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Cardio Module > 6. Adane - Acute Coronary Syndromes > Flashcards

6. Adane - Acute Coronary Syndromes Flashcards

1
Q

What are some clinical presentations of STEMI?

A

Vigorous physical exercise, emotional stress, medical illness/surgery, can occur at rest
- Pain is deep and visceral (does not have to be chest pain)

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2
Q

What are the two types of Troponin biomarkers for MI?

A

Troponin T and Troponin I

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3
Q

What are the most common biomarkers for MI?

A

Troponin T and I, they rise quickly and remain elevated

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4
Q

In the TIMI risk score for STEMI, what does a high risk score mean?

A

A higher risk score means a higher risk of death from a MI

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5
Q

What are the short term treatment goals of ACS?

Hint, there’s 5

A
  1. Restore blood flow ASAP
  2. Prevent death/MI complications
  3. Relieve chest discomfort
  4. Prevent coronary artery reocclusion
  5. Restore ST segment and T-wave changes on ECG
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6
Q

What are the long term goals for ACS?

Hint, there’s 3

A
  1. Control CV risk factors (non-pharm and modifiable risk factors)
  2. Prevent CV events: re-infarction, stroke, HF
  3. Improve quality of life
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7
Q

What does MONA stand for?

A

M: morphine
O: oxygen, when below 9
N: nitrates, to relieve chest pain
A: Aspirin (thromboxane inhibitor)

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8
Q

What are the two strategies for reperfusion?

A
  1. Primary Percutaneous Coronary Intervention (PCI)

2. Fibrinolytic drugs (clot busters)

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9
Q

How quickly should a PCI be performed?

A

90 minutes if at the same institution, 120 minutes if done at another institution

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10
Q

What is the benefit of a PCI?

A

Safer, with lower mortality and lower risk of intracranial hemorrhaging and other major bleeding

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11
Q

When should fibrinolytic drugs be used over PCI?

A
  1. Chest discomfort has lasted longer than 12 hours

2. No catheterization lab on site and cannot get to one in 120 minutes

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12
Q

What are the 3 fibrin specific fibrinolytics and the non-fibrin specific drugs?

A

Specific: Alteplase, Reteplase, Tenecteplase

Non-fibrin: streptokinase

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13
Q

What are the 7 contraindications of fibrinolytics in STEMI?

A
  1. Active internal bleeding
  2. Previous inter cranial hemorrhage
  3. Ischemic stroke w/in 3 months
  4. Know intracranial neoplasm
  5. Known structural vascular lesion
  6. Suspected aortic dissection
  7. Significant closed head or facial trauma w/in 3 months
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14
Q

Along w/ MONA, what other drugs are used to treat STEMI?

Hint, there’s 4 more

A
  1. Morphine
  2. Oxygen
  3. Nitrates
  4. Aspirin
  5. P2Y12 inhibitors
  6. Anticoagulants
  7. Stool softeners
  8. Statins, B-blockers, ACEI/ARBS
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15
Q

Nitrates: which nitrate, how long, and what is its job?

A

Sublingual nitroglycerin 400 mcg Q5 min, up to 3 doses.

Decreases LV preload and O2 demand, decreases BP, O2 demand and vasospasms

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16
Q

When should IV nitroglycerin be used? And when should it be avoided?

A

Used: if persistent ischemia
Avoided: after 24 hours of ischemic relief, PDE5 inhibitors used w/in 24-48 hours

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17
Q

Aspirin and ACS: MOA, dose, usage, interactions

A

MOA: inhibits synthesis of TXA2 (by inhibiting COX-1)
Dose: LD, 162-325mg PO before PCI, then maintenance dose of 81-325mg QD
Usage: prevent thrombotic occlusion, decreased risk of stent thrombosis and decrease mortality w/ fibrinolytics
Interactions: stop NSAIDS and COX-2 inhibits at time of STEMI

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18
Q

Examples of P2Y12 inhibitors, their usage and MOA

A

Clopidogrel, prasugrel, Tricagrelor
Use: in combination w/ aspirin
MOA: blocks receptor for ADP on platelets, reduced platelet aggregation and activation

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19
Q

Clopidogrel is converted by what and how does it bind?

A

Clopidogrel is a prodrug converted by CYP 450 and binds irreversibly to P2Y12 receptor

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20
Q

How should clopidogrel be administered if PCI w/ stent?

A

Use ASA 325mg + loading dose of 600mg clopidogrel

Give maintenance dose of 75mg QD for one year

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21
Q

Clopidogrel and its use w/ fibrinolytics

A

Use w/ ASA
- if 75, 75mg loading dose
Maintenance dose: 75mg QD for at least 14 days and up to 1 year

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22
Q

Prasugrel and its use if PCI w/ stent

A

Prasugrel is a prodrug, that irreversibly binds to P2Y12 receptor
Use w/ ASA + 60mg prasugrel loading dose on day 1
On day 2, maintenance dose of 10 mg for 1 year

23
Q

What are the contraindications of Prasugrel?

A
  • Patients w/ prior history of stroke or TIA

- Increased risk of bleeding in pts >75 yrs and weight

24
Q

Benefits of Prasugrel

A
  1. Least number of drug interactions

2. Pts w/ diabetes and STEMI + PCI

25
Q

What is the TRITON-TIMI 38 trial?

A

Compared Clopidogrel vs. Prasugrel in pts w/ ACS scheduled to receive PCI
- Prasugrel has an increased chance of bleeding, but has advantages over Clopidogrel (i.e. Drug interactions)

26
Q

What is Ticagrelor and why is it different from Clopidogrel and Prasugrel? What CYPs metabolize it?

A

P2Y12 inhibitors and is not a prodrug and is a reversible inhibitor of P2Y12.
Metabolized by CYP3A4 and 3A5 - potential for drug interactions

27
Q

Ticagrelor and its use if PCI w/ stent

A

Use ASA + 180mg Ticagrelor (loading dose) followed by 90mg BID for 1 year

  • Recommended maintenance dose of 80mg ASA
  • therapy should be discontinued 5 days before surgery
28
Q

What is the PLATO trial?

A

Compares Clopidogrel to Ticagrelor
Clopidogrel PO: 300-600mg x1 + 75mg QD
Ticagrelor PO: 180mg x1 + 90 mg BID
Clopidogrel has an increased risk of primary endpoint than Ticagrelor

29
Q

What is the use of unfractionated hepatic (UFH) w/ or w/o GPIIb/IIIa inhibitor?

A

Anticoagulant in STEMI managed w/ PCI

  • UFH bolus w/ GIIb/IIIa: 50-70 units/kg + UFH infusion
  • UFH alone: 70-100 units/kg + UFH infusion
30
Q

What are some examples of GPIIb/IIIa receptor antagonists, and what is their MOA?

A

Abciximab, Eptifibatide, Tirofiban

MOA: block GPIIb/IIIa receptors on platelets and inhibit platelet aggregation

31
Q

What is Bivalirudin?

A

A specific and reversible direct thrombin inhibitor

32
Q

4 examples of Anticoagulants

A
  1. Bolus and infusion UFH
  2. Exoxaparin - not for pts w/ end stage renal disease
  3. Fondaparinux
  4. Bolus and infusion Bivalirudin
33
Q

What are some side effects of anticoagulants, heparin/enoxaparin and GPIIb/IIIa?

A

H/E: bleeding, heparin induced thrombocytopenia
GPIIb/IIIa: bleeding, immune-related thrombocytopenia
- contraindicated if history of hemorrhagic stroke/recent ischemic stroke

34
Q

What is the use of b-blocks w/ PCI?

A

Decrease myocardial workload/O2 demand, decrease risk of ischemia, infractions and ventricular arrhythmias
- For use in pts w/o a cardiac or respiratory contraindications

35
Q

How early should a b-blocker be administered in pts w/ STEMI and for how long?

A

Started w/in 24 hours if pt has no contraindications and continues for 3 years (or indefinitely)

36
Q

When is IV b-blocker indicated?

A

Oral b-blockers are recommended

- IV w/ HTN or signs of ischemia, don’t use w/ pts w/ acute heart failure

37
Q

When should statins be used in pts w/ STEMI and PCI?

A

High dose atorvastatin (80mg/day) in all pts w/o contraindications

38
Q

When should ACEI/ARBs be used in STEMI and PCI?

A

ACEI: lisinopirl, captopril, ramipril, trandolapril
ARBs: valsartan
For use in pts w/ anterior infarction, post-MI or HF
Don’t use w/ acute kidney injury, but ok w/ chronic injury

39
Q

When should an aldosterone antagonist be used in pts w/ STEMI and PCI?

A
  • Pts w/ ACE inhibitor and b-blocker

- Have EF

40
Q

What is a CABG?

A

CABG stands for coronary artery bypass graft surgery

- indicated for STEMI + cardiogenic shock, failed PCI and coronary anatomy not amenable to PCI

41
Q

What should and shouldn’t be w/held before a CABG

A
  • ASA should not be w/held before urgent CABG
  • Clopidogrel and Ticagrelor should be discontinued 24 hrs before urgent CABG
  • Discontinue Eptifibatide, Tirofiban at least 2-4 hrs before urgent CABG
  • Discontinue abciximab at least 12 hrs before CABG
42
Q

Should fibrinolytics be used when pt has NSTE-ACS (Non-ST elevated Acute Coronary Syndrome)?

A

NEVER!

43
Q

What is NSTE-ACS?

A

Non-ST elevated acute cardiac syndrome

  • divided on basis of cardiac biomarkers of necrosis
  • clinical sign is chest pain
44
Q

NSTE ACE management

A
  • ECG w/in 10 minutes of arrival
  • Measure cardiac Troponin
  • Stratify risk to assess prognosis
45
Q

TIMI risk score for NSTE ACS

A

Age, >3 risks for CAD, known CAD, aspirin w/in 7 days, >2 episodes of chest discomfort w/in 24 hrs, ST changes, positive markers

46
Q

NSTEMI management

A
  1. Early invasive strategy - assessing. Coronary anatomy w/in 24 hrs
  2. Ischemia-guided - invasive diagnostic evaluation if pts have refractory/recurrent ischemic symptoms
  3. PCI or CABG if: risk of death or MI, acute HF, angina, cardiogenic shock
  4. Fibrinolytic therapy is not indicated in NSTE-ACS
47
Q

Pharmacotherapy for NSTE-ACS

Hint, there’s 8 (same as STEMI treatment)

A
  1. Morphine
  2. Oxygen
  3. Nitroglycerin
  4. Aspirin
  5. P2Y12 inhibitors
  6. Anticoagulants
  7. Stool softeners
  8. Statins, b-blockers, ACEI/ARBs
48
Q

NonSTEMI managed w/ PCI

A

Dual antiplatelet therapy
On ASA already: 81mg - 325 mg ASA before PCI
Not on ASA: 325mg ASA before PCI
Continue ASA 81-325mg QD and add P2Y12 inhibitor
*ASA dose,

49
Q

NonSTEMI w/ PCI and P2Y12 inhibitors

A

Clopidogrel: 300-600 mg x1 followed by 75mg QD
Prasugrel: 60mg x1 followed by 10mg QD
Ticagrelor: 180mg x1 followed by 90mg BID
Maintence dose for 1 year

50
Q

NonSTEMI w/ PCI and anticoagulants

A

Use to reduce the risk of intracoronary and catheter thrombus formation, discontinue after procedure
UFH w/ or w/o GPIIb/IIIa, Bivalirudin, enoxaparin

51
Q

Oral b-blockers w/ NonSTEMI

A

Metoprolol, carvedilol, bisoprolol
W/ in the first 24hrs in the absence of HF, low out-put, cardiogenic shock, other b-blocker contraindications
- IV b-blockers are harmful when risk for shock is present

52
Q

CCB w/ NonSTEMI

A

Recommended for ischemic symptoms when b-blockers are not successful/are contraindicated/cause unacceptable side effects

53
Q

ACEI/ARBs w/ NonSTEMI

A

Use w/in 24hrs in pts w/ HTN, DM and stable CKD

54
Q

How many deaths in the US are contributed to CVD?

A

About 1/3 of all deaths in the US

Cardio Module (12 decks)

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