30. Acute Coronary Syndromes Flashcards
Acute coronary syndrome (ACS) results from ____ in the coronary arteries
Plaque buildup (atherosclerosis) - can rupture, leading to clot (thrombus) formation and ischemia to the heart
Risk factors that can lead to plaque buildup
Age: Men > 45yo, women >55yo (or early hysterectomy)
Family hx: first-degree relative with coronary event before 55yo (men) or 65yo (women)
Smoking
HTN
Known coronary artery disease
Dyslipidemia
DM
Chronic stable angina
Lack of exercise
Excessive alcohol
Classic s/sx of ACS
Chest pain (pressure or squeezing) lasting ≥10 min
Severe dyspnea
Diaphoresis.
Syncope/presyncope and/or palpitations
Chest pain from ACS can radiate to ___
arms, back, neck, jaw, or epigastric region
T/F: ACS is a medical emergency
True
How should SL nitroglycerin be used in the setting of chest pain from ACS?
1 dose every 5 min for up to 3 doses
If not improved or worsened 5 min after first dose, call 911 immediately
____ should be preformed and evaluated within 10 min at the site of first medical contact. Pts with an acute MI (STEMI or NSTEMI) should be urgently transported to a hospital with ____ capability if possible.
12-lead ECG
Percutaneous coronary intervention (PCI)
_____ are the most sensitive and specific biomarkers for ACS. Levels should be obtained at presentation and 3-6hrs after symptom onset in all pts with ACS symptoms.
Troponins I and T (TnI and TnT)
Compare unstable angina vs NSTEMI vs STEMI symptoms
Chest pain
Compare unstable angina vs NSTEMI vs STEMI cardiac enzymes (postive or negative)
UA = negative
NSTEMI, STEMI = Positive
Compare unstable angina vs NSTEMI vs STEMI ECG changes
UA, NSTEM = none or transient ischemic changes
STEMI = ST segment elevation
Compare unstable angina vs NSTEMI vs STEMI Blockage
UA, NSTEMI = partial blockage
STEMI = complete blockage
ACS Treamtnet is aimed at providing immediate relief of ___ and preventing ___
ischemia
preventing MI expansion and death
___ is a coronary revascularization procedure that involves inflating a small balloon inside a coronary artery to widen it and improve blood flow. Usually a ___ is placed to keep the artery open.
PCI
Stent
NSTE-ACS treatment options
medications alone or with PCI
STEMI requires that the blocked arteries be opened asap with __ or ___
PCI or fibrinolysis
PCI is preferred if it can be performed within ___ of hospital arrival (optimal door-to-balloon time) or within ____ of first medical contact (which could be in an ambulance). IF PCI is not possible within timeframe, fibronyltic therapy is recommended and should be given within ____ of hospital arrival (door-to-needle)
90min of hospital arrival
120min of first medical contact
60 min
How do antianginals work?
Decrease myocardial oxygen demand or increase supply (blood flow) to relieve ischemia
How do antiplatelets work?
Inhibit platelet aggregation to prevent clot formation/growth
How do anticoagulants work?
Inhibit clotting factors to prevent clot formation and growth
What are the 3 types of meds used in addition to PCI or fibrinolytics for ACS?
Antianginal, antiplatelet, and anticoagulant
Drug treatment options for ACS mnemonic MONA-GAP-BA stands for ___
(Give ASAP)
Morphine - for pain relief and anxiety
Oxygen
Nitrates - reduces chest pain
Aspirin
(Give afterwards, depends on PCI vs CABG vs meds)
GPIIb/IIIa antagonists
Anticoagulants
P2Y12 inhibitors
(GIVE within 24 hrs as needed, continue outpatient)
Beta-blockers
ACE inhibitors
NSTE-ACS: MONA-GAP-BA ± PCI
STEMI: MONA-GAP-BA + PCI or fibrinolytic (PCI preferred)
How do nitrates work in ACS?
dilate coronary arteries and improve collateral blood flow
Decrease preload and afterload (modestly)
Reduces chest pain
Do NOT use IV nitroglycerin if SBP < ____, HR < ____ or if pt is experiencing right ventricular infarction
SBP < 90
HR < 50
Note: PDE-5i are contraindicated with NTG
What aspirin formulation and strength should be given to all ACS pts immediately if no contraindications are present?
Non-enteric-coated, chewable aspirin (162-325mg) - Do NOT use ER aspirin
Maintenance dose 81-162mg should be continued indefinitely
Maintenance aspirin dose ___mg daily should be continued indefinitely
81-162mg daily
Examples of GPIIB/IIIa receptor antagonists
abciximab, eptifibatide, and tirofiban
What anticoagulants are used in ACS patients?
LMWH (e.g. enoxaparin, dalteparin), UFH, and bivalirudin (preferred for STEMI)
Examples of P2Y12 inhibitors
Clopidogrel, prasugrel, ticagrelor
Why are beta-blockers given in ACS pts?
Increase long-term survival
Antianginal: decrease BP, HR, contractility, ischemia, reinfarction, and arrhythmias, prevent cardiac remodeling
What meds from MONA-GAP-BA are continued indefinitely?
Aspirin and ACEi
An oral ACEi should be started within ____ and continued indefinitely in all pts with LVEF < ___%
24hrs
LVEF < 40%
Can use ARB if the pt is ACEi intolerant, do NOT use IV ACEi within first 24 hrs d/t risk of hypotension
Why should NSAIDs (except aspirin) NOT be administered during hospitalization for ACS?
Increased risk of mortality, reinfarction, HTN, cardiac rupture, renal insufficiency, and HF
What meds should be avoided in the acute setting of ACS?
NSAIDs and IR nifedipine
Why should IR nifedipine not be used in the acute setting of ACS?
Increased risk of mortality
Aspirin irreversibly inhibits ___ which decreases production of ____
Inhibits COX-1 and COX-2
Decreases production of TXA2 (an inducer of platelet aggregation)
____ bind to ADP P2Y12 receptor preventing ADP-mediated activation of GPIIb/IIIa receptor complex
P2Y12 inhibitors
GPIIb/IIIa receptor antagonists block the platelet glycoprotein IIb/IIIa receptor, which is the binding site for ___
fibrinogen, von Willebrand factor, and other ligands
Protease-activated receptor-1 antagonists binds to the PAR-1 receptor, preventing ____
thrombin- and thrombin receptor agonist peptide-induced platelet aggregation
Clopidogrel and prasugrel are structurally similar and are classified as ____
thienopyridines
T/F: Clopidogrel and prasugrel are prodrugs and reversibly bind to P2Y12 receptor
False - irreversibly bind
T/F: Clopidogrel and prasugrel require loading dose prior to maintenance dose
True
Maintenance dose for clopidogrel (Plavix)
75mg PO daily
Boxed warning for Clopidogrel
Prodrug, activated by CYP2C19 - test to check CYP2C19 genotype
Contraindications for clopidogrel
Active serious bleeding (e.g. GI or intracranial)
Warnings for clopidogrel
Bleeding risk (stop 5 days prior to elective surgery)
Do NOT use with omeprazole or esomeprazole
Thrombotic thrombocytopenic purpura (TTP)
Which P2Y12 inhibitors should be dispensed in the original container?
Prasugrel (Effient)
Boxed warning for Prasugrel (Effient)
Do not initiate if CABG likely, stop at least 7 days prior to elective surgery
Others: bleeding, not reocmmended in pts ≥75yo d/t high bleeding risk unless pt is considered high risk (DM or prior MI)
Contraindications for Prasugrel (Effient)
Active serous bleeding, hx of TIA or stroke
Maintenance dose for ticagrelor (Brillinta)
90 mg PO BID for 1 year, then 60mg BID
Boxed warnings for ticagrelor (Brillinta)
Bleeding
After the initial aspirin dose of 165-325mg, do NOT exceed a maintenance dose of 100mg (higher daily doses = reduce effectiveness of ticagrelor)
Avoid use when CABG likely, stop 5 days before any surgery
Which Antiplatelet drugs used in ACS have a warning for thrombotic thrombocytopenic purpura (TTP)?
Clopidogrel (Plavix)
Prasugrel (Effient)
Ticagrelor (Brillinta)
Side effects for ticagrelor
Bleeding, dyspnea (>10%)
Others: increased SCr, uric acid
Which P2Y12 inhibitor is an injection?
Cangrelor (Kengreal) - transition to an oral P2Y12 inhibitor after PCI
Which medications should you avoid with clopidogrel?
PPI - esomeprazole and omeprazole (CYP2C19 inhibitors)
Which drugs should you avoid P2Y12 d/t increase bleeding risk?
NSAIDs, warnings, SSRIs, SNRIs
Example of GP IIb/IIIa receptor antagonists
Eptifibatide (Integrillin)
Others: abciximab (ReoPro), tirofiban (Aggrastat)
Side effects of Eptifibatide (integrillin)
Bleeding, thrombocytopenia
Alteplase (Activase, tPA, rtPA) and Tenecteplase (TNKase) cause fibrinolysis by binding to ___ and converting ___ to ____. Only used for STEMI, give within ___ min of hospital arrival (door-to-needle time)
fibrin
Plasminogen to plasmin
30 min
What is alteplase (Cathflo Activase) used for?
Restore function of potentially clotted central line and devices (not for STEMI)
Contraindications for alteplase, tenecteplase
Active internal bleeding
Hx of recent stroke
Severe uncontrolled HTN (control prior to use)
Any prior intracranial hemorrhage
Recent intracranial/intraspinal surgery or trauma (last 2-3 months)
Intracranial neoplasm, arteriovenous malformation or aneurysm
T/F: Alteplase contraindications and dosing is the same for STEMI vs ischemic stroke
False
For secondary prevention of ACS, aspirin is used ____
81 mg daily indefinitely, unless contraindicated
For secondary prevention of ACS, P2Y12 inhibitor is used ____
Medical management pts: ticagrelor or clopidogrel with aspirin 81mg for at least 12 months
PCI (any type of stent): clopidogrel, prasugrel, or ticagrelor with aspirin 81mg for at least 12 months (continuation may be considered if tolerating and not at high risk of bleeding)
For secondary prevention of ACS, nitroglycerin is used ____
SL tabs or spray PRN Indefinitely
For secondary prevention of ACS, beta-blocker is used ____
3 years, continue indefinitely in pts iwth HF or if needed for HTN
For secondary prevention of ACS, ACEi is used ____
Indefinitely in pts with EF <40%, HTN, CKD, or DM
Consider for all MI pts with no contraindications
For secondary prevention of ACS, aldosterone antagonists is used ____
Indefinitely in pts with EF ≤ 40% and symptomatic HF or DM receiving target doses of an ACEi and beta-blocker
contraindications: sig renal impairment (SCr > 2.5 in men, > 2 in women) or hyperkalemia (K > 5)
For secondary prevention of ACS, statin is used ____
Indefinitely (high-intensity statin for most pts)
Pts ≥ 75yo: consider moderate- or high-intensity statin
NSAIDs should generally be avoided in ACS pts but may be reasonable to use nonselective NSAIDs such as ___ (lowest CV risk) if other options are not sufficient. COX-2 selective NSAIDs have high CV risk and should be aovided.
Naproxen
In ACS + Afib pts, dual or triple antithrombic therapy can be used if anticoag is needed for ACS and DAPT after PCI with a stent, use for shortest time possible. ____ should be prescribed in any pt with ____ while taking triple antithrombotic therapy
hx of GI bleeding
