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Naplex 2023 > Acute Coronary Syndrome > Flashcards

Acute Coronary Syndrome Flashcards

1
Q

what results in ACS

A

atherosclerosis in coronary arteries that can rupture = clots that cause sudden, reduced blood flow to heart; imbalance of myocardial oxygen supply and demand

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2
Q

ACS risk factors

A

men >45 + women >55 (or early hysterectomy)
family history (1st degree with ACS <55 men or <65 women
smoking
hypertension
known CAD
dyslipidemia
diabetes
chronic stable angina
lack of exercise
excessive alcohol

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3
Q

signs/symptoms of ACS

A

chest pain (pressure/squeezing) for >=10 min
severe dyspnea
diaphoresis
pain radiates to arms, back,neck, jaw, epigastric region

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4
Q

what should be given in ACS at first

A

up to 3 doses sublingual nitroglycerin 5 minutes apart
if not improved or worse 5 min after 1st dose = call 911 immediately

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5
Q

types of ACS

A

NSTE-ACS (unstable angina and NSTEMI)
STEMI

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6
Q

symptoms in UA vs NSTEMI vs STEMI

A

chest pain same for all

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7
Q

cardiac enzymes in UA vs NSTEMI vs STEMI

A

negative in UA
positive in NSTEMI/STEMI

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8
Q

ECG changes in UA vs NSTEMI vs STEMI

A

none or transient ischemic changes (ST segment depression or prominent T-wave inversion in UA/NTEMI
ST segment elevation (mets defined criteria in >=2 contiguous leads (lead looking at same area of heart)

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9
Q

blockage in UA vs NSTEMI vs STEMI

A

partial blockage in UA/NSTEMI
complete blockage in STEMI

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10
Q

treatment goal

A

immediate relief of ischemia and preventing MI expansion

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11
Q

PCI

A

inflating balloon inside coronary artery to widen and improve blood flow
usu stent keeps artery open

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12
Q

NSTE-ACS treatment options

A

meds alone or PCI

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13
Q

STEMI treatment options

A

blocked arteries must be opened ASAP
PCI preferred in can be within 90 minutes (door-to-balloon time) or within 120 minutes of first medical contact
if no PCI within 120 min of medical contact - use fibrinolytic therapy within 30 minutes of hospital arrival (door-to-needle time)
MONA-GAP-BA + PCI/fibrinolytic (PCI preferred)

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14
Q

drug treatment options for ACS

A

MONA-GAP-BA
Morphine
Oxygen
Nitrates
Aspirin
-
GPIIb/IIa antagonists
Anticoagulants
P2Y12 inhibitors
-
Beta-blockers
ACEI

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15
Q

antianginals MOA

A

dec myocardial oxygen demand

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16
Q

antiplatelets MOA

A

prevent clot formation/growth

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17
Q

anticoagulants

A

prevent clot formation/growth

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18
Q

morphine clinical benefit

A

pain relief

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19
Q

Nitrates MOA

A

dilate coronary arteries = inc blood flow
dec preload
dec chest pain

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20
Q

nitrates clinical comments

A

SL nitroglycerin 0.4 mg X5 min X 3 doses
do not use IV NTG if SBP<90
nitrates CI with PDE-5 inhibors

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21
Q

Aspirin clinical benefit

A

non-eteric-coated, chewable
162-325 ASA given to all immediately
do not use enteric coated or extended-release
continue ASA 81-162 mg daily

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22
Q

GPIIIB/IIIA antagonists clinical comments

A

second-line
includes abcizimab, eptifibatide, and tirofiban

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23
Q

antigocatulants clinical comments

A

LMWHs (enoxaparin)
UFH
bivalirudin

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24
Q

P2Y12 clinical comments

A

clopidogrel
prasugrel
ticagrelor

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25
Q

Beta-blockers

A

given within 24 hours
inc long-term survival
oral
use b-1 selective without sympathomimetic activity preferred

26
Q

ACEI

A

oral
start within 1st 24 hours and continue indefinitely in all with LVEF<40%
can use ARB if intolerant

27
Q

meds to avoid in acute

A

NSAIDs except ASA (nonselective or COX-2 selective - do not give in hospitalization)
IR nifedipine should not be used (inc mortality)

28
Q

antiplatelet drugs MOA

A

inhibit platelet aggregation

29
Q

ASA MOA

A

irreversibly inhibit COX-1 and -2 = dec TXA2

30
Q

P2Y12 inhibitors MOA

A

clopidogrel, prasugrel, ticagrelor, cangrelor
bind ADP P2Y12 receptor
commonly used with ASA for DAPT
require loading doses

31
Q

GPIIb/IIIa receptor antagonists MOA

A

abciximab, eptifabatide, tirofiban
block platelet glycoprotein IIb/IIa receptor

32
Q

Protease-activated receptor-1 antagonist MOA

A

vorapaxar
bind PAR-1 receptor

33
Q

thienopyridines

A

clopidogrel and prasugrel
prodrugs that irreversibly bind P2Y12 receptor

34
Q

clopidogrel dosing

A

75 mg PO daily

35
Q

clopidogrel BBW

A

prodrug metabolized by CYP450 2C19 - check CYP2C19 genotype

36
Q

clopidogrel CI

A

serious bleeding

37
Q

clopidogrel warnings

A

bleeding risk - stop prior to elective surgery
do not use with omeprazole or esomeprazole
thrombotic thrombocytopenic purpura

38
Q

clopidogrel side effects

A

bleeding

39
Q

prasugrel dosing

A

dispense in original container

40
Q

prasugrel BBW

A

stop prior to elective surgery

41
Q

prasugrel CI

A

serious bleeding
history of TIA/stroke

42
Q

prasugrel warnings

A

bleeding risk
thrombotic thrombocytopenic purpura

43
Q

prasugrel side effects

A

bleeding

44
Q

ticagrelor dosing

A

90 mg BID for 1 year, then 60 mg BID

45
Q

ticagrelor BBW

A

do not exceed ASA 100 mg
stop before elective surgery

46
Q

ticagrelor CI

A

serious bleeding

47
Q

ticagrelor warnings

A

bleeding risk
thrombocytopenic purpura

48
Q

ticagrelor side effects

A

bleeding
dyspnea

49
Q

cangrelor dosing

A

injection

50
Q

cangrelor notes

A

transition to oral P2Y12 inhibitors after PCI

51
Q

P2Y12 inhibitor DI

A

additive bleeding risk: NSAIDs, warfarin, SSRIs, SNRIs

52
Q

clopidogrel DI

A

avoid with CYP2C19 inhibitors esomeprazole and omeprazole

53
Q

glycoprotein IIb/IIIa recepor antagonists names and side effects

A

abciximab, eptifibatide, tirofiban
bleeding
thrombocytopenia

54
Q

fibrinolytics MOA/administration/names

A

clot breakdown by binding to fibrin and converting plasminogen to plasmin
only for STEMI
give within 30 min door-to-needle
alteplase, Cathflo Activase, Tenecteplase (TNKase), reteplase

55
Q

alteplase MOA

A

type of fibrinolytic
recombinant tissue plasminogen activator (tPA)

56
Q

fibrinolytics CI

A

active internal bleeding
history of recent stroke
severe uncontrolled HTN

57
Q

fibrinolytics side effects

A

bleeding (ICH)

58
Q

fibrinolytics monitoring

A

Hbg
Hct
s/sx of bleeding

59
Q

fibrinolytics notes

A

alteplase dosing differs for ischemic stroke

60
Q

secondary prevention of ACS drugs

A

ASA: 81 mg qd indefinitely unless CI

P2Y12 inhibitor: medical therapy ticagrelor/clopidogrel w/ ASA 81 mg for >= 1 yr (clopidogrel preferred if STEMI with fibrinolytics); PCI-treated clopidogrel, prasugrel, ticagrelor with ASA 81 mg for >=12 months continuation considered in tolerant of DAPT and not high bleed risk

nitroglycerin SL or PRN spray indefinitely

BB: 3 years; indefinite if HF or for HTN

ACEI: indefinitely if EF <40%, HTN, CKD/diabetes, consider for all with no CI

aldosterone antagonist: indefinitely if HFrEF and symptomatic HF or diabetes on target ACEI and BB; CI: SCr >2.5 men 2 wome or K >5

statin: indefinitely high-intensity for most; >=75 yo: consider moderate or high-intensity

61
Q

pain consideration

A

if other options insufficient, can use naproxen (nonselective NSAID); COX-2 selective should be avoided bc high CV risk

62
Q

ACS + AFib consideration

A

dual to triple antithrombotic therapy
if triple, use shortest time possible
if history of GI bleed, give triple antithrombotic PPI

Naplex 2023 (21 decks)

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