Acute Coronary Syndrome

Question 1

ACS Categorization

Answer 1

a) Unstable Angina
b) Myocardial Infarction
i) STEMI
ii) NSTEMI

Question 2

What is the averge age of first ACS?

Answer 2

Late 60”s

Question 3

ACS occurs more in (males/females) ration

Answer 3

Male to female ratio 3:2

Question 4

ER Assesments of MI

Answer 4

1) Patient story
2) 12 ECG
3) Blood Tests –> Indicators of cell death

Question 5

A normal ECG is good evidence of….

Answer 5

Strong evidence to rule OUT ACS
Physicians will investigate other possible causes of sx’s (heartburn, gallbladder attack, etc)

Question 6

St Segment Depression Indicates

Answer 6

Strong evidence for coronary ischemia
However, ST depression is often associated with stable (fixed obstruction) angina. Further investigations will be needed to determine severity

Question 7

ST Elevation

Answer 7

A marker of complete coronary obstruction causing cardiac myocyte death
This finding suggests a serious MI requiring urgent revascularization in most cases
If blood flow is not restored quickly, the person is at high risk for major consequences such as heart failure, arrythmias, or even death.

Question 8

ST segment elavtion is refrred to as a

Answer 8

STEMI

Question 9

Q-waves in normal ECG

Answer 9

Absent

Question 10

Q waves in MI

Answer 10

Often will appear following (or during) a STEMI
Usually indicates extensive damage (transmural) to the heart wall
Often remains in the ECG for life (even after the acute event)

Question 11

a STEMI will be confirmed if….

Answer 11

if evidence of cell death is observed

Question 12

What are the most sensitive and specific marker of MI?

Answer 12

Tropnins

Question 13

Cardiac tropinins in MI

Answer 13

are the most sensitive and specific biomarkers in the context of ACS

Troponins ↑ in the blood within hrs of MI and remain elevated for several days

Question 14

The major classic presentation of STEMI is

Answer 14

ST elevation is a classic presentation of a major MI

Often leaves ECG evidence forever (Q-wave)

Question 15

What is left-bundle branch block?

Answer 15

Conduction in the left bundle of his is slow

Results in delayed depolarization of the left ventricle

Question 16

CRP is a test that indicates…

Answer 16

Inflammation

Question 17

tests adminstered in the E.R. if STEMI suspected….

Answer 17

ECG
Cardiac troponins (3 – 6 hrs after symptom onset)
Natriuretic peptides (B-type or pro-B type –> Brain Naturietic Peptide elvated in MI)
CXR

Question 18

Standard TX in ER

Answer 18

Oxygen (if O2 sats <90% or respiratory distress, etc)

ASA +/- ADP inhibitor

S/L NTG (IV NTG should be started if pain continues)
Ask about PDE5 inhibitor use!!!

Beta-blocker may be considered but onset slow and dangerous in acute setting if evidence of reduced CO, HF, or bradycardia

IV anticoagulation – recommended for all patients with suspected MI regardless of initial treatment strategy (e.g., UFH, enoxaparin, bivalirudin)

Old A** Never Beat Attacks

Question 19

A beta-blocker should only be used once a pt is…..

Answer 19

STABLE

Question 20

BB benfit has (increased/decreased) ove rthe years?

Answer 20

Decreased

Question 21

Betab-blockers are highly….

Answer 21

Beta-blockers are highly protective in people who have experienced damage to myocardial cells

Question 22

If there is more damage, a BB is….

Answer 22

More damage = higher SNS = more likely to benefit from BB

Question 23

if there is less damage, a BB is …..

Answer 23

Less damage = lower SNS = less likely to benefit from BB

Question 24

What is the first goal of a STEMI? Timing

Answer 24

Repurfusion

ALL patients presenting with STEMI with symptom onset within past 12 hours should receive reperfusion therapy (assuming eligibility criteria are met)

Primary PCI is the preferred method of reperfusion when done in a timely fashion

If PCI cannot be performed within 2hrs after first medical contact, fibrinolytic medications should be administered.
(tPA) –> Plasminogen to plasmin which breaks down fibrin

Question 25

Why is repurfusion tx benficial?

Answer 25

Reperfusion as quickly as possible after a STEMI has great potential to restore blood, ↓ the risk for damaged myocardium, and ↓ the risk of death

Question 26

Before a PCI, what drugs are given....

Answer 26

DAPT Anticoagulant TX

Question 27

Why are pre-PCI antiplatelet tx used?

Answer 27

Antiplatelets are started PRIOR to PCI procedures Helps protect against platelet activation that occurs during placement of stents Stent placement can cause endothelial damage

Question 28

What drugs can be used in PRe-PCL antiplatlet tx? DOses? Which drug not used when?

Answer 28

ASA - 81-325 (325 if not taking 81 already) Loading dose of P2Y12 inhibitor (either of the following) Clopidogrel 600mg Prasugrel 60mg Ticagrelor 180mg Prasugrel should NOT be used to patients with prior history of stroke or TIA**

Question 29

When is Pre-PCI antiplatlet tx initiated?

Answer 29

Administered in ED as soon as possible after decision for PCI

Question 30

What anticoagulants can be used before PCI?

Answer 30

Options include: LMWH --> enoxaparin UFH Bivalirudin

Question 31

Are IV anticoagulants always used before PCI?

Answer 31

YES

Question 32

Clopidogrel is adminstered as a....

Answer 32

Pro-drug --> requires liver activation --> May be a disadvantage for some

Question 33

Clopidogrel inhibits

Answer 33

ADP receptor

Question 34

Clopidogrel Inhibition Type

Answer 34

irreversible

Question 35

Prasurgrel MOA...

Answer 35

ADP receptor antagonits

Question 36

Prasurgrel is adminstered as... Comparison to clopidogrel?

Answer 36

Pro-drug --> Less intra-subject variability in conversion than Clopidogrel

Question 37

Prasurgrel Concerns for Usage

Answer 37

Concern regarding risk of serious bleeding in Patients >75 yrs Patients < 60kg

Question 38

Ticagrelor administration

Answer 38

Not a pro-drug

Question 39

Ticagrelor binding to ADP receptor

Answer 39

Reversible Inhibitor of ADP receptor (only one)

Question 40

STEMI Meds DAY 1

Answer 40

ABCDEK Mechanism + angina pain ASA + Ticagrelor Bispropol ramipril Statin NTG

Question 41

In DAPT, what is preferred over Clopidogrel?

Answer 41

Ticagrelor and Prasurgrel

Question 42

DAPT is used for how long...

Answer 42

1 year and then re-evaluate

Question 43

At 1 year, on DAPT, need to....

Answer 43

Determine bleeding risk: If not at high risk, Continue DAPT for 3 years - ASA 81 mg OD, Ticagrelor 60 mg BID or Clopidogrel 75 mg OD If high risk, SAPT --> ASA 81, or Clopidogrel 75 mg OD (1975)

Question 44

DAPT for 1 year Combos

Answer 44

ASA 81 OD Ticagrelor 90 BID Prasurgrel 10 mg OD Clopidogrel 75 mg OD

Question 45

Risk factors for bleeding...

Answer 45

Need for OAC, NSAIDs, or prednisone Age > 75 Frailty Anemia with Hb < 110 CrCl < 40ml/min Body weight < 60kg Bleeding hosp within previous year Prior stroke/intracranial bleed

Question 46

If high bleeding risk, DAPT can be...

Answer 46

If bleeding risk is high, DAPT d/c can generally be considered After 1 month for a BMS After 3 months for a DES

Question 47

Clopidogrel MOA

Answer 47

Irreversible P2Y12 inhbitor - Pro-drug that requires conversion by 2C19

Question 48

Prasugrel MOA

Answer 48

Iireversible P2Y12 inhibitor (Pro-drug - Less intra-subject variability than clopidogrel)

Question 49

Tocagrelor MOA

Answer 49

Doirect reversible inhibitor of P2Y12 (NOT A PRO_DREUG)

Question 50

Prasugrel Comparison to Clopidogrel

Answer 50

Faster onset of action with increased potency in platlet inhibition compared to clopidogrel In pts with MI undegroing PCI, prasugrel reduced MACE compared to clopidogrel

Question 51

Concerns of Prasugrel

Answer 51

Increased bleeding with prasugrel in patients who are olde rthan 75, hx of stroke or TIA and body weight less than 60kg Avoid prasugrel in patients with hx of stroke or TIA

Question 52

Why is clopidogrel commonly choosen over Prasugrel and Ticagrelor?

Answer 52

Less bleeding risk

Question 53

ADvers eeffect of tIcagrelor

Answer 53

Dyspnea

Question 54

ASA MOA

Answer 54

Irreversibly inhibits COX-1 to. decraese thromboxane A2 (inyhibits platlets)

Question 55

Indications for BB post MI

Answer 55

LVSD / Heart failure – absolute indication (not in acute phase) Arrhythmia – absolute indication STEMI – absolute indication STEMI without residual dysfunction – 3 years and re-evaluate (AHA) NSTEMI without residual dysfunction – “consider” BB

Question 56

ACE-i in M.I. What if ACE not tolerated?

Answer 56

Shown to ↓ mortality in patients with recent MI – used in virtually ALL people with MI (HOPE TRIAL) - Can use an ARB

Question 57

What ACEi to use in people with increased risk of ADR's

Answer 57

Short acting ACEI (captopril or enalapril)

Question 58

if significant renal dysfunction, ACEi.....

Answer 58

If significant renal dysfunction, may wish to wait till kidney’s are stabilized (SCr improved)

Question 59

ACEi are considered in all high risk pt's without HTN

Answer 59

TRUE

Question 60

Speciifc s/e of ACEi

Answer 60

Cough, Increased K+, Angioedema

Question 61

Drug Interactions of ACei

Answer 61

Anything that increases K+ Anything decreases renal perfusion

Question 62

C.I. of ACEi

Answer 62

- Teratogenic - Bilateral renal artery stenosis History of angioedema - First line in renal dz --> But need to monitor

Question 63

What other class of drugs may be prescribed?

Answer 63

MRA --> Eplerenone

Question 64

Adding MRA to BB and ACEi in post MI benfit? This does not apply when...

Answer 64

Adding eplerenone to BB and ACEI in the post-MI setting to patients with EF<40% was associated with ↓ mortality Does NOT apply IF significant renal dysfx (Cr > 170) or high K

Question 65

MRA is only given to people who present with....

Answer 65

heart failure after that heart attack

Question 66

what revascularization technique is preferred?

Answer 66

PCI

Question 67

CABG in STEMI when....

Answer 67

Urgent CABG indicated when coronary anatomy not amenable to PCI AND ischemia persists (or cardiogenic shock, severe HF, etc)

Question 68

CABG risks....

Answer 68

much higher risk for bleeding during the procedure.

Question 69

Before CABG, ____should be stopped and ____ should be used....

Answer 69

ADP inhibitors --> ASA should be used before surgery

Question 70

Elective CABG Meds Before Surgery

Answer 70

In NON-URGENT situations, ADP inhibitors should be d/c for at least 5 days before surgery!!!

Question 71

Uregent Situation - Primary CABG DAPT USe

Answer 71

If CABG is urgent, ADP inhibitors should be stopped at least 24hrs before surgery

Question 72

Post CABG Anti-platlet tx depends on....

Answer 72

Depends on situation STEMI or NSTEMI  eligible for DAPT Elective CABG  ASA only

Question 73

NSTEMI vs. Unstable ANgina DIagnosis

Answer 73

History of classic ischemic sx’s not relieved by rest ST-DEPRESSION on ECG If cell death can be proven in the context of ACS and ST depression, Jibby will be diagnosed with a NSTEMI (troponins positive – if positive, MI – if negative, unstable angina) If NO cell death can be proven in the context of ACS and ST depression, Jibby will be diagnosed with unstable angina

Question 74

In order to be diagnosed with MI....

Answer 74

Cardiac cell death must be dtermined

Question 75

What is a primary PCI? What are the features favouring PCI?

Answer 75

Some patients will be sent for angiography (and possible PCI) very quickly (invasive strategy) Features favouring invasive strategy STEMI Refractory angina Hemodynamic/electrical instability High risk features (Diabetes, previous MI, HF, etc)

Question 76

BB receommended for....

Answer 76

LVSD / Heart failure – absolute indication (not in acute phase) Arrhythmia – absolute indication STEMI – absolute indication STEMI without residual dysfunction – 3 years and re-evaluate (AHA) NSTEMI without residual dysfunction – “consider” BB

Question 77

Atrial Fib Define and Consequence

Answer 77

An arrhythmia of the atrium removing the atrial contraction altogether Clots can form in the left atrium due to pooling of blood These clots can embolize into the carotid artery and cause ischemia to the brain (i.e., stroke)

Question 78

Atrial FIb Tx

Answer 78

Anticoagulants (i.e., not antiplatelets) are effective for this condition

Question 79

ACS with Atrial FIb Tx

Answer 79

Makes the use of DAPT more likely to cause bleeding However, antiplatelets are still necessary for treating ACS

Question 80

ACS and A-Fib

Answer 80

Question 81

Unstable Angina TX

Answer 81

Similar to Fixed Obstruction --> DAPT could be avoided

Question 82

Describe th ediagnosis of AC S

Answer 82

Question 83

STE-ACS TX strategies

Answer 83

First Medical Contact (FMC) to needle time less than 30 minutes * FMC to balloon time less than 90 minutes

Question 84

When are fibrinolytics used for PCI?

Answer 84

Rural Settings - Unable to do PCI within 2 hours

Question 85

Fibrinolytic in ACS

Answer 85

Tenecteplase - Weight based dsoed - FAste rgiven, more ebenfit you get from it Most beenfit within hours of sx onset - More than 12 hours of sx, benefit quetsionable - sx 24 hours, no benefit - Do not give it Major concern —> Intracranial Hemorrhage Fibrinolytics - Follow up PCI Goals - Giving it as soon as possible

Question 86

NST-ACS TX Strategies

Answer 86

Question 87

Adjunctive RX Therapy ACS

Answer 87

* Anticoagulants * Antiplatelets * ACEi/ARBs * Beta-Blockers * Statins

Question 88

Anti-coags STEMI and NSTE-ACS

Answer 88

Question 89

Choice of ANti-coags in ACS

Answer 89

STEMI - Most clincial experience - Unfractionated Heparin, Bivalrudin (better bleed risk data - 10x price - cost imits use - option for people who cannot be on heparin), enoxaparin (less clinical experience), fondapaarinux (low bleed risk, need to give additional heparin in PCI, sub-Q formualtion) if fibrinolytic —> ENOXAPARIN --> Heparin - Also used in rural settingds Heparin CI - History of HIT NSTEMI - ENoxaparin drug of choice

Question 90

Anti-coag Duration

Answer 90

Continue anticoagulation until sucessfully revascularized - If someone undergoing medical management, continue anticoagulation for atleast 48 hours Indication outside of ACS (hx of VTE, PE< a-fib), continue it after - Switch to an oral

Question 91

Antiplatlets ACS

Answer 91

Question 92

Beta-Blcokers ACS Started:

Answer 92

Oral beta blockers should be administered within 24 hours in all patients who do not have any of the following: 1) Signs of heart failure 2) Evidence of low-output state 3) Increased risk of cardiogenic shock 4) Other contraindications (prolonged PR, 2-3 degree AV block, reactive airway disease) (Class I; Level A/B)

Question 93

Statin AXS

Answer 93

High-intensity statin therapy should be initiated or continued in all patients with STEMI or NSTE-ACS and no contraindications to its use.

Question 94

Nitartes ACS

Answer 94

Reduce symptoms of myocardial ischemia – Reduce preload – Increase coronary artery blood flow * Do not attenuate myocardial injury or impact MACE Patients with NSTE-ACS with continuing ischemic pain may receive sublingual nitroglycerin (0.3 mg to 0.4 mg) every 5 minutes for up to 3 doses, after which an assessment should be made about the need for intravenous nitroglycerin if not contraindicated.

Question 95

O2 and Morphine - ACS

Answer 95

No reduction in mortality, recurrent myocardial infarction, or MACE with oxygen supplementation in normoxic acute MI patients * Avoid routine prehospital administration of supplemental oxygen to STEMI patients with SaO2 90% (Weak Recommendation, Low-Quality Evidence) * Opioids (e.g. IV morphine and fentanyl) historically used for acute MI pain * No RCTs with hard clinical endpoints; may result in harm * Avoid of routine I.V. opioid administration for STEMI-related discomfort. Use may be considered for severe pain with the goal of relieving pain and reducing anxiety (Weak Recommendation, Low-Quality Evidence).

Question 96

LMWH MOA

Answer 96

Enoxaparin, Dalteparin (Only ones approved for NSTEMI, stable angina, Enoxaparin Only One for STEMI) MOA: Same as heparin: Catalyzes antithrombin inactivates factor IIa and IXa, Xa, XIa, & XIIa Binds to antithrombin, but more selectively enhances inhibition of factor Xa mopre tha n Heparin Lower risk of HIT, OD Dosing, More predictable PK, Less Monitoring

Question 97

UFH MOA

Answer 97

HEPARIN MOA: Catalyzes antithrombin inactivates factor IIa and IXa, Xa, XIa, & XIIa * Prolongs aPTT * Cannot bind to thrombin already in a clot * Also binds to cells and other plasma proteins  unpredictable pharmacokinetics / dynamics Works immediately after IV administration 🩺 Think: Fast-acting, broad anticoagulant effect 💡 Reversible with protamine sulfate

Question 98

Fondaparinux MOA

Answer 98

Fondaparinux MOA: Glycosaminoglycan – fondaparinux Inhibits factor Xa (ONLY) Benefit: NO HIT - USE IN HIT CrCl < 30 - Do not use 🩺 Think: Pure Xa blocker via AT 💡 No reversal agent (but low bleeding risk)

Question 99

Direct Thrombin I(nhibitors

Answer 99

Direct Thrombin Inhibitors (DTIs) Examples: Bivalirudin (IV) (Also dabigatran, but that’s oral) MOA: Directly bind to and inhibit thrombin (factor IIa) without needing antithrombin Prevents thrombin from converting fibrinogen → fibrin 🩺 Think: Used in HIT (heparin-induced thrombocytopenia) 💡 No antidote (except dabigatran, which uses idarucizumab)