ACS (lecture 7)

Question 1

Every NSTE ACS patient, regardless of the level of risk, should promptly receive antianginal medications, antiplatelet therapy, and a statin, unless contraindicated.

Conversely, the high-risk patient should receive antianginal medications, antiplatelet therapy, a statin, ____, and coronary angiography followed by revascularization

Answer 1

intensive anticoagulant therapy

Question 2

Antianginal Therapy = ?

Answer 2

Nitro (CI if taken PDE5 in last 24-48)
ß blockers
CCB

Question 3

β-Blockers should not be administered to patients with decompensated heart failure, hypotension, hemodynamic instability, or advanced _____. Because most patients with chronic obstructive pulmonary disease or peripheral vascular disease tolerate β-blockers without difficulty, these conditions should not automatically preclude their use.

Answer 3

atrioventricular block

Question 4

Calcium-channel blockers, which cause arterial vasodilation, increase coronary arterial blood flow and lower systemic arterial pressure. The non-dihydropyridine calcium-channel blockers diltiazem and verapamil slow heart rate and are recommended for the patient with a contraindication to ____ or persistent or recurrent symptoms despite treatment with nitroglycerin or a β-blocker.

Answer 4

a β-adrenergic blocker

Question 5

Antiplatelet Agents?

Answer 5

ASA

clopidogrel/prasugrel/ticagrelor (P2y12)

Abciximab (GPIIa/IIIb Inhibitor)

Question 6

ACS patients should receive dual antiplatelet therapy (aspirin and clopidogrel, or similar agent) acutely and for up to 1 year unless the patient has an aspirin allergy

Answer 6

Rog

Question 7

Anticoagulant treatment with unfractionated heparin, low-molecular-weight heparin (LMWH), or fondaparinux is appropriate, with ____ recommended for the patient at increased risk of bleeding.

Answer 7

fondaparinux

Question 8

___ is superior to unfractionated heparin in preventing MI or death during hospitalization in NSTE ACS patients who have elevated serum cardiac biomarkers as well as in those considered to be at high risk for recurrent ischemia

Answer 8

LMWH (enoxaparin and dalteparin)

Question 9

____, a direct thrombin inhibitor, is currently recommended as an alternative anticoagulant for patients undergoing PCI. ____ is the anticoagulant of choice for the patient with ACS who has heparin-induced thrombocytopenia.

Answer 9

Bivalirudin

Question 10

In the absence of contraindications, high-dose atorvastatin (40 to 80 mg daily) or rosuvastatin (20 to 40 mg daily) should be given orally to the patient with NSTE ACS, regardless of the baseline serum low-density lipoprotein cholesterol concentration; a lower dose is not as effective in reducing ischemic events. The addition of ____ should also be considered even if patients achieve desirable LDLs on a statin.

Answer 10

ezetimibe

Question 11

____ is performed to relieve angina that is persistent or recurrent despite optimal medical therapy, to prevent recurrent ischemia or MI in patients at high risk for a subsequent ischemic event, and to improve survival in patients with suitable coronary arterial anatomy.

Answer 11

Coronary revascularization

Question 12

Two most common SE of niacin in the tx of hypertriglyceridemia?

Answer 12

Flushing/pruritus

Question 13

Summary of Recommendations. The USPSTF strongly recommends that clinicians routinely screen men __ years and older and women 45 years and older for lipid disorders and treat abnormal lipid levels in persons who are at increased risk of coronary heart disease (A recommendation)

Answer 13

35

Question 14

Elderly patients, especially women, and patients with diabetes are particularly prone to painless or atypical MI, which is the pre- sentation of MI in as many as one third to one half of such patients

Answer 14

In these patients, acute MI can be manifested as sudden dyspnea (which can progress to pulmonary edema), weakness, lightheadedness, nausea, and vomiting. Confusional states, sudden loss of consciousness, a new rhythm disorder, and an unexplained fall in blood pressure are other uncommon pre- sentations.

Question 15

No physical findings are diagnostic or pathognomonic of acute MI. The physical examination often is entirely normal or may reveal only nonspecific abnor- malities. An S4 gallop frequently is found if it is carefully sought. Blood pressure often is initially elevated, but it may be normal or low. Signs of sympathetic hyperactivity (tachycardia, hypertension, diaphoresis, or any combination of these three) often accompany _____ wall MI, whereas parasympathetic hyperactivity (bradycardia, hypotension, or both) is more common with infe- rior wall MI

Answer 15

anterior

Question 16

The rapid triage of ST elevation MI patients to reperfusion therapy, most often for coronary angiography with intent to perform PCI, should not be delayed by routine imaging studies.

Answer 16

A chest radiograph is the only imaging test routinely considered in the emergency department for ST elevation MI

Question 17

____ is indicated to evaluate a new murmur and other suspected mechanical com- plications of acute MI (e.g., papillary muscle dysfunction or rupture, acute ventricular septal defect, and LV free wall rupture with tamponade or pseu- doaneurysm).

Answer 17

Doppler echocardiography

Question 18

When fibrinolysis is used, an accelerated regimen of a tissue plasminogen activator (plus ___) is preferred to streptokinase because the patency rate of the infarct-related artery at 90 minutes is higher and mortality is lower.

Answer 18

IV heparin

Question 19

Initiation or continuation of ____, beginning on admission, is supported by clinical trials.

Answer 19

high-intensity statin therapy (e.g., atorvastatin 80 mg/day or rosuvastatin 20 to 40 mg/day)