ACS Rogers Parts 3-5 (Not done)

Question 1

true or false: we are unlikely to use a GPIIb/IIIa inhibitor in STEMI treatment

Answer 1

false (unlikely to use in UA/NSTEMI)

Question 2

clopidogrel loading dose range

Answer 2

300-600 mg

Question 3

how long does platelet inhibition take with cangrelor?

Answer 3

within 2 minutes

Question 4

what medication is used during PCI when pt did not receive a loading dose P2Y12 inhibitor?

Answer 4

cangrelor

Question 5

ticagrelor loading dose

Answer 5

180 mg

Question 6

ticagrelor maintenance dose

Answer 6

90 mg bid

Question 7

prasugrel loading dose

Answer 7

60 mg

Question 8

prasugrel maintenance dose

Answer 8

10 mg daily

Question 9

cangrelor loading dose

Answer 9

30 mcg/kg, followed by 4 mcg/kg/min x 2 hours

Question 10

is there a maintenance dose for cangrelor?

Answer 10

no, use an oral agent

Question 11

a 600 mg loading dose is preferred for clopidogrel, except in what circumstance?

Answer 11

when using fibrinolytic

Question 12

clopidogrel loading dose for pt on a fibrinolytic + age > 75

Answer 12

no loading dose (due to inc risk of bleeding)

Question 13

clopidogrel loading dose when using fibrinolytic + age of 75 or less

Answer 13

300 mg

Question 14

CI for prasugrel

Answer 14

history of TIA/stroke

Question 15

true or false: ticagrelor is NOT recommended in pts 75 or older, < 60 kg, or bleeding risk

Answer 15

false (Prasugrel, not ticagrelor)

Question 16

what CYP metabolizes clopidogrel?

Answer 16

CYP2C19

Question 17

how long do we need to hold aspirin, ticagrelor, clopidogrel, and prasugrel before CABG?

Answer 17

aspirin -> doesn’t need to be held
ticagrelor -> 3 days
clopidogrel -> 5 days
prasugrel -> 7 days

Question 18

Patient is a 71 year old male that arrives at the ER via ambulance. He had crushing pain in his chest for 15 minutes that relieved when the EMT administered nitroglycerin. ECG performed in ambulance shows normal sinus rhythm (NSR) with no S or T wave abnormalities. High sensitivity troponin drawn in the ER is 2300ng/L. Patient takes clopidogrel 75mg daily at home for ischemic stroke 3 years ago (took this morning). Which of the following is the best initial antiplatelet recommendation?

a. ASA 325mg x1
b. Clopidogrel 600mg x 1
c. ASA 325mg x 1 and ticagrelor 180mg x 1
d. ASA 325mg x 1 and prasugrel 90mg x 1

Answer 18

c. ASA 325mg x 1 and ticagrelor 180mg x 1

(a. needs loading dose of P2Y12, b. needs aspirin, d. prasugrel is CI in ischemic stroke and wrong loading dose)

Question 19

true or false: GPIIb/IIIa inhibitors are usually given before PCI

Answer 19

false (given during PCI)

Question 20

what is “bail out” therapy for GPIIb/IIIa inhibitors?

Answer 20

use during procedure if a thrombus develops or low blood after stenting (basically if there are thrombus complications during PCI)

Question 21

which GPIIb/IIIa inhibitor is not renally adjusted?

a. abciximab
b. eptifibatide
c. tirofiban

Answer 21

a. abciximab

Question 22

gold standard for diagnosis of HIT

Answer 22

serotonin release assay (SRA)

Question 23

enoxaparin is eliminated by _______

Answer 23

kidneys (accumulates in renal impairment)

Question 24

bivalirudin is not used together with GPIIb/IIIa inhibitors, except in what case?

Answer 24

bail out

Question 25

true or false: fondaparinux cannot be used in pts with a history of HIT

Answer 25

false

Question 26

true or false: fondaparinux can be used alone for PCI

Answer 26

false

Question 27

fondaparinux is CI in CrCl < _____ mL/min

Answer 27

< 30

Question 28

dosing for enoxaparin if CrCl < 30

Answer 28

1 mg/kg q24h

Question 29

dosing for bivalirudin if CrCl < 30

Answer 29

1 mg/kg/hr

Question 30

dosing for bivalirudin if pt is on dialysis

Answer 30

0.25 mg/kg/hr

Question 31

for ischemia guided strategy for UA/NSTEMI, which of the following is not used? a. UFH b. bivalirudin c. enoxaparin d. fondaparinux

Answer 31

b. bivalirudin (a is 48 hours; c and d are for duration of hospital stay/up to 8 days)

Question 32

for early invasive strategy of UA/NSTEMI, which of the following is not ideally used? a. UFH b. bivalirudin c. enoxaparin d. fondaparinux

Answer 32

d. fondaparinux (the others can be used until PCI, fondaparinux is not ideal, don't use alone for PCI)

Question 33

for fibrinolytic therapy for STEMI, which of the following is not used? a. UFH b. bivalirudin c. enoxaparin d. fondaparinux

Answer 33

b. bivalirudin (can be considered for HIT; a is used for 48 hours; c and d for duration of hospital stay up to 8 days)

Question 34

which of the following do we give for pt who is getting a PCI for a STEMI? SELECT ALL THAT APPLY? a. UFH b. bivalirudin c. enoxaparin d. fondaparinux

Answer 34

a, b (used until PCI, bivalirudin preferred in high bleeding risk)

Question 35

maintenance dose for UFH

Answer 35

12 units/kg/hr infusion titrate to aPTT target (no maintenance dose during PCI)

Question 36

metoprolol tartrate starting dose

Answer 36

25-50 mg Q6-12h

Question 37

target dose for metoprolol tartrate and succinate

Answer 37

tartrate 100 mg bid succinate 200 mg bid

Question 38

what are the cardioselective beta blockers that we should know? (4 of them on chart; lecture 5, slide 10)

Answer 38

atenolol, metoprolol, bisoprolol, nebivolol

Question 39

use sustained-release metoprolol succinate, carvedilol, or bisoprolol in pts with what condition?

Answer 39

HFrEF

Question 40

for diabetes pts, a beta blocker can mask the symptoms of hypoglycemia, but it will not mask a _____ _____

Answer 40

cold sweat

Question 41

Patient is an 82 year old female that presented with NSTEMI and received a drug-eluting stent (LAD) several hours ago. Temp 37.2, BP is 125/71, HR 67bpm, RR 16, O2 sat 96% on room air. EF = 35%. Patient has no edema in extremities. Patient was on diltiazem 120mg daily prior to admission. Which of the following would you recommend? a. Continue diltiazem 120mg daily b. Continue diltiazem 120mg daily and add carvedilol 6.25mg bid c. D/C diltiazem and start carvedilol 6.25mg bid d. D/C diltiazem (BP too low to start a BB at this time)

Answer 41

c. D/C diltiazem and start carvedilol 6.25 mg bid (dilitazem is CI in HFrEF)

Question 42

how many sprays are needed to prime Nitrolingual?

Answer 42

5 sprays

Question 43

how many sprays are needed to prime Nitromist?

Answer 43

10 sprays