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Clinical Therapeutics > ACS Case > Flashcards

ACS Case Flashcards

1
Q

What are the risk factors for CAD?

A

Age >65, M>F, smoking, dyslipidemia, HTN, DM, abdominal obesity, family hx, cocaine use

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2
Q

What labs should be drawn for initial assessment?

A

CBCD, BMP, Troponin, +/- CKMB or BNP

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3
Q

What diagnostics need to be ordered upon initial assessment?

A

12-lead EKG, CXR

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4
Q

According to AHA guidelines how soon upon arrival should EKG be done?

A

10 minutes

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5
Q

EKG findings with suspected UA/NSTEMI

A

Normal, ST depression, transient ST elevation, T wave inversion in lead 3 is normal new T-wave inversion is abnormally, marked t wave inversion >2mm suggests ischemia

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6
Q

EKG should be repeated @ what intervals?

A

15-30 minutes during the first hour

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7
Q

Initial ED intervention

A

Peripheral IV access, telemetry monitoring, O2

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8
Q

What meds should be given initially?

A

MONA: Morphine, O2, Nitro, Aspirin

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9
Q

What is the mechanism of action of NTG?

A

Decreases cardiac pre-load and afterload

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10
Q

How should the orders for NTG be prescribed for pt in ED?

A

NTG 0.4mg Q 5 minutes X 3
OR
400mcg Sublingual Hold if BP less than 100/50

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11
Q

What should NOT be given in potential ACS/NSTEMI?

A

Ibuprofen

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12
Q

What type of XRay should be ordered?

A

Portable!! Done in AP format

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13
Q

If pt has relief of pain form NTG, does it indicate a cardiac process?

A

No, NTG was originally designed for GI stuff, used for acid reflux

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14
Q

Pt presents with chest pain, have normal EKG in ED and first troponin negative, painfree now can they be discharged?

A

No

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15
Q

What is the army risk stratification for prognosis?

A

Perform rapid determination of likelihood, 12 lead EKG within 10 mins

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16
Q

Troponin should be ordered for all pts with what?

A

Symptoms consistent with ACS

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17
Q

How often should troponin be ordered?

A

At presentation and 3-6 hours after onset

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18
Q

Obtain supplemental EKG leads V7-9 in who?

A

Pts with initial nondiagnostic EKG at intermediate/high risk for ACS

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19
Q

High likelihood history for ACS

A

Chest or left arm pain, prior documented angina

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20
Q

High likelihood on exam for ACS

A

Transient MR murmur, hypotension, diaphoresis, pulmonary edema, or rales

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21
Q

High likelihood EKG findings for ACS

A

New or transient ST segment deviation or T wave inversion in multiple precordial leads

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22
Q

What cardiac markers will be high for high likelihood of ACS?

A

Elevated troponin or CKMB

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23
Q

Intermediate likelihood for ACS for history

A

Chest or left arm pain or discomfort as chief symptoms

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24
Q

Intermediate likelihood on exam for ACS

A

Extracardiac vascular disease

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25
Q

Intermediate likelihood on EKG for ACS

A

Fixed Q waves

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26
Q

Intermediate likelihood for cardiac markers ACS

A

Normal

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27
Q

Low likelihood on history for ACS?

A

Probably ischemic symptoms in absence of any of the intermediate characteristics

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28
Q

Low likelihood on exam for ACS

A

Chest discomfort reproduced by palpation

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29
Q

Low likelihood on EKG for ACS

A

T-wave flattening or inversion in leads with dominant R waves or normal EKG

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30
Q

What risk score predicts the risk of death or MI at 30 days after admission

A

PURSUIT

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31
Q

What does TIMI predict?

A

Risk of all cause mortality, MI and severe recurrent ischemia requiring urgent revascularization within 14 days after admission

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32
Q

What does GRACE predict?

A

Risk of hospital death and post-discharge death at 6 months

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33
Q

What does HEART predict?

A

Prediction of combined endpoint of MI, PCI, CABG, or death within 6 weeks after presentation

34
Q

Which scoring method is widely-used and most well known?

A

TIMI

35
Q

TIMI

A

Better suited for pt with confirmed NSTEMI or known unstable angina

36
Q

GRACE score

A

Risk stratification for patients with CONFIRMED ACS

37
Q

HEART score

A

Better suited for undifferentiated pt with possible acute coronary syndrome

38
Q

Which scoring method is better suited for pts with confirmed dNSTEMI or known unstable angina?

A

TIMI

39
Q

Which scoring method is used for pts with confirmed ACS?

A

GRACE

40
Q

Which scoring method is better suited for undifferentiated pts with possible ACS?

A

HEART score

41
Q

What does HEART stand for for the scoring methods?

A 
H: History
E: EKG
A: Age >65
R: Risk factors
T: Troponin
42
Q

What is the scoring for HEART?

A

0-3, discharge home
4-6 admit for clinical observation
7-10 early invasive strategies

43
Q

What is the scoring for TIMI?

A

Low: 0-2
Intermediate: 3-4
High: 5-7

44
Q

What is the treatment for possible ACS?

A

MONA, provocative testing within 72 hours (stress test)

45
Q

What is the treatment for definite ACS (NSTEMI/UA)?

A

Aspirin, P2y12 inhibitors, anticoags, NTG, BB

Cath lab, stent, medically managed

46
Q

What 3 things make up ACS?

A
  1. Unstable angina
  2. NSTEMI
  3. STEMI
47
Q

What is the dosing for morphine?

A

2-4mg PRN

48
Q

What is the dosing for antiplatelet therapy?

A

Aspirin 325 + Ticagrelor 180mg QD

49
Q

What anticoag should be used for ACS?

A

Lovenox 1mg/kg/SC Q 12 hours

50
Q

What BBs should be used for ACS?

A

Lopressor 5mg IV NPO or 25mg PO BID

51
Q

What can be given for cholesterol management for ACS?

A

Lipitor (Atorvastatin 80mg)

52
Q

What is the dosing for aspirin?

A

162-325mg

53
Q

What is the dosing for Plavix (Clipidogrel)

A

300 or 600mg loading dose; 75mg/daily

54
Q

What is the dosing for Brilinta (Ticagrelor)?

A

180mg loading dose; 90mg BID

55
Q

What is the dosing for Enoxaparin (anticoag)

A

1mg/kg SC Q12hr

56
Q

What is used to remember the discharge plan of action?

A

ABCDEFHI

57
Q

Discharge plan of action

A 
A: Aspirin, NTG, ACEI/ARB
B: BB/BP Metoprolol
C: Cholesterol + cigarette cessation Lipitor
D: Diet and DM
E: Education and exercise 
F: Follow up care
H: hospitalization course and HTN management 
I️: immunizations
58
Q

What is a thrombus?

A

Platelet aggregation + fibrin formation

59
Q

Fibrin creates what?

A

Meshwork which allows for platelet to adhere together

60
Q

What are the anti-platelet drugs?

A

ADP receptor antagonists, GP 2b/3a antagonists

61
Q

What are the ADP receptor antagonists?

A

Plavix (Clopidogrel)
Effient (Prasugrel)
Brilinta (Ticagrelor)

62
Q

What are the GP 2b/3a antagonists?

A

Reopro (Abciximab)
Aggrastat (Tirofiban)
Integrilin (Eptifibatide)

63
Q

What are some other anti-platelet drugs?

A

Persantine (Dipyridamole), Aggrenox (Dipryidamole/ASA), Pletal (Cilostazol), Pentoxifylline

64
Q

When is aspirin given for NSTEMI/UA?

A

Given prior to PCI full dose, then given low dose daily

65
Q

When are the P2y12 inhibitors given with NSTEMI/UA?

A

Prior to PCI, then provided daily for up to one year

66
Q

What is the exception to the P2y12 inhibitors?

A

Prasugrel, if used will be given right at PCI then daily for up to on year

67
Q

When should the GP2b/3a be given for NSTEMI/UA?

A

Given during coronary angioplasty or stent placement in pts with ACS

68
Q

What are the pros of choosing Ticagrelor?

A

Rapid and extensive platelet inhibition, reversible inhibition and rapid offset effect, less susceptible to genetic variation and DDIs, reduction in ischemia event rates vs clopidogrel, similar overal bleeding risk vs clopidogrel, proven efficacy regardless of txt strategy

69
Q

What are the pros of choosing Prasugrel?

A

Rapid and extensive platelet inhibition, less susceptible to genetic variation and DDIs, reduction in ischemic event rates following PCI vs Clopidogrel, greatest efficacy in pts with DM and STEMI, once-daily dosing

70
Q

What are the pros of choosing Clopidogrel?

A

Affordable, long hx of use, only agent with proven efficacy in pts undergoing thrombolytic, once-daily dosing

71
Q

Cons of choosing Ticagrelor?

A

Expensive, increased risk of non-CABG surgery bleeding vs Clopidogrel, twice-daily dosing, dyspnea and ventricular pauses

72
Q

What are the cons of choosing Prasugrel?

A

Expensive, high risk of major bleeding, especially in pts undergoing CABG, coronary anatomy should be defined by angiography before initiation, questionable utility it pts undergoing procedures other than PCI

73
Q

What are the cons of choosing Clopidogrel?

A

Response variability, with a poor response assocaited with increased risk of thrombosis, susceptible to genetic variation and DDIs, questions regarding appropriate dosing

74
Q

What is the function of anticoagulants?

A

Decrease formation of clots

75
Q

Anticoagulants primary ADR

A

Increased bleeding risk, less clotting = more bleeding

76
Q

What are the indirect thrombin inhibitors?

A

Heparin/Enoxaparin/Fondaparinux

77
Q

How do indirect thrombin inhibitors work?

A

Work on anti-thrombin and inactivate factor Xa

78
Q

What are the direct thrombin inhibitors?

A

Bivarlirudin (Angiomax)
Argatroban
Dabigatran (Pradaxa)

79
Q

What must be monitored for UFH unfractionated heparin?

A

PTT; concern for HIT

80
Q

Heparin

A

Rapid onset, IV administration, unpredictable anticoag effect, risk of HIT, greater bleeding risk than LMWH

81
Q

Enoxaparin

A

No PTT monitoring, less protein binding, less inactivation, less HIT risk, SQ administration, simpler dose calcs, caution with elderly and renal impairment

Clinical Therapeutics (8 decks)

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