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957 Block 3 > 6. ACS > Flashcards

6. ACS Flashcards

1
Q

What are the key characteristics of stable angina? (5)

A
  • reproducible pain
  • improves with rest
  • lasts < 10 minutes
  • ECG normal
  • no ↑ in cardiac enzymes
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2
Q

What are the key characteristics of unstable angina? (5)

A
  • occurs with increased frequency or less activity
  • may not be relieved with rest or NTG
  • lasts > 10 minutes
  • associated with ECG changes without ST segment elevation
  • no ↑ in cardiac enzymes
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3
Q

What are the key characteristics of NSTEMI? (5)

A
  • occurs with increased frequency or less activity
  • may not be relieved with rest or NTG
  • lasts > 10 minutes
  • associated with ECG changes without ST segment elevation
  • increase in cardiac enzymes
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4
Q

What are the key characteristics of STEMI? (3)

A
  • complete occasion resulting in constant pain
  • associated with ECG changes: ST segment elevation
  • increased cardiac enzymes
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5
Q

What are the initial therapies in ACS?

A
  • ECG monitoring
  • IV access
  • ONAM
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6
Q

What does the ONAM acronym stand for?

A
  • oxygen
  • nitroglycerin
  • antiplatelets
  • morphine
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7
Q

What is the therapeutic goal of nitroglycerine administration?

A

relieve myocardial ischemia via coronary vasodilation

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8
Q

There is no reduction in mortality in ACS with the use of nitroglycerine. (T/F)

A

True

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9
Q

How many times can you repeat SL NTG?

A

3x q 5 minutes

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10
Q

What should be monitored after administration of NTG?

A
  • HR
  • BP
  • ECG
  • chest pain/ symptoms
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11
Q

Mean arterial pressure should be ______ to maintain coronary perfusion.

A

> 65 mmHg

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12
Q

What are the ADRs of NTG?

A

headache

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13
Q

IV NTG is highly recommended in MI patients with what comorbidities?

A
  • HF
  • persistent ischemia
  • HTN
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14
Q

What is the therapeutic goal of antiplatelet therapy?

A
  • limit infarct size
  • reduce recurrent ischemia/infarction
  • improve survival
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15
Q

What are the antiplatelet agents for acute therapy?

A
  • Aspirin
  • Clopidogrel
  • Prasugrel
  • Ticagrelor
  • Cangrelor
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16
Q

What is the dosage of Aspirin in acute therapy?

A

162 - 325 mg chewed and swallowed

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17
Q

Why might clopidogrel be used instead of aspirin?

A

Aspirin allergy

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18
Q

What is the dose of clopidogrel in acute therapy?

A

300 - 600 mg PO once

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19
Q

Why might dual antiplatelet therapy be deferred?

A

Patient has unknown coronary anatomy

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20
Q

What is the dose of prasugrel in acute therapy?

A

60 mg PO once

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21
Q

Prasugrel has a higher, more consistent level of platelet inhibition over clopidogrel. (T/F)

A

True

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22
Q

What medication is reserved for those going to cath lab for PCI.

A

Prasugrel

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23
Q

What is the dose of ticagrelor in acute therapy?

A

180 mg PO once

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24
Q

What is the route of administration of cangrelor?

A

IV

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25
Q

What medication is reserved for patients who aren’t on oral DAPT at the time of PCI?

A

cangrelor

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26
Q

What medication should be administered to UA/NSTEMI patients as soon as possible after hospital presentation?

A

Aspirin

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27
Q

What medication should be continued indefinitely after administration in the hospital after UA/NSTEMI?

A

Aspirin

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28
Q

What is the continued daily dose of clopidogrel for those who are unable to take aspirin?

A

75 mg

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29
Q

Why might a patient be unable to take daily aspirin?

A
  • hypersensitivity (asthma)

- gastrointestinal intolerance

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30
Q

What is the therapeutic goal of analgesia in ACS?

A

pain control and relief of anxiety

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31
Q

What is the pain associated with MI caused by?

A

ischemia

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32
Q

What is the analgesic agent of choice in ACS?

A

IV morphine sulfate

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33
Q

Why is morphine sulphate the analgesic agent of choice in ACS?

A
  • blocks SNS discharge from CNS
  • peripheral artery dilation
  • reduces myocardial demand
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34
Q

What is the initial dose of IV morphine in ACS?

A

2 - 5 mg every 15 minutes

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35
Q

What is the maintenance dose of IV morphine in ACS?

A

4 - 8 mg every 4-6 hrs

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36
Q

What should be monitored during IV administration of morphine in ACS?

A
  • pain relief
  • hypotension
  • respiratory depression
  • allergic reactions
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37
Q

What are the controversial aspects of administration of morphine to ACS patient?

A
  • does not improve survival
  • chest pain is a marker of disease progression
  • drug seeking behaviors
38
Q

Why might a clinician want to withhold analgesia so that a patient experiences chest pain?

A

recurrent pain is a marker of ischemia and can be used to prioritize escalation of care

39
Q

What is the conventional DAPT strategy?

A

ASA + P2Y12 Inhibitor

40
Q

Which antiplatelet medication might interact with aspirin?

A

ticagrelor

41
Q

In what patients should prasugrel not be used?

A
  • age > 75 years
  • weight < 60 kg
  • “little old ladies”
42
Q

What OTC medication should not be used with clopidogrel?

A

omeprazole

43
Q

Separating administration of omeprazole and clopidogrel will prevent drug interaction. (T/F)

A

False: cannot be taken within the same day

44
Q

Avoid using other potent CPY_____ _______ with clopidogrel.

A
  • 2C19

- inhibitors

45
Q

In what patients is prasugrel contraindicated?

A

history of stroke or TIA

46
Q

When is it acceptable to administer prasugrel to a patient > 75 years old?

A
  • STEMI

- diabetes mellitus

47
Q

At what maintenance dose of aspirin does an interaction with ticagrelor occur?

A

> 100 mg

48
Q

What is the dose of heparin for ACS?

A

LD: 60 u/kg (max 4000 u)
MD: 12 u/kg/h (max 1000 u/h)

49
Q

What is the dose of enoxaparin for ACS?

A

1 mg/kg every 12 hours

50
Q

What is the dose of dalteparin for ACS?

A

120 u/kg every 12 hours (max 10,000 u/h)

51
Q

What is the most commonly used LMWH agent for ACS?

A

enoxaparin

52
Q

What is the dose of fondaparinux for ACS?

A

2.5 mg daily

53
Q

Fondaparinux is used with both medical management and PCI. (T/F)

A

False: only medical management

54
Q

What is the dose of bivalirudin for ACS before going to cath lab?

A

“up-front” bolus: 0.1 mg/kg

drip: 0.25 mg/kg/h

55
Q

What is the dose of bivalirudin for ACS when in the cath lab?

A
  • bolus in cath lab: 0.5 mg/kg

- drip: 1.75 mg/kg/h

56
Q

What must be monitored with the administration of unfractionated heparin?

A

aPTT

57
Q

What is the antidote for heparin?

A

protamine

58
Q

What is the method of elimination of LMWH?

A

renal

59
Q

What is the method of elimination of fondaparinux?

A

renal

60
Q

Before undergoing PCI, GP IIb/IIIa inhibitors cannot be used in conjunction with PGY12 inhibitors. (T/F)

A

True: only use GP IIb/IIIa inhibitors if PGY12 inhibitors are not used

61
Q

The goal is __% platelet inhibition during PCI.

A

90

62
Q

What is the main adverse effect of GP IIb/IIIa inhibitors?

A

bleeding

63
Q

Abciximab can only be used up-front for PCI. (T/F)

A

True

64
Q

Thrombolytics promote thrombolysis by hydrolyzing the _______-_______ peptide bond in plasminogen to form ___________.

A
  • arginine560 - valine561

- active plasmin

65
Q

Which thrombolytic agent might cause an allergic reaction?

A

streptokinase

66
Q

Which thrombolytic agent is not fibrin selective?

A

streptokinase

67
Q

Which thrombolytic shows the best reperfusion?

A

reteplase (rPA)

68
Q

What are the contraindications thrombolytics? (6)

A
  • active internal bleeding
  • history of CVA
  • recent surgery or trauma
  • intracranial neoplasm or aneurysm
  • known bleeding disorder
  • severe uncontrolled HTN (SBP > 180)
69
Q

Why should anticoagulants and anti platelets be used with thrombolytics?

A

prevents re-occlusion (recurrent MI)

70
Q

In a STEMI, is thrombolysis or PCI preferred?

A

PCI

71
Q

What are the 2 strategies of PCI?

A
  • bare metal stent

- drug-eluting stent

72
Q

For secondary prevention of ACS, at least how many medications should a patient be on?

A

4

73
Q

What are the indication for aspirin in secondary prevention of ACS?

A
  • all patients pose-MI or UA

- anyone with CAD

74
Q

What are the indication for statins in secondary prevention of ACS?

A

all patients post-ACS

75
Q

What are the indication for β blockers in secondary prevention of ACS?

A

all patients post-ACS with no contraindications

76
Q

What are the indication for ACE-I/ARBs in secondary prevention of ACS?

A
  • Low EF
  • HTN
  • DM
  • renal dysfunction
77
Q

What are the indication for aldosterone antagonists in secondary prevention of ACS?

A
  • Low EF and HF symptoms

- DM

78
Q

What is the minimum duration of DAPT with a bare metal stent?

A

4 weeks

79
Q

What is the minimum duration of DAPT with a drug-eluting stent?

A

1 year

80
Q

What are the drugs being eluted in a drug-eluting stent?

A

anti-proliferative (tacrolimus, cyclosporin, everolimus)

81
Q

There is a benefit of continuing DAPT if DAPT score is what?

A

≥ 2

82
Q

DAPT should be stopped if DAPT score is what?

A

< 2

83
Q

Older age contributes to a _____ DAPT score.

A

lower

84
Q

What is the purpose of HMG CoA reductase inhibitors post-ACS?

A
  • slows progression of CAD with hyperlipidemia

- plaque stabilization

85
Q

If cangrelor is administered, when can the patient be switched to ticagrelor?

A

can transition to ticagrelor at any time

86
Q

What medication should be started immediately after cangrelor is stopped?

A

clopidogrel or prasugrel

87
Q

What is the MOA of Vorapaxar?

A

PAR-1 antagonist

88
Q

What is the black box warning/ contraindications for Vorapaxar?

A
  • history of stroke, TIA, or ICH

- active bleeding

89
Q

What is the dose of Vorapaxar?

A

2.08 mg PO daily

90
Q

What medications are harmful post-ACS?

A
  • hormone therapy with estrogen

- NSAIDs

957 Block 3 (6 decks)

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