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NAPLEX 2024 > 30. Acute Coronary Syndromes > Flashcards

30. Acute Coronary Syndromes Flashcards

1
Q

Acute coronary syndrome (ACS) results from ____ in the coronary arteries

A

Plaque buildup (atherosclerosis) - can rupture, leading to clot (thrombus) formation and ischemia to the heart

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2
Q

Risk factors that can lead to plaque buildup

A

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

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3
Q

Classic s/sx of ACS

A

Chest pain (pressure or squeezing) lasting ≥10 min
Severe dyspnea
Diaphoresis.
Syncope/presyncope and/or palpitations

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4
Q

Chest pain from ACS can radiate to ___

A

arms, back, neck, jaw, or epigastric region

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5
Q

T/F: ACS is a medical emergency

A

True

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6
Q

How should SL nitroglycerin be used in the setting of chest pain from ACS?

A

1 dose every 5 min for up to 3 doses
If not improved or worsened 5 min after first dose, call 911 immediately

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7
Q

____ 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.

A

12-lead ECG
Percutaneous coronary intervention (PCI)

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8
Q

_____ 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.

A

Troponins I and T (TnI and TnT)

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9
Q

Compare unstable angina vs NSTEMI vs STEMI symptoms

A

Chest pain

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10
Q

Compare unstable angina vs NSTEMI vs STEMI cardiac enzymes (postive or negative)

A

UA = negative
NSTEMI, STEMI = Positive

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11
Q

Compare unstable angina vs NSTEMI vs STEMI ECG changes

A

UA, NSTEM = none or transient ischemic changes
STEMI = ST segment elevation

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12
Q

Compare unstable angina vs NSTEMI vs STEMI Blockage

A

UA, NSTEMI = partial blockage
STEMI = complete blockage

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13
Q

ACS Treamtnet is aimed at providing immediate relief of ___ and preventing ___

A

ischemia
preventing MI expansion and death

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14
Q

___ 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.

A

PCI
Stent

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15
Q

NSTE-ACS treatment options

A

medications alone or with PCI

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16
Q

STEMI requires that the blocked arteries be opened asap with __ or ___

A

PCI or fibrinolysis

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17
Q

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)

A

90min of hospital arrival
120min of first medical contact
60 min

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18
Q

How do antianginals work?

A

Decrease myocardial oxygen demand or increase supply (blood flow) to relieve ischemia

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19
Q

How do antiplatelets work?

A

Inhibit platelet aggregation to prevent clot formation/growth

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20
Q

How do anticoagulants work?

A

Inhibit clotting factors to prevent clot formation and growth

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21
Q

What are the 3 types of meds used in addition to PCI or fibrinolytics for ACS?

A

Antianginal, antiplatelet, and anticoagulant

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22
Q

Drug treatment options for ACS mnemonic MONA-GAP-BA stands for ___

A

(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)

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23
Q

How do nitrates work in ACS?

A

dilate coronary arteries and improve collateral blood flow
Decrease preload and afterload (modestly)
Reduces chest pain

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24
Q

Do NOT use IV nitroglycerin if SBP < ____, HR < ____ or if pt is experiencing right ventricular infarction

A

SBP < 90
HR < 50

Note: PDE-5i are contraindicated with NTG

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25
Q

What aspirin formulation and strength should be given to all ACS pts immediately if no contraindications are present?

A

Non-enteric-coated, chewable aspirin (162-325mg) - Do NOT use ER aspirin
Maintenance dose 81-162mg should be continued indefinitely

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26
Q

Maintenance aspirin dose ___mg daily should be continued indefinitely

A

81-162mg daily

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27
Q

Examples of GPIIB/IIIa receptor antagonists

A

abciximab, eptifibatide, and tirofiban

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28
Q

What anticoagulants are used in ACS patients?

A

LMWH (e.g. enoxaparin, dalteparin), UFH, and bivalirudin (preferred for STEMI)

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29
Q

Examples of P2Y12 inhibitors

A

Clopidogrel, prasugrel, ticagrelor

30
Q

Why are beta-blockers given in ACS pts?

A

Increase long-term survival
Antianginal: decrease BP, HR, contractility, ischemia, reinfarction, and arrhythmias, prevent cardiac remodeling

31
Q

What meds from MONA-GAP-BA are continued indefinitely?

A

Aspirin and ACEi

32
Q

An oral ACEi should be started within ____ and continued indefinitely in all pts with LVEF < ___%

A

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

33
Q

Why should NSAIDs (except aspirin) NOT be administered during hospitalization for ACS?

A

Increased risk of mortality, reinfarction, HTN, cardiac rupture, renal insufficiency, and HF

34
Q

What meds should be avoided in the acute setting of ACS?

A

NSAIDs and IR nifedipine

35
Q

Why should IR nifedipine not be used in the acute setting of ACS?

A

Increased risk of mortality

36
Q

Aspirin irreversibly inhibits ___ which decreases production of ____

A

Inhibits COX-1 and COX-2
Decreases production of TXA2 (an inducer of platelet aggregation)

37
Q

____ bind to ADP P2Y12 receptor preventing ADP-mediated activation of GPIIb/IIIa receptor complex

A

P2Y12 inhibitors

38
Q

GPIIb/IIIa receptor antagonists block the platelet glycoprotein IIb/IIIa receptor, which is the binding site for ___

A

fibrinogen, von Willebrand factor, and other ligands

39
Q

Protease-activated receptor-1 antagonists binds to the PAR-1 receptor, preventing ____

A

thrombin- and thrombin receptor agonist peptide-induced platelet aggregation

40
Q

Clopidogrel and prasugrel are structurally similar and are classified as ____

A

thienopyridines

41
Q

T/F: Clopidogrel and prasugrel are prodrugs and reversibly bind to P2Y12 receptor

A

False - irreversibly bind

42
Q

T/F: Clopidogrel and prasugrel require loading dose prior to maintenance dose

A

True

43
Q

Maintenance dose for clopidogrel (Plavix)

A

75mg PO daily

44
Q

Boxed warning for Clopidogrel

A

Prodrug, activated by CYP2C19 - test to check CYP2C19 genotype

45
Q

Contraindications for clopidogrel

A

Active serious bleeding (e.g. GI or intracranial)

46
Q

Warnings for clopidogrel

A

Bleeding risk (stop 5 days prior to elective surgery)
Do NOT use with omeprazole or esomeprazole
Thrombotic thrombocytopenic purpura (TTP)

47
Q

Which P2Y12 inhibitors should be dispensed in the original container?

A

Prasugrel (Effient)

48
Q

Boxed warning for Prasugrel (Effient)

A

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)

49
Q

Contraindications for Prasugrel (Effient)

A

Active serous bleeding, hx of TIA or stroke

50
Q

Maintenance dose for ticagrelor (Brillinta)

A

90 mg PO BID for 1 year, then 60mg BID

51
Q

Boxed warnings for ticagrelor (Brillinta)

A

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

52
Q

Which Antiplatelet drugs used in ACS have a warning for thrombotic thrombocytopenic purpura (TTP)?

A

Clopidogrel (Plavix)
Prasugrel (Effient)
Ticagrelor (Brillinta)

53
Q

Side effects for ticagrelor

A

Bleeding, dyspnea (>10%)
Others: increased SCr, uric acid

54
Q

Which P2Y12 inhibitor is an injection?

A

Cangrelor (Kengreal) - transition to an oral P2Y12 inhibitor after PCI

55
Q

Which medications should you avoid with clopidogrel?

A

PPI - esomeprazole and omeprazole (CYP2C19 inhibitors)

56
Q

Which drugs should you avoid P2Y12 d/t increase bleeding risk?

A

NSAIDs, warnings, SSRIs, SNRIs

57
Q

Example of GP IIb/IIIa receptor antagonists

A

Eptifibatide (Integrillin)

Others: abciximab (ReoPro), tirofiban (Aggrastat)

58
Q

Side effects of Eptifibatide (integrillin)

A

Bleeding, thrombocytopenia

59
Q

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)

A

fibrin
Plasminogen to plasmin
30 min

60
Q

What is alteplase (Cathflo Activase) used for?

A

Restore function of potentially clotted central line and devices (not for STEMI)

61
Q

Contraindications for alteplase, tenecteplase

A

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

62
Q

T/F: Alteplase contraindications and dosing is the same for STEMI vs ischemic stroke

A

False

63
Q

For secondary prevention of ACS, aspirin is used ____

A

81 mg daily indefinitely, unless contraindicated

64
Q

For secondary prevention of ACS, P2Y12 inhibitor is used ____

A

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)

65
Q

For secondary prevention of ACS, nitroglycerin is used ____

A

SL tabs or spray PRN Indefinitely

66
Q

For secondary prevention of ACS, beta-blocker is used ____

A

3 years, continue indefinitely in pts iwth HF or if needed for HTN

67
Q

For secondary prevention of ACS, ACEi is used ____

A

Indefinitely in pts with EF <40%, HTN, CKD, or DM
Consider for all MI pts with no contraindications

68
Q

For secondary prevention of ACS, aldosterone antagonists is used ____

A

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)

69
Q

For secondary prevention of ACS, statin is used ____

A

Indefinitely (high-intensity statin for most pts)
Pts ≥ 75yo: consider moderate- or high-intensity statin

70
Q

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.

A

Naproxen

71
Q

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

A

hx of GI bleeding

NAPLEX 2024 (74 decks)

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