35 - ACS Flashcards
Don’t use fibrinolytic therapy in ____
NSTEMI
Describe the urgent acute tx for UA/NSTEMI
need early, urgent coronary angiography followed by if possible, by revascularization with PCI or bypass surgery in all high risk patients
UA/NSTEMI:
What do you use for initial attempts at symptom relief
nitroglycerin
UA/NSTEMI:
What drug do you start ASAP in all patients without contraindications?
Beta blocker
UA/NSTEMI:
When are CCBs indicated?
used to control ongoing symptoms of ischemia in patients receiving max doses of BBs and nitrates
UA/NSTEMI:
Which type of CCBs should be used cautiously with BBs?
Non-DHPs (diltiazem, verapamil)
- they act more centrally and behave similar to BBs
- can cause LV dysfunction, severe bradycardia or increased AV nodal block
UA/NSTEMI:
What CCB should you avoid bc it can cause acute drop in BP and cause a stroke?
IR nifedipine
UA/NSTEMI:
Why are ACEi’s used?
they reduce mortality
UA/NSTEMI:
When should you initiate an ACEi?
within 24 hours of presentation
UA/NSTEMI:
What is the preferred heparin in those who don’t have significant renal dysfunction (i.e. CrCl > 30)
Enoxaparin
UA/NSTEMI:
What do you use if CrCl < 30?
UFH is appropriate
UA/NSTEMI:
How long is heparin used for?
usually used x 2-5 days
UA/NSTEMI:
Do you use heparin following successful PCI?
Not usually
UA/NSTEMI:
_____ is as effective as enoxaparin in patients with NSTEMI
fondaparinux (factor Xa inhibitor)
UA/NSTEMI:
When would you consider bivalrudin (direct thrombin inhibitor)?
Bivalrudin use is considered a reasonable strategy in patients with ACS undergoing PCI with concomitant P2Y12 inhibition and/or GP2b/3a inhibitor use
UA/NSTEMI:
Give ____ indefinitely as part of antiplatelet therapy
ASA
UA/NSTEMI:
What are the 3 P2Y12 platelet receptor inhibitors that are classified as thienopyridines?
- Clopidogrel
- Prasugrel
- Ticlopidine (rarely used bc the other 2 are more safe)
UA/NSTEMI:
What is an example of P2Y12 platelet receptor inhibitor that is classified as a cyclopentyltriazolopyrimidine?
Ticagrelor
UA/NSTEMI:
_____ does not require metabolic activation
Ticagrelor
UA/NSTEMI:
How long do you hold each agent before surgery? (clopidogrel, prasugrel and ticagrelor)
- Clopidogrel and Ticagrelor = hold 5 days
- Prasugrel = hold 7 days
UA/NSTEMI:
List some Glycoprotein 2b/3a inhibitors (antiplatelet agents)
eptifibatide, tirofiban, abciximab
UA/NSTEMI:
eptifibatide, tirofiban, abciximab - These agents can cause _______
thrombocytopenia
*so have to monitor platelet counts
STEMI:
If can’t do PCI within ___ hours, do pharmacoinvasive strategy
2
STEMI:
List 2 options for thrombolytic therapy
alteplase or tenecteplase
STEMI:
When should thrombolytic therapy bc started?
best if started within 6 hours of symptom onset
STEMI:
Give _____ to all STEMI patients receiving alteplase or tenecteplase
IV UFH
STEMI:
What is an alternative to IV UFH?
enoxaparin (LMWH)
STEMI:
Who should you caution enoxaparin in?
in those > 75 yo or those with renal insufficiency due to increased risk of bleed
STEMI:
Heparins should be continued for a minimum of ___ hours
48
STEMI:
____ is initiated for life
ASA
STEMI:
Initiate ___ once hemodynamically stable to reduce mortality and risk of recurrent MI
BB
STEMI:
What is your target for BB’s?
Titrate doses to a resting HR of 50-60 bpm
STEMI:
What drug do we absolutely NOT recommend in STEMI patients?
CCBs - they increase morbidity and mortality in STEMI patients
STEMI:
In what situation could you use a CCB?
ONLY if person is CI to BB. Use cautiously. Consider low-dose diltiazem and monitor HR closely
STEMI:
Use ____ if ischemia is persistant or recurrent
nitrates
STEMI:
When should you start an ACEi?
within 24 hours of the event unless patient is hypotensive
STEMI:
When would you use an ARB?
if patient can’t tolerate ACEi
STEMI:
When would you use a MRA (ex. spironolactone or eplerenone)?
if patient on ACEi and BB still have symptoms of HF, LVEF < 40% or both
STEMI:
Add ____ as DAPT with ASA
clopidogrel
STEMI:
How do you treat pericarditis ?
increases ASA dose or adding NSAID, corticosteroid or colchicine
