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BB PHARM 152 > ACS > Flashcards

ACS Flashcards

1
Q

Presentation of Coronary Atherosclerosis

A

Silent disease
chronic, stable angina
acute coronary syndromes (ACS)
- unstable angina, NSTEMI, STEMI

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2
Q

What are the type of ACS?

A

unstable angina and myocardial infarction

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3
Q

What are the types of MI?

A

STEMI
NSTEMI

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4
Q

What are the classic signs of ACS?

A

pressure/pain behind the sternum
pain radiates to arms, neck and jaw
persisted for over 5 minutes despite trying to rest

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5
Q

What are some symptoms for women getting ACS?

A

sweating
dyspnea
nausea
abdominal pain
fainting

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6
Q

What are the main assessments that determine treatment at ER?

A

the story and the pt
12 lead ECG
blood test for biomarkers of cardiac cell death

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7
Q

What are the major indications of MI?

A

in the blood tests will show increased troponins
have to have evidence of cardiac cell death

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8
Q

What does a normal ECG mean?

A

strong evidence to rule out ACS
will investigate other possible causes

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9
Q

What does a ST segment depression mean in the ECG?

A

strong evidence for coronary ischemia
ST depression is often associated with stable angina too

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10
Q

What does a ST segment elevation mean in the ECG?

A

a marker of complete coronary obstruction causing cardiac myocyte death
suggests a serious MI requiring urgent revascularization
STEMI (ST elevation MI)

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11
Q

What could happen in severe cases of ST segment elevation on a ECG?

A

major consequences if blood flow is not restored is heart failure, arrhythmias or even death

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12
Q

What does a Q wave show?

A

often will appear following a STEMI
usually indicates extensive damage
often remains in the ECG for life

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13
Q

T/F Healthy people have no Q wave appear during an ECG

A

True

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14
Q

What is needed to confirm STEMI

A

Must have evidence of cell death

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15
Q

what is the biomarker of myocardial necrosis

A

troponins (most sensitive and specific)

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16
Q

How long is troponins levels elevated after MI?

A

increase within hours and remain for several days

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17
Q

What is the definition of STEMI?

A

ST elevation is a classic presentation of a major MI
often leaves ECG evidence forever

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18
Q

What is LBBB?

A

left bundle branch block
conduction in the left bundle of his is slow
results in delayed depolarization of the left ventricle

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19
Q

What are some factors that will be there if diagnosed with STEMI

A

history of classic ischemic sx’s not relieved by rest
ST segment elevation on ECG
evidence of Cardiac cell death

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20
Q

What are some tests adminstered in ER?

A

ECG
Cardiac troponins
natriuretic peptides
CXR

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21
Q

Standard treatment in the ER

A

oxygen
ASA (might add ADP inhibitor if PI is choosen)
S/L NTG
BB
IV anticoagulation

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22
Q

What are the takeaways from BHAT?

A

several post MI trials showing similar benefits on lowering risk of death
recent years the management of STEMI has improved dramatically in other areas
most BB studies in the post MI setting are old

we didnt have surgery
very helpful in severe

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23
Q

Why the benefit of BB have decreased over the years?

A

post MI risk is lower today due to mechanical revascularization and medication use
therefore people are likely to have less damage

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24
Q

What level of troponin is in a healthy person?

A

zero

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25
Q

What is the first goal of STEMI treatment is? Within how many hours?

A

reperfusion
within 12 hours

26
Q

What is preferred method of reperfusion?

A

Primary PCI

27
Q

What if you cannot do a PCI within 2 hours, what do you do?

A

fibrinolytic medication should be given

28
Q

Why is it important to reperfusion as quickly as possible after a STEMI?

A

has the greater potential to restore blood
lowering the risk for damaged myocardium
lower risk of death

29
Q

What is needed prePCI?

A

antiplatelets and anticoagulants
specific –> ADP receptor antagonists
probably LMWH or UFH

30
Q

Why have antiplatelets prior to PCI?

A

helps protect against platelet activation that occurs during placement of stents
as it causes endothelial damage

31
Q

What is the loading dose for ADP inhibitors?

A

Clopidogrel 600 mg
Ticagrelor 180 mg

32
Q

What is the major difference between ticagrelor and other ADP inhibitors?

A

it is reversible vs irreversible
it is not a prodrug

33
Q

What is the acronym for the meds given in a heart meds?

A

ABC CKD BE CAD

34
Q

What is given if pt has already had 81 ASA?

A

they give 325 mg ASA

35
Q

Why is ACEi given if there is no hypotension?

A

it can help lower the chance of death (HOPE)

36
Q

What is DAPT?

A

dual antiplatelet therapy
taking a ADP inhib and ASA
this is used for a set amount of time after ACS

37
Q

List some factors that increase bleeding risk on DAPT

A

Need for OAC, NSAIDs, or prednisone
Age > 75
Frailty
Anemia with Hb < 110
CrCl < 40ml/min
Body weight < 60kg
Bleeding hosp within previous year
Prior stroke/intracranial bleed

38
Q

List some issues pertaining to DAPT

A

increase bleeding risk (compared to mono)
optimal duration in unclear
not sure if it is helpful in low risk pt

39
Q

Current Recommendations for BB post MI

A

LVSD / Heart failure – absolute indication (not in acute phase)
Arrhythmia – absolute indication
STEMI – absolute indication
STEMI without residual dysfunction – 3 years and re-evaluate (AHA)
NSTEMI without residual dysfunction – “consider” BB

40
Q

What is the caution with ACEI?

A

caution in first 24 hrs of MI because risk of hypotension or renal dysfunction

41
Q

Efficacy of ACE inhibitors

A

Mechanism↓ RAAS
First line in HTN when: ACVD, CKD, HF
Considered in all high risk pts even without HTN (HOPE)
Protects against CV events and renal disease progression (through BP mechanism for CV events, glomerular mechanism for CKD, uncertainty whether it has other protective benefits such as tissue specific effects)

42
Q

Safety of ACE inhibitors

A

General BP related side effects
Renal specific effects: drop in GFR expected after starting ACEI (up to 25% is safe)
Cough (can be quite common)
Increased K (through RAAS effect)
Angioedema (rare swelling reaction… often around mouth/lips)

43
Q

DI of ACEI

A

Anything that ↑ K (all other RAAS blockers)
Anything that decreases renal perfusion (NSAIDs, Diuretics, etc)

44
Q

Convenience of ACEi

A

Most are once (or twice daily)
Many single pill combinations available (these are important)

45
Q

CI of ACEi

A

Teratogenic
Bilateral renal artery stenosis
History of angioedema
First line in renal dz – BUT need caution in renal dz!!!

46
Q

What is the purpose of aldosterone blockade?

A

adding eplerenone to BB and ACEi in the post mI setting to pt with EF<40% was associated with lower mortality

47
Q

When is CABG used for a STEMI?

A

when coronary anatomy not amenable to PCI and ischemia persists

48
Q

What is the danger in CABG?

A

poses a much higher risk for bleeding during the procedure

49
Q

If possible what should not be used before CABG?

A

should not have used ADP inhibitors within the last 5 days
at least 24 hours if urgent

50
Q

What is the post antiplatelet therapy CABG?

A

just ASA if elective

possibility if STEMI or NSTEMI for DAPT

51
Q

What is the condition if ST depression and ischemia is seen with cell death?

A

This is a NSTEMI

52
Q

What is the condition if ST depression and ischemia is seen without cell death?

A

unstable angina

53
Q

When is 325 ASA given?

A

If they have already taken 81 ASA that day before

54
Q

What is a primary PCI used for?

A

STEMI
refractory angina
hemodynamic/electrical instability
high risk features (DB, previous MI, HF)

55
Q

When is beta blockers recommended?

A

LVSD/HF
Arrhythmia
STEMI
STEMI without residual dysfunction (for 3 years then see)

56
Q

What is the specific time that BB are consider but not automatically used?

A

NSTEMI without residual damage

57
Q

Why are ACEi recommended?

A

it has been shown to decrease mortality after recent MI

58
Q

What are the strong indications to use ACEi after MI?

A

EF < 40%
HTN
CKD

59
Q

Why does A Fib complicate the use of DAPT?

A

because there is an increase in risk of bleeding

60
Q

What is A Fib?

A

Atrial fibrillation
an arrhythmia of the atrium removing the atrial contraction altogether

clots can form due to pooling blood in the left atrium

61
Q

What is recommended for AFIB instead of DAPT?

A

anticoagulants

62
Q

What is the medical treatment after UA?

A

Many get a scheduled for a elective PCI to remove the blockage

BB PHARM 152 (1 decks)

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