30. Acute Coronary Syndromes Flashcards by Brynn Gilbert

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

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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

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Classic s/sx of ACS

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

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Chest pain from ACS can radiate to ___

arms, back, neck, jaw, or epigastric region

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T/F: ACS is a medical emergency

True

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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

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____ 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)

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_____ 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)

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Compare unstable angina vs NSTEMI vs STEMI symptoms

Chest pain

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

UA = negative
NSTEMI, STEMI = Positive

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Compare unstable angina vs NSTEMI vs STEMI ECG changes

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

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Compare unstable angina vs NSTEMI vs STEMI Blockage

UA, NSTEMI = partial blockage
STEMI = complete blockage

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

ischemia
preventing MI expansion and death

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___ 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

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NSTE-ACS treatment options

medications alone or with PCI

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

PCI or fibrinolysis

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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

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How do antianginals work?

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

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How do antiplatelets work?

Inhibit platelet aggregation to prevent clot formation/growth

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How do anticoagulants work?

Inhibit clotting factors to prevent clot formation and growth

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

Antianginal, antiplatelet, and anticoagulant

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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)

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How do nitrates work in ACS?

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

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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

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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