgitation, hemodynamic instability, sustained ventricular tachycardia or ventricular fibrillation

75
Q

when is immediate invasive

A

Within 2 hr

76
Q

when is early invasive

A

Within 24 hrs

77
Q

when is delayed invasive

A

Within 25-72 hrs

78
Q

when to do early invasive

A

Grace score more than 140; temporal change in troponin, new ST segment depression

79
Q

when to do delayed invasive

A

eGFR less than 60, EF less than 40%, early postinfarction angina, PCI within 6 months prior, GRACE score 109-140 or TIMI score than 2

80
Q

what is the target LDL-C

A

less than 70 mg/dL

81
Q

severe ischemic pain that usually occurs at rest and is associated with transient ST segment elevation

A

Prinzmetal variant angina

82
Q

what causes prinzmetal variant angina

A

focal spasm of an epicardial coronary artery with resultant transmural ischemia and abnormalities in left ventricular function

83
Q

diagnostic hallmark of Prinzmetal variant angina

A

coronary angiography demonstrates transient coronary spasm

84
Q

main therapeutic agents for prinzmetal variant angina

A

nitrates and calcium channel blocker

85
Q

most dangerous manifestation of ischemic heart disease

A

ACS

86
Q

most common cuase of nontraumatic chest pain presenting in the ER

A

gastrointestinal

87
Q

True or false. Myocardial ishcemic discomfort does not radiate to the trapezius muscle

A

True.

88
Q

Differential if the chest pain radiates to the trapezious muscle

A

pericarditis

89
Q

Canadian Cardiovascular Society Functional Classification. Experiences limitation in physical activity. Chest heaviness when climbing more than 1 flight of stairs

A

CCS III

90
Q

Canadian Cardiovascular Society Functional Classification. Angina present with strenuous or rapid or prolonged exertion at work or recreation

A

CCS I

91
Q

Canadian Cardiovascular Society Functional Classification. Comfortable at rest but walking more than two blocks on the level and climbing more than 1 flight of stairs at normal pace and in normal condition

A

CCS II

92
Q

Canadian Cardiovascular Society Functional Classification. Marked limitation in ordinary physiscal activity. Walking one block on the level and climbing one flight of stairs causes angina

A

CCS III

93
Q

Canadian Cardiovascular Society Functional Classification. Inability to carry on any physical activity without discomfort. Anginal syndrome may be present at rest

A

CCS IV

Cardiology (14 decks)

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