3: ACS

Question 1

pattern of pain with ACS

Answer 1

pain at rest of crescendo pattern of pain on minimal exertion

Question 2

TIMI risk scores

Answer 2

count up the following risk factors:

• over 65 y/o
• at least 3 risk factors for CAD
• ST deviation on admit EKG
• priory coronary stenosis more than 50%
• at least 2 anginal episodes in last 24 h
• elevated cardiac markers
• use of ASA (aspirin) in last 7d

Question 3

high risk for ACS

Answer 3

one of the following:

• accelerating tempo of ischemic sx in preceding 48h
• prolonged ongoing (>20min) rest pain
• pulm edema, most likely from ischemia
• new or worsening MR murmur
• S3 or new/worsening rales
• hypotension, bradycardia, tachycardia
• older than 75
• angina at rest with transient ST changes
• bundle branch block, new or presumed new
• sustained ventricular tachycardia
• elevated troponin

Question 4

intermediate risk for ACS

Answer 4

one of the following:

• prior MI, peripheral or cerebrovasc disease, CABG, ASA use
• prolonged rest angina, now resolved, with mod-high risk of CAD
• rest angina less than 20min or relieved with rest/NTG
• age less than 70
• T wave inversions
• path Q waves
• slightly elevated cardiac markers

Question 5

low risk for ACS

Answer 5

one of the following:

• new onset or progressive CCS class 3 or 4 angina the past 2 weeks w/o prolonged rest pain but with mod-high risk of CAD
• normal or unchanged EKG during episode of chest pain
• normal cardiac markers

Question 6

ddx when: ST elevation everywhere w/ no reciprocal changes

Answer 6

pericarditis

• also associated with PR depression
• the ST elevation will be subtle

Question 7

ddx when: DEEP, symmetric T wave inversion in multiple leads in a person w/ headache

Answer 7

intracranial hemorrhage

Question 8

contraindications of nitrates in ACS

Answer 8

phosphodiesterase inhibitors

RV infarction

Question 9

what does RV infarction look like?

Answer 9

hypotension
JVD
clear lungs

Question 10

contraindications to B-blockers in ACS

Answer 10

hypotension
severe bronchospasm
bradycardia (heart block)
suspected coronary spasm (Prinzmetal angina or cocaine)

Question 11

function of B-blockers in ACS

Answer 11

decreases demand and increases supply to decrease O2 deficit

• decreased: HR, afterload, contractility, O2 wastage, exercise vasoconstriction
• increased: heart size, diastolic perfusion, collaterals

Question 12

what is considered standard of care now? aka your ass will get sued if you don’t give it to a patient with ACS

Answer 12

B-blockers

Question 13

why use 81mg aspirin?

Answer 13

still get desired response + decreases risk of bleeding to use lower dose

Question 14

what type of clopidogrel treatment is preferred?

Answer 14

pretreatment - reduces deaths

Question 15

what about clopidogrel and CABG?

Answer 15

hold clopidogrel for 5d before CABG

Question 16

what’s the deal with prasugrel? how do you dose it?

Answer 16

loading dose 60mg
maintenance 10mg daily

decreased combined endpoints of death/MI/revascularization than plavix, but higher bleeding complications

Question 17

prasugrel indications

Answer 17

over 70 y/o

stroke

Question 18

heparin deal? what kind of heparin?

Answer 18

heparin decreases risk of death/MI more than no heparin

low MW heparin better than un-fractionated heparin (UNH)

Question 19

name 3 GPIIb/IIIa inhibitors

Answer 19

abciximab
integrilin (most used)
tirofiban

Question 20

benefit of GPIIb/IIIa inhibitors

Answer 20

increased reduction in death/MI

best for stented diabetics (only use for high risk patients, not for everybody)

Question 21

look up ticagrelor?

Answer 21

dunnnnnooo

Question 22

who goes straight to cath lab?

Answer 22

recurrent ischemia despite treatment attempts 
CHF 
cardiogenic shock 
prior PCI w/i 6 mo (restenosis) 
prior CABG

Question 23

when is there no benefit to aggressive strategy?

Answer 23

if no EKG changes + no troponins

Question 24

early secondary prevention focuses on what two things?

Answer 24

early diabetes control

early cholesterol control

Question 25

do you still use meds when you opt for invasive strategy?

Answer 25

yes - invasive strategy is not a substitute

medical therapy for long-term shit