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Acute Care I > ACS: NSTEMI > Flashcards

ACS: NSTEMI Flashcards

1
Q

Type of MI
Atherosclerotic plaque rupture, ulceration, fissure, ore erosion with resulting intraluminal thrombus in >/=1 coronary arteries leading to decreased mocardial blood flow &/or distal embolization & subsequent myocardial necrosis

A

Type I

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2
Q

Type of MI
myocardial necrosis when condition other than coronary plaque instability causes imbalance b/t myocardial oxygen supply & demand (hypotension, HTN, tachy/bradyarrhythmias, anemia, hypoxemia, coronary artery spasm, spontaneous coronary artery dissection (SCAD), coronary embolism, & myocardial dyfxn)

A

Type 2

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3
Q

Type of MI
death when biomarkers not available & types 4 & 5 MI (r/t PCI & CABG)

A

Type 3

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4
Q

Differential Dx of ACS in setting of acute CP
Cardiac

A

Myopericarditis
Cardiomyopathies
Tachyarrhythmias
Acute HF
HTN emergency
Aortic valve stenosis
Takotsubo syndrome
coronary spasm
cardiac trauma

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5
Q

Differential Dx of ACS in setting of acute CP
Pulmonary

A

PE
Tension PTx
Bronchitis, Pneumonia
Pleuritis

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6
Q

Differential Dx of ACS in setting of acute CP
Vascular

A

Aortic dissection
Symptomatic aortic aneurysm
Stroke

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7
Q

Probability of Ischemia
Central
Pressure
Squeezing
Gripping
Heaviness
Tightness
Exertional/stress-related
Retrosternal

A

High

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8
Q

Probability of Ischemia
Left sided
Dull
Aching

A

Moderately High

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9
Q

Probability of Ischemia
Stabbing

A

Moderate

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10
Q

Probability of ischemia
Right-sided
Tearing
Ripping
Burning

A

Mild

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11
Q

Probability of Ischemia
Sharp
Fleeting
Shifting
Pleuritic
Positional

A

Low

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12
Q

Summary of Recommendations for Early Hospital Care
Administer Supplemental O2 only with what?

A

SpO2 < 90%
Respiratory distress
Other high-risk features for hypoxemia

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13
Q

Summary of Recommendations for Early Hospital Care
Administer sublingal NTG how often and how many doses for continuing ischemic pain and then assess the need for what?

A

5min x 3
IV NTG

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14
Q

Summary of Recommendations for Early Hospital Care
Administer IV NTG for?

A

persistent ischemia
HG
or HTN

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15
Q

Summary of Recommendations for Early Hospital Care
Nitrates are contraindicated with recent use of what?

A

A phosphodiesterase inhibitor

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16
Q

Summary of Recommendations for Early Hospital Care
IV morphine sulfate may be reasonable for what?

A

continued ischemic CP despite maximally tolerated anti-ischemic medications

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17
Q

Summary of Recommendations for Early Hospital Care
Initiate oral beta blockers w/n 24 hours in the absence of?

A

HF
low-output state
risk for cardiogenic shock
other contraindications to BB use

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18
Q

Summary of Recommendations for Early Hospital Care
Use of what is recommended for beta-blocker therapy w/ concomitant NSTE-ACS, Stabilized HF, and reduced systolic fxn?

A

sustained-release metoprolol succinate
carvedilol
bisoprolol

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19
Q

Summary of Recommendations for Early Hospital Care
Administer initial therapy with non-DHP CCBs w/ recurrent ischemia and contraindications to BB in the absence of what?

A

LV dysfxn
increased risk for cardiogenic shock
PR interval > 0.24s,
second or third degree AV block w/o a cardiac pacemaker

20
Q

Summary of Recommendations for Early Hospital Care
Administer oral non-DHP CCB w/ recurrent ischemia after use of what in the absence of contraindications?

A

BB
Nitrates

21
Q

Summary of Recommendations for Early Hospital Care
Long-acting CCB and nitrates are recommended for patients w/ what?

A

coronary artery spasm

22
Q

Summary of Recommendations for Early Hospital Care
Initiate or continue high-intensity statin therapy in patients w/ what?

A

no contraindications

23
Q

Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
Aspirin
Non-enteric-coated aspirin to all patients promptly after presentation?
Aspirin maintenance dose continued indefinitely?

A

162-325mg

81-325mg

24
Q

Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
P2Y12 inhibitors: Clopidogrel
Loading dose followed by daily maintenance dose in patients unable to take aspirin?

A

75mg (loading dose 300-600mg)

25
Q

Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
P2Y12 inhibitor, in addition to ASA, for up to 12 mo for patients treated initially w/ either an early invasive or initial ischemia guided strategy?

A

Clopidogrel - loading dose of 300-600 mg, then 75mg daily

Ticagrelor - 180 mg loading dose, then 90 mg BID

26
Q

Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
GP IIb/IIIa inhibitor in patients treated with an early invasive strategy and DAPT w/ intermediate/high-risk features (eg positive troponin)
Preferred options are?

A

Eptifibatide
Tirofiban

27
Q

Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
Parenteral anticoagulation and fibrinolytic therapy
SC enoxaparin for duration of hospitalization or until PCI is performed

A

1mg/kg SC q 12h (reduce dose to 1mg/kg/d SC in patients w/ CrCl < 30ml/min)
Initial 30 mg IV loading dose in selected patients

28
Q

Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
Parenteral anticoagulation and fibrinolytic therapy
Bivalirudin until diagnostic angiography or PCI is performed in pts w2/ early invasive strategy only

A

Loading dose 0.1 mg/kg followed by 0.25mg/kg/h
Only provisional use of GP IIb/IIa inhibitor in patients also treated w2/ DAPT

29
Q

Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
Parenteral anticoagulation and fibrinolytic therapy
IV UFH for 48h or until PCI is performed

A

Initial loading dose 60 IU/kg (max 4000 IU) w/ initial infusion of 12 IU/kg/h (max 1000 IU/h)
Adjust to therapeutic aPTT range

30
Q

What scoring system provides an estimation of the 6mo mortality for patients w/ ACS based on patients risk factors?

A

The GRACE scoring system

31
Q

Factors Associated w/ Appropriate Selection of Early invasive strategy or Ischemia-guided strategy in patients w/ NSTE-ACS
Immediate invasive (w/n 2 hr)

A

Refractory angina
S/sx of HF or new or worsening mitral regurge
Hemodynamic instability
Recurrent angina or ischemia at rest or w/ low-level activites despite intensive medical therapy
Sustained VT or VF

32
Q

Factors Associated w/ Appropriate Selection of Early invasive strategy or Ischemia-guided strategy in patients w/ NSTE-ACS
Ischemia-guided strategy

A

Low-risk score (eg, TIMI [0-1], GRACE [<109])
Patient or clinician preference in the absence of high-risk features

33
Q

Factors Associated w/ Appropriate Selection of Early invasive strategy or Ischemia-guided strategy in patients w/ NSTE-ACS
Early invasive (w/n 24hr)

A

None of the above, but GRACE risk score > 140 Temporal change in Tn
New or presumably new ST depression

34
Q

Factors Associated w/ Appropriate Selection of Early invasive strategy or Ischemia-guided strategy in patients w/ NSTE-ACS
Delayed invasive (w/n 25-72h)

A

None of the above but DM & Renal insufficiency (GFR < 60mL/min/1.73msquared)
Reduced LV Systolic fxn (EF <40%)
Early post-infarction angina
PCI w/n 6mo
Prior CABG
GRACE risk score 109-140; TIMI score >/= 2

35
Q

In patients who have received prior anticoagulation therapy during PCI
Enoxaparin
For prior treatment w/ enoxaparin, if last SC dose was administered 8-12 h earlier or if < 2 therapeutic SC doses of enoxaparin have been administered an IV dose of enoxaparin at what dose should be given?

A

0.3mg/kg

36
Q

In patients who have received prior anticoagulation therapy during PCI
Enoxaparin
If the last SC dose was administered w/8 h, what dose should be given?

A

no additional enoxaparin should be given

37
Q

In patients who have received prior anticoagulation therapy during PCI
Bivalirudin
For patients who have received UFH, wait 30 min then give what loading dose and what infusion dose?

A

Loading dose - 0.75mg/kg
Infusion dose - 1.75mg/kg/h

38
Q

In patients who have received prior anticoagulation therapy during PCI
Bivalirudin
For patients already receiving bivalirudin infusion give how much additional loading dose and increase infusion dose to how much?

A

loading dose - 0.5mg/kg
infusion dose - 1.75mg/kg/h

39
Q

In patients who have received prior anticoagulation therapy during PCI
UFH
IV GPI planned: additional UFH as needed (eg 2000-5000 U) to acieve ACT of what?

A

200-250s

40
Q

In patients who have received prior anticoagulation therapy during PCI
UFH
No IV GPI planned: additional UFH as need (eg 2000-5000 U) to achieve ACT of ____ for HemoTec, or ____ for Hemochron

A

250-300s
300-350s

41
Q

NSTE-ACS Definite or Likely
Ischemia-Guided Strategy
Initiate what?

A

DAPT and Anticoagulant therapy

42
Q

NSTE-ACS Definite or Likely
Early Invasive Strategy initiate what?
Can consider what if high risk?

A

DAPT and anticoagulation therapy
GPI

43
Q

NSTE-ACS Definite or Likely
If medical therapy is ineffective and patient goes for PCI w/ Stenting Initiate/continue what?
GPI indicated if not treated with what at time of PCI?

A

DAPT and anticoagulation therapy

Bivalirudin

44
Q

NSTE-ACS Definite or Likely
If medical therapy is ineffective and patient goes for CABG initiate/continue what? and discontinue what?

A

ASA therapy
P2Y12 inhibitor and GPI

45
Q
A

Acute Care I (25 decks)

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