Acute Coronary Syndrome Flashcards
what results in ACS
atherosclerosis in coronary arteries that can rupture = clots that cause sudden, reduced blood flow to heart; imbalance of myocardial oxygen supply and demand
ACS risk factors
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
signs/symptoms of ACS
chest pain (pressure/squeezing) for >=10 min
severe dyspnea
diaphoresis
pain radiates to arms, back,neck, jaw, epigastric region
what should be given in ACS at first
up to 3 doses sublingual nitroglycerin 5 minutes apart
if not improved or worse 5 min after 1st dose = call 911 immediately
types of ACS
NSTE-ACS (unstable angina and NSTEMI)
STEMI
symptoms in UA vs NSTEMI vs STEMI
chest pain same for all
cardiac enzymes in UA vs NSTEMI vs STEMI
negative in UA
positive in NSTEMI/STEMI
ECG changes in UA vs NSTEMI vs STEMI
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)
blockage in UA vs NSTEMI vs STEMI
partial blockage in UA/NSTEMI
complete blockage in STEMI
treatment goal
immediate relief of ischemia and preventing MI expansion
PCI
inflating balloon inside coronary artery to widen and improve blood flow
usu stent keeps artery open
NSTE-ACS treatment options
meds alone or PCI
STEMI treatment options
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)
drug treatment options for ACS
MONA-GAP-BA
Morphine
Oxygen
Nitrates
Aspirin
-
GPIIb/IIa antagonists
Anticoagulants
P2Y12 inhibitors
-
Beta-blockers
ACEI
antianginals MOA
dec myocardial oxygen demand
antiplatelets MOA
prevent clot formation/growth
anticoagulants
prevent clot formation/growth
morphine clinical benefit
pain relief
Nitrates MOA
dilate coronary arteries = inc blood flow
dec preload
dec chest pain
nitrates clinical comments
SL nitroglycerin 0.4 mg X5 min X 3 doses
do not use IV NTG if SBP<90
nitrates CI with PDE-5 inhibors
Aspirin clinical benefit
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
GPIIIB/IIIA antagonists clinical comments
second-line
includes abcizimab, eptifibatide, and tirofiban
antigocatulants clinical comments
LMWHs (enoxaparin)
UFH
bivalirudin
P2Y12 clinical comments
clopidogrel
prasugrel
ticagrelor
Beta-blockers
given within 24 hours
inc long-term survival
oral
use b-1 selective without sympathomimetic activity preferred
ACEI
oral
start within 1st 24 hours and continue indefinitely in all with LVEF<40%
can use ARB if intolerant
meds to avoid in acute
NSAIDs except ASA (nonselective or COX-2 selective - do not give in hospitalization)
IR nifedipine should not be used (inc mortality)
antiplatelet drugs MOA
inhibit platelet aggregation
ASA MOA
irreversibly inhibit COX-1 and -2 = dec TXA2
P2Y12 inhibitors MOA
clopidogrel, prasugrel, ticagrelor, cangrelor
bind ADP P2Y12 receptor
commonly used with ASA for DAPT
require loading doses
GPIIb/IIIa receptor antagonists MOA
abciximab, eptifabatide, tirofiban
block platelet glycoprotein IIb/IIa receptor
Protease-activated receptor-1 antagonist MOA
vorapaxar
bind PAR-1 receptor
thienopyridines
clopidogrel and prasugrel
prodrugs that irreversibly bind P2Y12 receptor
clopidogrel dosing
75 mg PO daily
clopidogrel BBW
prodrug metabolized by CYP450 2C19 - check CYP2C19 genotype
clopidogrel CI
serious bleeding
clopidogrel warnings
bleeding risk - stop prior to elective surgery
do not use with omeprazole or esomeprazole
thrombotic thrombocytopenic purpura
clopidogrel side effects
bleeding
prasugrel dosing
dispense in original container
prasugrel BBW
stop prior to elective surgery
prasugrel CI
serious bleeding
history of TIA/stroke
prasugrel warnings
bleeding risk
thrombotic thrombocytopenic purpura
prasugrel side effects
bleeding
ticagrelor dosing
90 mg BID for 1 year, then 60 mg BID
ticagrelor BBW
do not exceed ASA 100 mg
stop before elective surgery
ticagrelor CI
serious bleeding
ticagrelor warnings
bleeding risk
thrombocytopenic purpura
ticagrelor side effects
bleeding
dyspnea
cangrelor dosing
injection
cangrelor notes
transition to oral P2Y12 inhibitors after PCI
P2Y12 inhibitor DI
additive bleeding risk: NSAIDs, warfarin, SSRIs, SNRIs
clopidogrel DI
avoid with CYP2C19 inhibitors esomeprazole and omeprazole
glycoprotein IIb/IIIa recepor antagonists names and side effects
abciximab, eptifibatide, tirofiban
bleeding
thrombocytopenia
fibrinolytics MOA/administration/names
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
alteplase MOA
type of fibrinolytic
recombinant tissue plasminogen activator (tPA)
fibrinolytics CI
active internal bleeding
history of recent stroke
severe uncontrolled HTN
fibrinolytics side effects
bleeding (ICH)
fibrinolytics monitoring
Hbg
Hct
s/sx of bleeding
fibrinolytics notes
alteplase dosing differs for ischemic stroke
secondary prevention of ACS drugs
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
pain consideration
if other options insufficient, can use naproxen (nonselective NSAID); COX-2 selective should be avoided bc high CV risk
ACS + AFib consideration
dual to triple antithrombotic therapy
if triple, use shortest time possible
if history of GI bleed, give triple antithrombotic PPI
