6 ACS part III

Question 1

Treatment Overview - STEMI

MONA
reperfusion (PCI vs ___ )
antiplatelets (DAPT = ___ + ___ )
- ___ month duration
- fibrinolytic: ___ preferred
- PCI: ___ or ___ preferred
- GPIIb/IIIa inh

anticoagulation
- UFH or ___

BB
ACEi or ARB
Statin
NTG prn

Answer 1

fibrinolytic
ASA, P2Y2i
- 12
- clopidogrel
- ticagrelor, prasugrel
- bivaldirudin

Question 2

Treatment Overview - UA/NSTEMI

MONA
Reperfusion
- early ___ strategy vs ___ guided strategy

Antiplatelets
- DAPT = ___ + ___
- ___ month duration
- ___ or ___ preferred
- +/1 GPIIb/IIIa inh ( ___ to use)

Anticoagulation
- ___ or UFH

BB
ACEi or ARB
Statin
NTG prn

Answer 2

• invasive, ischemic
• ASA + P2Y12i
• 12
• ticagrelor, prasugrel
• unlikely
• LMWH

Question 3

Antiplatelet classes (3)

Answer 3

ASA
P2Y12i
GPIIb/IIIa inh

Question 4

ASA

ASA ___ mg or ___ mg immediately upon presention (MONA)

ASA (81 mg/d to 325 mg/d) should be continued daily, but __ mg is the preferred dose
- no evidence that higher dose is more effective, just more likely to cause greater toxicity

Take with ___

Answer 4

162, 325
81
food

Question 5

P2Y12i

oral meds: ___ , ___ , and ___
- loading dose followed by maintenance dose in additon to ___
- DAPT is recommended for ___ months in STEMI or NSTEMI/UA
- DAPT is always ___ + ___

IV: ___
- $$
- platelet inhibition within __ mins
- use during ___ when patient did not receive ___ dose of P2Y12i

Answer 5

clopidogrel, ticagrelor, prasugrel
- ASA
- 12
- ASA + P2Y12i

cangrelor
- 2
- PCI, loading

Question 6

P2Y12i

clopidogrel (Plavix)
Loading Dose: ___ - ___ mg
Maintenance dose: __ mg daily

Answer 6

300-600 mg
75 mg

Question 7

P2Y12i

clopidogrel (Plavix)
- ___ mg loading dose results in a greater, more rapid, and more reliable platelet inhibition

this dose is preferred except when using a fibrinolytic
- fibrinolytic + age > 75 = ___
- fibrinolytic + age less than or equal to 75 = ___ mg loading dose

Answer 7

600
- no loading dose
- 300

Question 8

P2Y12i

ticagrelor (Brilinta)
Loading Dose: ___ mg
Maintenance Dose: ___ mg BID

Answer 8

180
90

Question 9

P2Y12i

prasugrel (Effient)
Loading Dose: ___ mg
Maintenance Dose: ___ mg daily

Answer 9

60
10

Question 10

P2Y12i

cangrelor
Loading Dose: ___ mcg/kg, followed by ___ mcg/kg/min x 2 hours
Maintenance Dose: use an ___ agent

Answer 10

30, 4
oral

Question 11

P2Y12i - Clopidogrel

• prodrug - converted to active metabolite by CYP ___
• most common due to ins coverage

Answer 11

2C19

Question 12

P2Y12i

ticagrelor
- greater inhibition of platelet aggregation than ___
- PLATO: death from vascular cause, MI, or stroke decreased with ticagrelor
- max dose of ASA is ___ mg daily in combination with ticagrelor
- SE: ___ and ___ pauses

Answer 12

• clopidogrel
• 81 mg
• dyspnea, ventricular

ASA need to be < 100 mg but 81 mg is most common

Question 13

P2Y12

Prasugrel
- not recommended for ischemia guided strategy ( ___ or ___ preferred)
- Contraindicated in patients with history of ___ / ___
- greater inhibition of platelet aggregation than clopidogrel post ___
- not recommened in patients greater than ___ year old, less than ___ kg, or high bleeding risk ( ___ mg may be used if deemed necessary)

Answer 13

• ticagrelor, clopidogrel
• TIA, stroke
• PCI
• 75, 60, 5

Question 14

Which P2Y12i are prodrugs (2)

Answer 14

clopidogrel, prasugrel

Question 15

Switching between P2Y12i

Answer 15

Question 16

NSTEMI/UA

Ischemia guided therapy
- ___ or ___ preferred

Early invasive strategy (PCI)
- ___ or ___ preferred

Answer 16

• clopidogrel, ticagrelor
• ticagrelor, prasugrel

Question 17

STEMI

fibrinolytic
- ___ preferred

PCI
- ___ or ___ preferred

Answer 17

• clopidogrel
• ticagrelor, prasugrel

Question 18

Stents

Drug eluting stents (DES) may not be preferred if patient is unable to tolerate or comply with a prolonged course of ___
- DES are assoicated with a higher rate of late stent ___

Answer 18

DAPT
- thrombosis

Question 19

CABG

T or F: ASA does not need to be held prior to CABG

Answer 19

T

Question 20

CABG - P2Y12i

hold prior to ___ CABG
- ticagrelor - ___ days
- clopidogrel - ___ days
- prasugrel - ___ days

hold for 24 hours prior to ___ CABG if possible

Answer 20

elective
- 3
- 5
- 7

urgent

Question 21

Answer 21

Question 22

Answer 22

Question 23

Answer 23

Question 24

GPIIb/IIIa inh

abciximab, epifibatide, and tirofiban
- potent ___ antiplatelets given in ___ to ASA and P2Y12i
- given at the time of ___
- expensive
- not used routinely

Answer 24

• IV, addition
• PCI

Question 25

GPIIb/IIIa inh

STEMI/NSTEMI

Consider on an individual basis at the time of PCI
- NSTEMI: high risk features such as positive ___
- STEMI: large ___ burden
- inadequate P2Y12i loading
- “Bail out” (used during procedure if ___ develops or low blood after stenting

Answer 25

• troponin
• thrombus
• thrombus

Question 26

GPIIb/IIIa inh

___ (ReoPro)

Bolus Dose: ___ mg/kg IV

Maintenance Dose: ___ mcg/kg/min

• continue up to ___ hours

Answer 26

abciximab
0.25
0.125
12

Question 27

GPIIb/IIIa inh

___ (Integrilin)

Bolus Dose: ___ mcg/kg IV x 2 (10 min apart)
- “ ___ bolus”

Maintenance Dose: ___ mcg/kg/min
- continue up to ___ hours

Renal Adjustment
CrCl < 50 mL/min: ____ mcg/kg/min

Answer 27

eptifibatide
180
- double

2
- 18
- 1

Question 28

GPIIb/IIIa inh

___ (Aggrastat)

Bolus Dose: ___ mcg/kg IV

Maintenance Dose: ___ mcg/kg/min
- continue up to ___ hours

Renal Adjustment
CrCl < 60 mL/min: ___ mcg/kg/min

Answer 28

tirofiban
25
0.15
- 18

0.075

Question 29

GPIIb/IIa inh - CI

CIs are ___ for each agent.

Things that you should look at:
- active bleeding
- any history of hemorrhagic ___
- severe uncontrolled HTN (SBP > ___ or DBP > ___ )
- major surgery within ___ weeks
- dialysis

Answer 29

different
- stroke
- 180, 110
- 6

Question 30

Answer 30