43. Acute Coronary Syndromes (ACS) Flashcards
Angelo has coronary artery disease and has had a stent placement. He has come to the pharmacy to get his clopidogrel refilled. Angelo has active peptic ulcer disease and states he has stool that looks dark and tarry. He wife notes that the toilet bowl needs more regular scrubbing. Choose the correct statement concerning clopidogrel:
A. He should take one 300 mg tablet daily.
B. He should take one 75 mg tablet daily.
C. The patient needs 2C9 pharmacogenetic testing to continue receiving clopidogrel.
D. The patient should be seen right away and instructed to contact his doctor before using any more clopidogrel or aspirin.
E. The pharmacist should contact the prescriber; he requires the addition of an H2 receptor antagonist.
D. Clopidogrel has a risk of bleeding. This patient may have a current bleed. Due to the bleeding risk, clopidogrel should not be used concurrently with anticoagulants or with NSAIDs (except if used with aspirin).
P2Y12 Inhibitors: binds to the adenosine diphosphate (ADP) P2Y12 receptor on platelet surface which prevents ADP-mediated activation of the GPIIb/IIIa receptor complex resulting in a reduction of platelet aggregation. prasugrel and ticagrelor is indicated for reduction of thrombotic events in patients with ACS.
clopidogrel (Plavix): irreversible binding, prodrug (2C19). Boxed warning: effectiveness depends on the activation to an active thiol metabolite mainly by 2C19. Poor metabolizes exhibit higher cardiovascular events than patients with normal 2C19 function. CI: active bleed (PUD, ICH). Warning: avoid 2C19 inhibitors (omeprazole, esomeprazole), thrombotic thrombocytopenic purpura (TTP) has been reported (fever, weakness, extreme skin paleness, purple skin patches, yellowing of the skin/eyes, neurological changes. SE: bleeding, bruising, rash, pruritus. Discontinue 5 days prior to major surgery.
Maureen was diagnosed with an acute STEMI. The physician is determining if she is a candidate for fibrinolysis. Which of the following is an absolute contraindication to fibrinolysis?
A. An intracranial hemorrhage within the past 60 days
B. A BP of 165/98
C. Hypersensitivity to soy products
D. Ischemic stroke within the past 4 years
E. Concurrent use of aspirin
A. Absolute contraindications to fibrinolysis include any prior intracranial hemorrhage, suspected aortic dissection, active bleeding, intracranial or intraspinal surgery or trauma in last 3 months, previous ischemic stroke within 3 months and others.
Fibrinolytics: they cause fibrinolysis by binding to fibrin in a thrombus (clot) and converting entrapped plasminogen to plasmin. CI: Absolute (active bleeding, or bleeding diathesis, any prior intracranial hemorrhage, recent intracranial or intraspinal surgery or trauma in last 3 months, intracranial neoplasm, arteriovenous malformation, or aneurysm, aortic dissection, severe uncontrolled hypertension unresponsive to emergency therapy, ischemic stroke within past 3 months except acute ischemic stroke within 4.5 hours), Relative (pregnancy, active peptic ulcer, current use of anticoagulants). SE: bleeding, hypotension, intracranial hemorrhage, fever
alteplase (Activase, t-PA)
tenecteplase (TNKase)
reteplase (Retevase, r-PA)
All of the following are antiplatelet agents used in the treatment of ACS except:
A. Clopidogrel
B. Dalteparin
C. Tirofiban
D. Ticagrelor
E. Aspirin
B. Dalteparin is an anticoagulant.
clopidogrel (Plavix), ticagrelor (Brilinta): P2Y12 inhibitos
tirofiban (Aggrastat): GP IIb/IIIa inhibitor
Which of the following are likely signs/symptoms of a heart attack? (Select ALL that apply.)
A. Uncomfortable pressure, squeezing, or pain in the chest that lasts more than a few minutes, or goes away and comes back
B. Shortness of breath
C. Trouble speaking and weakness predominantly on one side of the body
D. Decreased troponin levels
E. Increased CK-MB level
A, B, E. Confusion and trouble speaking are more likely symptoms of a stroke. Most myocardial infarctions involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain. The pain can be in one or both arms, the back, neck, jaw or stomach. Shortness of breath is common. Patients will have increased troponin and CK-MB levels.
S/sx: chest pain (encompasses discomfort, pressure, squeezing) lasting >10 minutes, severe dyspnea, diaphoresis, syncope/presyncope, palpitations. pain may radiate to arms, back, neck, jaw, epigastric area. precipitating factors include exercise, cold weather, extreme emotions, stress, sexual intercourse.
The hospital where Maureen is admitted does not have the capability to perform percutaneous coronary intervention (PCI) and fibrinolysis may be done as an alternative. What is the mechanism of action of alteplase?
A. Binds to fibrin and converts plasmin to plasminogen
B. Binds to antithrombin and converts thrombin to fibrin
C. Binds to thrombin and converts fibrinogen to fibrin
D. Binds to thrombin and converts fibrin to fibrinogen
E. Binds to fibrin and converts plasminogen to plasmin
E. Fibrinolytics work by binding to fibrin and converting entrapped plasminogen to plasmin. Plasmin then degrades the fibrin mesh into soluble end products leading to clot dissolution.
Fibrinolytics: they cause fibrinolysis by binding to fibrin in a thrombus (clot) and converting entrapped plasminogen to plasmin. CI: Absolute (active bleeding, or bleeding diathesis, any prior intracranial hemorrhage, recent intracranial or intraspinal surgery or trauma in last 3 months, intracranial neoplasm, arteriovenous malformation, or aneurysm, aortic dissection, severe uncontrolled hypertension unresponsive to emergency therapy, ischemic stroke within past 3 months except acute ischemic stroke within 4.5 hours), Relative (pregnancy, active peptic ulcer, current use of anticoagulants). SE: bleeding, hypotension, intracranial hemorrhage, fever
alteplase (Activase, t-PA)
tenecteplase (TNKase)
reteplase (Retevase, r-PA)
A patient at the hospital is receiving morphine for chest pain. What are the advantages/reasons for using morphine in a patient with chest pain?
A. Provides analgesia, increases blood pressure and reduces preload
B. Reduces preload, provides analgesia and reduces myocardial oxygen demand
C. Reduces myocardial oxygen demand, reduces anxiety and reduces clot expansion
D. Reduces chest pain, increases myocardial oxygen supply and increases blood pressure
E. Provides analgesia, reduces preload and increases ejection fraction
B. With the use of morphine, be careful with the blood pressure-hypotension can result. Morphine can cause respiratory depression if overdosed.
Treatment:
MONA
morphine: reduce pain to help reduce anxiety, has vasodilation properties
oxygen: O2 via nasal cannula (only if patient is desaturating O2 <90%)
nitrates: SL tabs/spray, 1 dose and if pain persist call 911, then take 2 more doses every 5-10 minutes (max 3 doses)
aspirin: 162-325mg, must chew the aspirin dose for quick onset
Which of the following laboratory tests is the most sensitive marker for detecting myocardial damage in the blood of a patient with an acute coronary syndrome?
A. CKMB
B. BNP
C. Troponins
D. Myoglobin
E. Echocardiogram
C. Troponins are the most sensitive and specific laboratory test for detecting myocardial damage due to ischemia in patients with ACS.
Unstable Angina: chest pain (NSTE-ACS, non-ST segment elevation acute coronary syndrome)
NSTEMI: chest pain, increased troponins (NSTE-ACS, non-ST segment elevation acute coronary syndrome)
STEMI: chest pain, increase troponins, ECG changes (ST segment elevation)
Which of the following side effects is common with Brilinta?
A. Tachyarrhythmias
B. Decreased serum creatitine
C. Hepatic impairment
D. Dyspnea
E. Puffy eyes
D.
ticagrelor (Brilinta): reversible binding, not a prodrug. Boxed warning: can cause significant or fatal bleeding. maintenance doses of aspirin above 100mg reduce the effectiveness of ticagrelor and should be avoided (after any initial aspirin dose, maintenance aspirin dose should not exceed 100mg daily). CI: active bleeding, history of ICH, severe hepatic impairment. SE: bleeding, dyspnea, increase SCr, bradyarrhythmias. Do not start in patients likely to undergo CABG surgery. Discontinue 5 days prior to any major surgery.
Duane is a 77 year old male (6’3”, 315 pounds) who presents to the emergency department with a NSTEMI. He was given aspirin 325 mg in the field and was started on a nitroglycerin drip that is currently running at 200 mcg/min. His oxygen saturation is 94% and he has received morphine sulfate 2 mg IV x 2 and metoprolol 5 mg IV in the past 30 minutes. The patient still has ongoing ischemia and is going for PCI. The physician wants to start ReoPro on this patient. Which of the following statements are correct regarding ReoPro?
A. The aPTT must be monitored while the patient is receiving ReoPro.
B. The INR must be monitored while the patient is receiving ReoPro.
C. ReoPro must be filtered during administration.
D. ReoPro must be shaken upon reconstitution.
E. All patients receiving ReoPro should be transitioned to the oral formulation as soon as possible due to cost.
C. ReoPro is a protein and should be not shaken during reconstitution. The medication requires filtering during administration and platelets must be monitored. ReoPro is not available orally.
Glycoprotein IIb/IIIa Receptor Antagonists: blocks platelet glycoprotein IIb/IIIa receptor, which is the binding site for fibrinogen, von Willebrand factor, and other ligands to block platelet aggregation and prevent thrombosis. Eptifibatide and tirofiban have reversible blockade and abciximab has irreversible blockade. all agents are IV. CI: thrombocytopenia (platelets <100,000), history of bleeding diathesis, recent (within 6 weeks) GI or GU bleeding of clinical significance (abciximab), active internal bleeding, recent (within 4-6 weeks) major surgery or trauma (4 weeks for tirofiban/eptifibatide and 6 weeks for abciximab), increase prothrombin time, history of stroke within 2 years (abciximab), history of stroke within 30 days or any history of hemorrhagic stroke (eptifibatide/tirofiban), severe uncontrolled hypertension, hypersensitivity to murine proteins (abciximab), dependency on renal dialysis (eptifibatide). SE: bleeding, thrombocytopenia (esp. abciximab), hypotension. Do not shake vials upon reconstitution.
abciximab (ReoPro): irreversible blockade. requires filter for administration
eptifibatide (Integrilin): reversible blockade
tirofiban (Aggrastat) reversible blockade
A patient at the hospital is receiving nitroglycerin for chest pain. What are the advantages/reasons for using nitroglycerin in a patient with chest pain? (Select ALL that apply.)
A. Increases blood pressure
B. Reduces systemic vascular resistance and preload
C. Dilates coronary vessels and increases blood flow
D. Relieves chest pain
E. Helps with fibrinolysis
B, C, D. With the use of nitroglycerin, monitor for bradycardia and/or tachycardia, hypotension and for drug interactions with the PDE5 inhibitors used for erectile dysfunction.
Ronald is being discharged from the hospital after he suffered a myocardial infarction. He has a past medical history significant for hypertension. Upon discharge, he will continue taking his Zestril therapy which was started yesterday in addition to his hydrochlorothiazide for hypertension. How long is it recommended that Ronald take his Zestril therapy?
A. 6 months
B. 1 year
C. 2 years
D. 3 years
E. Indefinitely
E.
Secondary Prevention in s/p MI
Aspirin: 81-325mg daily indefinitely (if taking ticagrelor, ASA dose <100mg/day)
P2Y12 inhibitor: clopidogrel, prasugrel, ticagrelor for up to 1 year
Beta blockers: daily for 3 years
ACE-I: daily indefinitely
Aldosterone antagonists: indefinitely if they have LVEF <40% without significant renal impairment
Statin: high intensity if ≤75 years of age, moderate intensity if >75 years of age
Nitroglycerin: PRN only
Control risk factors: smoking cessation, physical activity, diet and weight management
Duane is a 77 year old male (6’3”, 315 pounds) who presents to the emergency department with a NSTEMI. He was given aspirin 325 mg in the field and was started on a nitroglycerin drip at 100 mcg/min. His oxygen saturation is 94% and he has received morphine sulfate 2 mg IV x 2 and metoprolol 5 mg IV in the past 30 minutes. His blood pressure is 164/101, HR is 95 BPM, and his respiratory rate is 22 BPM. Which of the following medications should not be given to the patient due to increased mortality?
A. Procardia
B. Demadex
C. Atacand
D. Cardizem
E. Vasotec
A.
IR nifedipine (Procardia) should not be used due to increased risk of mortality
Which of the following patients should be placed on statin therapy post MI?
A. Patients < 75 years old
B. Patients ≤ 75 years old
C. Patients > 75 years old
D. Patients ≥ 75 years old
E. All patients who are S/P MI
E. Statin therapy should be initiated in all patients who have had a heart attack.
Secondary Prevention in s/p MI
Aspirin: 81-325mg daily indefinitely (if taking ticagrelor, ASA dose <100mg/day)
P2Y12 inhibitor: clopidogrel, prasugrel, ticagrelor for up to 1 year
Beta blockers: daily for 3 years
ACE-I: daily indefinitely
Aldosterone antagonists: indefinitely if they have LVEF <40% without significant renal impairment
Statin: high intensity if ≤75 years of age, moderate intensity if >75 years of age
Nitroglycerin: PRN only
Control risk factors: smoking cessation, physical activity, diet and weight management
Which of the following medications should be avoided in a patient presenting with ACS?
A. Metoprolol
B. Lisinopril
C. Celecoxib
D. Aspirin
E. Enoxaparin
C. NSAIDs should be avoided in patients with ACS.
Which of the following statements are true regarding clopidogrel? (Select ALL that apply.)
A. It increases bleeding risk
B. It is metabolized to its active form by CYP 2C19
C. It should be discontinued about 12 hours prior to major surgery
D. It binds irreversibly to the platelet
E. The typical maintenance dose is 300 mg daily
A, B, D. Clopidogrel is a prodrug that is converted to its active form by CYP 2C19. It binds irreversibly to platelet receptors and is commonly dosed 75 mg daily for maintenance. It should be discontinued 5 days prior to major surgery.
clopidogrel (Plavix): irreversible binding, prodrug (2C19). Boxed warning: effectiveness depends on the activation to an active thiol metabolite mainly by 2C19. Poor metabolizes exhibit higher cardiovascular events than patients with normal 2C19 function. CI: active bleed (PUD, ICH). Warning: avoid 2C19 inhibitors (omeprazole, esomeprazole), thrombotic thrombocytopenic purpura (TTP) has been reported (fever, weakness, extreme skin paleness, purple skin patches, yellowing of the skin/eyes, neurological changes. SE: bleeding, bruising, rash, pruritus. Discontinue 5 days prior to major surgery.
prasugrel (Effient): irreversible binding, prodrug, only one in class with CI to history of TIA/stroke. Boxed warning: can cause significant or fatal bleeding, not recommended in patient ≥75 years due to increased risk of intracranial bleeding, do not start in patient undergoing urgent CABG surgery, discontinue 7 days prior to any major surgery. CI: active bleeding, patients with history of TIA or stroke. Warning: thrombotic thrombocytopenia purpura (TTP). SE: bleeding (more than clopidogrel)
ticagrelor (Brilinta): reversible binding, not a prodrug. Boxed warning: can cause significant or fatal bleeding. maintenance doses of aspirin above 100mg reduce the effectiveness of ticagrelor and should be avoided (after any initial aspirin dose, maintenance aspirin dose should not exceed 100mg daily). CI: active bleeding, history of ICH, severe hepatic impairment. SE: bleeding, dyspnea, increase SCr, bradyarrhythmias. Do not start in patients likely to undergo CABG surgery. Discontinue 5 days prior to any major surgery.
A patient at the hospital is receiving a beta blocker for chest pain. Which of the following are true regarding the use of beta blockers in this setting?
A. In STEMI, beta-blockers should not be used.
B. They can be administered PO or IV.
C. They should be combined with a long-acting non-dihydropyridine calcium antagonist.
D. They increase myocardial oxygen demand.
E. Beta-blockers with ISA activity are preferred.
B. Beta blockers reduce myocardial oxygen demand and should be given to all patients without contraindications who present with UA/NSTEMI within 24 hours. In STEMI, the should be given promptly. They can be administered PO or IV.
MONA
morphine: reduce pain to help reduce anxiety, has vasodilation properties
oxygen: O2 via nasal cannula (only if patient is desaturating O2 <90%)
nitrates: SL tabs/spray, 1 dose and if pain persist call 911, then take 2 more doses every 5-10 minutes (max 3 doses)
aspirin: 162-325mg, must chew the aspirin dose for quick onset
GAP-BA
glycoprotein (GP) IIb/IIIa inhibitors: blocks fibrinogen, prevent platelet aggregation
anticoagulants: UFH/LMWH
p2Y12 inhibitor:
beta blocker: helps with remodeling
ACE-I: oral to decrease BP, help with remodeling
