ACS Part 2

Question 1

Short term goals of therapy for ACS

Answer 1

-Restore blood flow
-Provide relief of ischemia
-Prevent morbidity
-Prevent re-occlusion of artery
-Prevent mortality

Question 2

Initial recommended tests for a patient suffering from ACS

Answer 2

-12-lead ECG within 10 minutes of arrival
-Serial troponin levels 3-6 hours after symptoms onset

Question 3

What is MONA?

Answer 3

-Morphine
-Oxygen
-Nitrogen
-Aspirin

Question 4

What is the initial dose of morphine for a patient with ACS?

Answer 4

4-8 mg IV, followed by 2-8 mg IV every 5-15 minutes

Question 5

Why give morphine to patients with ACS?

Answer 5

To relieve chest pain

Question 6

Side effects of morphine

Answer 6

-Sedation
-Respiratory depression
-Nausea/vomiting

Question 7

Why should NSAIDs be avoided in patients with ACS?

Answer 7

Lead to sodium and water retention leading to an increased risk of MACE

Question 8

What is the target oxygen saturation

Answer 8

Over 90%

Question 9

Why is nitroglycerin used in patients with ACS?

Answer 9

It is a vasodilator that increases blood flow to the heart

Question 10

What is the dose of SL nitroglycerin recommended for a patient with ACS?

Answer 10

0.3-0.4 mg every 5 minutes

Question 11

What is the dose of IV nitroglycerin recommended for a patient with ACS?

Answer 11

Start at 10 mcg/min then titrate up every 5 minutes to a max dose of 200 mcg/min

Question 12

Side effects of nitroglycerin

Answer 12

-Headache
-Hypotension

Question 13

Is transdermal nitroglycerin suitable for the treatment of ACS?

Answer 13

NO the onset of action is not rapid enough

Question 14

When does nitroglycerin tolerance develop?

Answer 14

Over 24 hours of continuous use

Question 15

What do you do when a patient begins to experience nitroglycerin tolerance?

Answer 15

increase the dose or change to intermittent administration and aim for more than 10 hours a day of nitroglycerin free period

Question 16

Which drug are nitrates most contraindicated in?

Answer 16

phosphodiesterase inhibitors

Question 17

How long after taking sildenafil is it safe to take nitroglycerin?

Answer 17

24 hours

Question 18

How long after taking vardenafil is it safe to take nitroglycerin?

Answer 18

24 hours

Question 19

How long after taking tadalafil is it safe to take nitroglycerin?

Answer 19

48 hours

Question 20

Why are nitrates contraindicated with phosphodiesterase inhibitors?

Answer 20

Both medications cause vasodilation which will cause severe hypotension

Question 21

What dose of aspirin should you give to a patient with ACS?

Answer 21

162-325 mg chewable aspirin for one dose

Question 22

Which ACS patients are eligible to take aspirin?

Answer 22

ALL patients without contraindications

Question 23

Can an enteric coated aspirin be used?

Answer 23

YES however it must be chewed to allow quicker absorption

Question 24

If a patient already took a maintenance dose of aspirin that day would you still give a loading dose?

Answer 24

YES you would give three additional 81 mg tablets for a total dose of 324 mg

Question 25

When should a patient receive MONA?

Answer 25

As soon as possible

Question 26

Types of reperfusion strategies

Answer 26

-Percutaneous coronary intervention (PCI)
-Coronary artery bypass graft (CABG)
-Fibrinolytic therapy

Question 27

What is a coronary angiography?

Answer 27

-A catheter is inserted into the radial and femoral artery and fed up to the heart
-Dye is injected into the coronary arteries
-An x-ray picture is taken and shows the blocked arteries
-A stent is placed in blocked arteries, if needed

Question 28

What is a PCI?

Answer 28

This procedure uses a small balloon to reopen a blocked artery to increase blood flow. A stent is placed, if needed, to keep the artery open long-term

Question 29

What is a CABG?

Answer 29

A vein or artery from another part of the body is removed and attached to the heart to “bypass” the blocked artery/arteries

Question 30

What are the types of fibrinolytics?

Answer 30

-Tenecteplase (TNK-tPA)
-Reteplase (rPA)
-Alteplase (tPA)

Question 31

Dosing for tenecteplase

Answer 31

-< 60 kg: 30mg
-60-69 kg: 35 mg
-70-79 kg: 40 mg
-80-89 kg: 45 mg
-90 or more kg: 50 mg

Question 32

Dosing for reteplase

Answer 32

10 units for 2 doses 30 minutes apart

Question 33

Dosing for alteplase

Answer 33

-15 mg bolus
-Then 0.75 mg/kg over 30 mins (max:50 mg)
-Then 0.5 mg/kg (max: 35 mg) over 60 min
-Max total dose of 100 mg

Question 34

Contraindications for fibrinolytics

Answer 34

-History of intracranial hemorrhage
-Ischemic stroke within the past 3 months
-Presence of cerebral vascular malformation or a primary metastatic intracranial malignancy
-Aortic dissection
-Active bleeding
-Significant closed-head or facial trauma within the past 3 months

Question 35

Why is a PCI preferred over fibrinolytics?

Answer 35

-Higher rates of infarct artery patency
-Lower rates of ischemia, reinfarction, and emergency repeat revascularization procedures
-Lower rates of intracranial hemorrhage
-Lower rates of death

Question 36

Who should receive reperfusion therapy?

Answer 36

All eligible STEMI patients whose symptoms began in the past 12 hours

Question 37

What is the door to needle time

Answer 37

Within 30 minutes of hospital arrival

Question 38

What is the door to balloon time

Answer 38

Within 90 minutes of hospital arrival

Question 39

When are fibrinolytics recommended?

Answer 39

STEMI patients who are not at a PCI-capable hospital and more than 120 minutes away from a PCI-capable hospital

Question 40

What reperfusion methods are recommended for patients with NSTEMI/UA?

Answer 40

-Early invasive = coronary angiography +/- revascularization
-Ischemia-guided = “medical” management

Question 41

When is early invasive reperfusion recommended?

Answer 41

-Preferred for patients with high-risk features such as:
-Refractory angina
-New-onset heart failure
-Rising troponin
-New ST-segment depression