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ACS/AMI II Flashcards

1
Q

Formula for volume of contrast that will cause CIN

A

Vol. Contrast = 4 x CrCl

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2
Q

In pt’s with stage II or III CKD and UA/NSTEMI, is early invasive or conservative strategy preferred?

A

Invasive (Class IIa)

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3
Q

what to do for pt w/ 2 vessel dz (incld pLAD) and LV dysfxn?

A

CABG

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4
Q

What did TACTICS-TIMI 18 show for women with UA/NSTEMI?

A

Had more death, MI, and hospitalization if low trop and LHC

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5
Q

Reasonable

A

Class IIa

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6
Q

what GRACE score is high risk?

A

> 140

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7
Q

What is the timing of cath in early invasive strategy?

A

12-24 hrs

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8
Q

Reasons for NSTEMI with normal coronary anatomy on angio

A

Auto lysis of thrombus
Spasm
Non coronary trops (PE, etc)

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9
Q

Name 2 platelet receptors that can activate platelets

A

Thrombin receptor

ADP receptor

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10
Q

Thienopyridines (clopidogrel, prasugrel) mech

A

Irreversibly Block P2Y12 receptor and inhibit ADP-induced plt activation

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11
Q

Ticagrelor mech

A

Non-thienopyridine REVERSIBLE antagonist of P2Y12 ADP platelet receptor

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12
Q

GP 2b3a inhibitors and reversibility

A

Eptifibatide
Tirofiban (reversible)
Abciximab (irreversible)

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13
Q

Class I indication in NSTEMI for pt’s intolerant of ASA

A

Clopidogrel

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14
Q

Chronic ASA dosing after DES

A

325 for 3-6 mo’s

After 3-6 mo’s, 81mg indefinitely

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15
Q

CURE study

A

Lower stroke/MI/CV Death w/ Plavix & ASA c/w ASA & placebo

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16
Q

What to remember about pt’s who are poor metabolizes from abnormal CYP2C19 fxn?

A

Clopidogrel is less effective, consider alternative treatment

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17
Q

which trial showed that carriers of reduced fxn allele CYP2C19 have higher incidence of CV death, MI, or stroke?

A

TRITON-TIMI 38

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18
Q

Does prasugrel get affected by poor CYP2C19 metabolism?

A

No

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19
Q

Which anti platelets are Class I before PCI in NSTEMI?

A

Plavix

GP2b3a

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20
Q

What did TRITON TIMI 38 show for Plavix vs prasugrel?

A

Prasugrel had lower CV death, MI AND STROKE

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21
Q

Contraindications to prasugrel

A

Prior CVA
Age> 75
Weight <60kg

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22
Q

What did TRITON TIMI 38 show for IST?

A

50% Lower with prasugrel c/w clopidogrel

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23
Q

Why is ticagrelor faster acting than clopidogrel?

A

B/c it is not a prodrug

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24
Q

Which anti platelet drug reversibly binds to ADP receptor? When can that come in handy?

A

Ticagrelor

Need for Sx

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25
Q

Which trial showed that ticagrelor lowers death from vascular causes and IST c/t Plavix?

A

PLATO

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26
Q

In PLATO, was there a difference in bleeding b/w ticagrelor and Plavix?

A

Not statistically sig but inc’d trend in non-CABG bleeding for ticagrelor

27
Q

Which anti platelet has the fastest onset?

A

Ticagrelor

28
Q

Which anti platelet has the most variable response?

A

Plavix

29
Q

Plavix and ticagrelor need to be held for 5 d before CABG. What about prasugrel.

A

7-10d

30
Q

Which anti platelet has the highest bleeding risk.

A

Prasugrel

31
Q

Which anti platelet has the most side effects (esp. SOB)?

A

Ticagrelor

32
Q

Which anti platelet requires a max ASA dose of 81mg?

A

Ticagrelor

33
Q

Which is the only ADP antagonist you can use in pt w/ prior ICH?

A

Plavix

34
Q

Which ADP antagonist is preferred if pt is a high bleed risk?

A

Plavix

35
Q

Which ADP antagonists are preferred in STEMI?

A

Prasugrel

Ticagrelor

36
Q

Which ADP Antagonists are preferred in complex PCI or DM?

A

Prasugrel

Ticagrelor

37
Q

What part of the plt pathway do GP2b3a antagonists inhibit?

A

Aggregation

38
Q

**Which GP2b3a antagonist requires dose adjustments for CrCl<50?

A

Eptifibatide

39
Q

Ticagrelor can cause insig bradycardia. What other SE is common and what is the mech?

A

SOB

adenosine release

40
Q

In the EARLY ACS trial, what were the results of eptifibatide use when pt’s also received ASA, hep, and Plavix? Was there a benefit to giving it upstream in NSTEMI vs. immediately prior to PCI?

A

Increased TIMI major bleeding

No

41
Q

Main results for ACUITY study and bivalirudin?

A

In ACS , Less bleeding with bivalirudin alone (c/t hep and GP2b3a or bival + GP2b3a)

42
Q

how long before CABG do you have to d/c IV GP IIb/IIIa inhibitors?

A

4h

43
Q

when do you stop lovenox before CABG?

A

12-24hrs

44
Q

when do you stop fondaparinux before CABG?

A

24h

45
Q

when do you stop bivalirudin before CABG?

A

3h

46
Q

what two antiplatelets/anticoagulants can you continue for CABG?

A

ASA, UFH

47
Q

in a pt with NSTEMI/UA, if you find CAD on angio but decide on OMT, when can you d/c GPIIb/IIIa inhibitors if started pre-angio?

A

at least 12h

48
Q

in pt. w/ NSTEMI/UA w/ CAD on angio going for just OMT, when do you D/C UFH?

A

after 48h (2d)

49
Q

in pt. w/ NSTEMI/UA w/ CAD on angio going for just OMT, when do you D/C lovenox or fondaparinux?

A

on discharge from hospital

50
Q

in pt. w/ NSTEMI/UA w/ CAD on angio going for just OMT, when is the max time you can d/c bivalirudin?

A

72 h (at a dose of .25mg/kg/h)

51
Q

in pt. w/ NSTEMI/UA w/ CAD on angio going for just OMT, how long do you cont. ASA and clopidogrel?

A

ASA forever

Clopidogrel at least 1 mo (prefer 1 yr)

52
Q

what are preferred strategies in patients that require triple antithrombotic therapy but are at high bleeding risk?

A

d/c ASA first

consider BMS

53
Q

When ASA blocks COX, production of what is decreased?

A

TXA2

54
Q

What did CURRENT-OASIS-7 show for pt’s undergoing PCI and Plavix 600 vs 300?

A

600 lowered ischemic events but caused more bleeding

55
Q

According to TRITON-TIMI-38, what happens if a pt is on clopidogrel and has CYP2C19 reduced-fxn allele?

A

Higher CV death/MI/Stroke

56
Q

Is prasugrel a prodrug?

A

Yes

57
Q

Which GP2b3a inhibitor is contraindicated to give upstream for UA/NSTEMI?

A

Abciximab

58
Q

Which GP2b3a inhibitors are Class I at time of PVI for UA?

A

All

59
Q

Does prasugrel have more major bleeding than Plavix according to TRITON-TIMI-38?

A

Yes

60
Q

Is ticagrelor a prodrug?

A

No

61
Q

Which anti platelet agent has been shown to reduce BOTH all-cause mortality and CV mortality?

A

Ticagrelor

62
Q

Which anti platelet should you not use if patient had any type of AVB?

A

Ticagrelor

63
Q

How do you decide if pt w/ UA/NSTEMI should get conservative management over early invasive strategy?

A

Low risk TIMI/Grace score

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