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Cardiology- Acute Care > Acute Coronary Syndrome > Flashcards

Acute Coronary Syndrome Flashcards

1
Q

Characteristic symptoms of STEMI?

A

Worsening pain/pressure in chest; may be accompanied by radiation.

Caused by total coronary artery occlusion.

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2
Q

Objective findings of STEMI?

A

ST-segment elevation > 1mm + positive biomarkers (troponin I or T elevation)

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3
Q

Characteristic symptoms of unstable angina and NSTEMI?

A

Partial coronary artery occlusion.

Pressure-type chest pain occurring at rest or with minimal exertion.

Pain may present w/ diaphoresis, dyspnea, nausea, abdominal pain, or syncope.

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4
Q

Objective findings for Non-ST Elevation ACS Unstable Angina?

A

ST-segment depression, T-wave inversion, or transient/non-specific ECG changes

No positive biomarkers for cardiac necrosis (no myocardial injury)

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5
Q

Objective findings for NSTEMI?

A

ST-segment depression, T-wave inversion, or transient/non-specific ECG changes

Positive biomarkers (troponin I or T elevation) -myocardial injury has occurred

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6
Q

What are the 2 methods to restore patency in infarcted-artery during STEMI?

A

STEMI requires urgent revascularization with:
1. Percutaneous coronary Intervention (PCI) - preferred
2. Drug therapy via fibrinolytics (Lytic therapy)

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7
Q

When is fibrinolytic therapy indicated in STEMI?

A

For pts when PCI cannot be done w/i 120 min.

Must give fibrinolytic within 30 min from door-to-needle

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8
Q

Goal of NSTE-ACS treatment?

A

Prevent total occlusion of artery. Control chest pain and other symptoms

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9
Q

What are the 2 methods to treat NSTE-ACS?

A

Treat based on risk (TIMI or GRACE scores used to asses risk)

Can treat with:
1. Early invasive strategy (Interventional approach)

  1. Ischemia-guided strategy (conservative method using medications)
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10
Q

What is early invasive strategy and when is it used in NSTE-ACS?

A

Early invasive strategy: diagnostic angiography with intent for revascularization.

Indicated for: refractory angina, hemodynamic/electrical instability

Note: Invasive therapy superior to ischemia-guided therapy (lower rates of recurrent UA, hospitalization, MI and death) in those with risk features:
1. Age >70 yo,
2. Previous MI/revascularization,
3. ST deviation,
4. HF, LVEF <40%,
5. High TIMI or GRACE scores,
6. Elevated troponins,
7.Diabetes.

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11
Q

Who is Early invasive therapy in NSTE-ACS NOT indicated for?

A

Not for serious comorbidities/CIs to procedures (ex. hepatic, renal, pulmonary failure, cancer)
Risk outweighs benefit of revascularization

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12
Q

Who can receive ischemia-guided therapy in NSTE-ACS?

A
  1. Low risk score (TIMI 0 or 1, GRACE <109)
  2. Acute chest pain with low chance of ACS + troponin negative (preferred for low-risk women)
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13
Q

List initial anti-ischemic and analgesic therapies for Acute coronary syndrome? (MONA-B). Give dosing, if possible.

A

M- morphine (or other narcotic analgesic)
*Morphine 1-5 mg IV Q5-30 min
* Pro: analgesia, decreased pain-induced sympathetic/adrenergic tone, slows absorption of antiplt therapy

O- Oxygen
* Consider if SaO2 <90%, respiratory distress, or high-risk features of hypoxemia
*Pro: attenuate anginal pain secondary to tissue hypoxia
*Giving supp. O2 w/o depressed SaO2 associated w/ increased morbidity and mortality

N- Nitroglycerin
*NTG spray or SL tab (0.3-0.4 mg) Q5min up to 3 doses to relieve acute chest pain
*Call 911 if pain not relieved after 1 dose
*Use IV NTG w/i 48hrs for persistent ischemic chest pain, HF, HTN
*Dose: IV NTG 5-10 mcg/min; titrate to chest pain relief or max 200 mcg/min
*Facilitates coronary vasodilation; may help in severe cardiogenic pulmonary edema

A- Aspirin
*Aspirin chewable 162-325 mg x 1 dose
*If aspirin allergy: clopidogrel
*Pro: MORTALITY REDUCING TX, inhibits plt activation

B- Beta-blocker
*Pro: decrease myocardial ischemia, reinfarction, and frequency of dysrhythmias; increase long-term survival
*Start w/i 24 hrs in pts w/o signs of HF or other contraindications to B-blockade (PR interval > 0.24 sec, 2nd/3rd degree heart block, active asthma, reactive airway disease)
*Continue in NSTE-ACS pts w/ normal LV function
* In stabilized HFrEF, use metoprolol succ, bisoprolol, carvedilol
* IV B-blocker may harm pts w/ risk factors for shock (Age >70 yo, HR >110 bpm, SBP <120 mmHg)

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14
Q

When is nitroglycerin contraindicated in ACS?

A
  1. Sildenafil or vardenafil use w/i 24 hours
  2. Tadalafil use w/i 48 hrs
  3. SBP <90 mmHg or >30mmHg below baseline
  4. HR <50 bpm
  5. HR >100 bpm in absence of symptomatic HF
  6. Right ventricular infarction
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15
Q

Which combination of therapy classes should be initiated in all pts w/ NSTEMI and NSTE-ACS?

A

All pts should get antiplatelet and anticoagulant therapy - Mainstay of ACS management
-Aspirin + P2Y12 receptor antagonists (+/- GP 2b/3a inhibitors in some pts)

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16
Q

List allowed antiplatelet strategies for NSTE-ACS Ischemia-guided treatment?

A
  1. Aspirin +
  2. Clopidogrel or ticagrelor +/-
  3. GP 2b/3a inhibitor
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17
Q

List allowed antiplatelet strategies for NSTE-ACS Invasive treatment?

A
  1. Aspirin +
  2. Clopidogrel or ticagrelor or prasugrel +/-
  3. GP 2b/3a inhibitor
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18
Q

When can ticagrelor and prasugrel be used over clopidogrel in early invasive NSTE-ACS?

A

For low bleeding risk pts

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19
Q

List allowed antiplatelet strategies for STEMI going to primary PCI?

A
  1. Aspirin +
  2. Clopidogrel or ticagrelor or prasugrel +/-
  3. GP 2b/3a inhibitor
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20
Q

List allowed antiplatelet strategies for STEMI + fibrinolytic treatment? What fibrinolytics can be used?

A
  1. Aspirin +
  2. Clopidogrel +/-
    *Pre-PCI after fibrinolytic: 300 mg LD w/i 24hr of event; 600 mg if >24hr after tx
  3. GP 2b/3a inhibitor

Fibrinolytics
1. Alteplase
2. Reteplase
3. Tenecteplase

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21
Q

When is GP 2b/3a inhibitor used for ACS management?

A

In pts w/ high-risk features (ex. elevated troponin) not adequately pre-treated w/ clopidogrel or ticagrelor

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22
Q

Length of therapy for patients receiving DAPT after-ACS?

A

At least 12 months for all pts getting aspirin + P2Y12 inhibitor

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23
Q

Doses of aspirin for pts w/ initial ACS presentation, undergoing PCI, after ACS?

A

Class I rec: all pts get aspirin

Initial presentation: 162-325 mg

Undergoing PCI: 81- 325 mg

After ACS: 81 mg administered indefinitely

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24
Q

How is choice for oral P2Y12 inhibitor choice made?

A

Class I rec: all pts get P2Y12 inhibitor

Choice of P2Y12 made based on ischemia-guided vs. early invasive treatment.

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25
Q

Which P2Y12 inhibitors are preferred in ischemia-guided therapy?

A

Clopidogrel
Ticagrelor

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26
Q

Which P2Y12 inhibitors are preferred in early invasive therapy?

A

Clopidogrel
Ticagrelor
Prasugrel

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27
Q

When is prasugrel contraindicated for use?

A
  1. History TIA or stroke
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28
Q

What is a drug-drug interaction consideration that affects the efficacy of ticagrelor?

A

Efficacy decreased in higher doses of aspirin (dose >300 mg daily) vs. lower doses (doses <100 mg daily)

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29
Q

When is ticagrelor chosen over clopidogrel in NSTE-ACS or STEMI?

A

Pts treated w/ early invasive strategy or coronary stenting

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30
Q

When is prasugrel chosen over clopidogrel in NSTE-ACS or STEMI?

A

Pts undergoing PCI who are not at high bleeding risk complications and have no history of TIA/stroke

*NOTE: ISAR-REACT 5 trial: prasugrel superior to ticagrelor in reducing ischemic endpoints w/o increasing bleeding risk in ACS pts undergoing PCI

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31
Q

Dosing of P2Y12 inhibitors given before PCI?

A
  1. Clopidogrel 600mg LD, 75mg daily
  2. Prasugrel 60mg LD, 10mg daily
  3. Ticagrelor 180mg LD, 90mg BID

From ACC/AHA and NSTE-ACS guideline recs

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32
Q

Dosing of P2Y12 inhibitors for NSTE-ACS pts treated w/ early invasive or ischemia-guided therapy?

A
  1. Clopidogrel 600mg LD, 75mg daily
  2. Ticagrelor 180mg LD, 90mg BID
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33
Q

When is the maintenance dose of prasugrel decreased?

A

Prasugrel 5mg used if:
* Weight <60 kg
* Age >/= 75yo

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34
Q

Which P2Y12 inhibitor is vs. is NOT a pro-drug and have reversible/irreversible platelet binding?

A

Clopidogrel, prasugrel
* Prodrug
*Irreversible platelet binding

Ticagrelor
*Not prodrug
*Reversible, non-competitive binding

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35
Q

Which P2Y12 inhibitor has drug-drug interactions w/ CYP 2C19?

A

Clopidogrel
Box warning: 2C19 genetic polymorphism
PPIs inhibit 2C19 (avoid using clopidogrel + esomeprazole/omeprazole)

36
Q

Discuss relevant drugs interactions with ticagrelor.

A
  1. Strong 3A4 inhibitors increase TIC concentrations
  2. Strong 3A4 inducers decrease TIC concentrations (do not exceed simvastatin or lovastatin 40mg)
  3. Limit aspirin to <100mg daily
  4. Monitor digoxin concentrations
  5. Monitor in asthma and bradycardia
37
Q

Discuss relevant drugs interactions with prasugrel.

A

No clinically significant drug interactions

38
Q

What are the surgery hold times for P2Y12 inhibitors?

A

Clopidogrel, ticagrelor- 5 days
*Emergency CABG: hold at least 24hrs to minimize bleed risk

Prasugrel - 7 days

39
Q

Contraindications for individual P2Y12 inhibitors?

A
  1. Clopidogrel
    • Active bleeding (NOTE: clopidogrel has less bleeding risk PRA and TIC with standard dosing)
  2. Prasugrel
    • Active bleed, TIA, CVA (cardiovascular accident)
  3. Ticagrelor
    *Active bleed, ICH, severe hepatic disease
40
Q

Potential use for cangrelor?

A

Cangrelor- IV P2Y12 inhibitor w/ rapid onset and offset
Used in PCI only for those who can’t get oral P2Y12

Potential use: bridge therapy after stopping oral P2Y12 inhibitors in high-risk pts undergoing CABG

Note: onset of clopidogrel, prasugrel is delayed when co-administered w/ cangrelor; cangrelor may preferentially bind P2Y12 and prevents irreversible inhibition w/ CLO and PRA’s active metabolites. Therefore, don’t give CLO or PRA until after stopping cangrelor infusion.

41
Q

Cangrelor dose?

A

Dose: 30 mcg/kg bolus, 4 mcg/kg/min

42
Q

Eptifibatide (Integrilin) dosing in ACS with or without PCI?

A

PCI: 180 mcg/kg IV bolus x 1 (10 min apart), 2 mg/kg/min started after 1st bolus dose for 18-24 hrs
*Double bolus in STEMI and NSTE-ACS PCI

Without PCI: single dose bolus above; uncertain benefit in pts adequately treated w/ P2Y12 inhibitor

Renally dose adjust:
*CrCl <50 mL/min: reduce dose by 50%
* CI: hemodialysis

43
Q

Tirofiban (Aggrastat) dosing in ACS with or without PCI?

A

PCI: 25 mcg/kg IV over 3 min; 0.15 mcg/kg for 15 hour

Renally dose adjust:
*CrCl <60 mL/min: reduce dose by 50%

44
Q

Benefit of adding GP 2b/3a inhibitor to aspirin?

A

Benefits those w/ high-risk features (elevated biomarkers, diabetes, undergoing revascularization) and inadequate pre-treatment w/ CLO or TIC

45
Q

Can UFH + GP 2b/3a be used together?

A

Class 2a rec, 2014 NSTE-ACS guideline

It is reasonable to give GP 2b/3a Inhibitors to high-risk pts w/ NSTE-ACS treated w/ UFH and adequately pre-treated w/ CLO or TIC.

GP 2b/3a inhibs should be used in combo with heparin (either UFH or LMWH) or used provisionally w/ bivalirudin.

46
Q

What are common adverse effects of GP 2b/3a inhibitors? (List 3)

A
  1. Bleeding (1.4%-10.6%)
  2. Renally dose adjust (eptifibatide, tirofiban are small molecules) to decrease bleed risk
  3. Thrombocytopenia (monitor Hgb/Hct)
    *Giving w/ UFH doesn’t increase thrombocytopenia risk
47
Q

What is the role of anticoagulant use in ACS?

A

Anticoagulant should be given to ALL pts w/ ACS in addition to antiplatelet therapy.
*Reason: reduce risk of intracoronary and catheter thrombus formation
*Anticoagulants typically used in the procedural setting

Anticoagulants increase bleeding risk (must monitor)

48
Q

List available options of anticoagulants for STEMI (PCI).

A

UFH
Bivalirudin

49
Q

List available options of anticoagulants for STEMI w/ fibrinolytic therapy.

A

UFH
Enoxaparin
Fondaparinux

50
Q

When are fibrinolytics preferred in STEMI treatment? Duration of therapy for anticoagulants?

A

Fibrinolytics preferred when PCI cannot be done w/i 120min of first medical contact. Goal for fibrinolytic: door-to-needle time <30 min.

Those who get fibrinolytics should be on anticoagulation for at least 48 hrs w/ IV UFH or IV/SQ enoxaparin during hospitalization, up to 8 days (preferred) or IV/SQ fondaparinux during hospitalization, up to 8 days.

51
Q

List available options of anticoagulants for NSTE-ACS, early invasive strategy.

A

UFH
Enoxaparin
Bivalirudin

52
Q

List available options of anticoagulants for NSTE-ACS, ischemia-guided strategy.

A

UFH
Enoxaparin
Fondaparinux

53
Q

List monitoring parameters for unfractionated heparin (UFH).

A

aPTT or ACT, Hgb/Hct, Platelet count

Adjust dose based on activated partial thromboplastin time (aPTT) or activated clotting time (ACT).

54
Q

What is the dose of UFH in NSTE-ACS?

A

Bolus 60 un/kg (max 4000 un)
Infuse starting at 12 un/kg/hr (max 1000 un/hr)
Continue for 48 hrs or until PCI

55
Q

What is an advantage of using UFH in ACS?

A

UFH is not renally cleared, so can be used safely in renal impairment pts.

56
Q

List monitoring needs for Enoxaparin and Fondaparinux?

A

Monitor Hgb, Hct, platelet count
Require SCr to calculate CrCl for dosing
Does not require routine anti-Xa monitoring

57
Q

Enoxaparin dose for NSTE-ACS?

A

1 mg/kg SC Q12hr for 24-48 hrs or until PCI or throughout hospitalization (up to 8 days)
Optional: 30 mg IV bolus in ???

58
Q

Enoxaparin dose in STEMI + PCI?

A

30 mg IV bolus, then 1 mg/kg SQ Q12hr (NOT TO EXCEED 100 mg on 1st two doses)

If >75yo: omit bolus, then 0.75 mg/kg SQ Q12hr (not to exceed 75mg on 1st two doses)

59
Q

Enoxaparin dose in ACS for pts w/ CrCl <30 mL/min?

A

1 mg/kg SQ daily

60
Q

Clinical pearls for Fondaparinux use (1. class 2. half-life 3. monitoring 4. contraindications)

A
  1. Factor Xa inhibitor
  2. Longest half-life anticoagulant (17 hrs)
  3. Monitor Hgb, Hct, platelet count
    Require SCr to calculate CrCl for dosing
    Does not require routine anti-Xa monitoring
  4. Contraindicated in CrCl <30 mL/min

*No increased risk of HIT
*NOT used as the sole anticoagulant during PCI

61
Q

Advantage of using bivalirudin when other anticoagulants cannot be used in PCI?

A

Can be used in history of/suspected HIT

62
Q

Monitoring (labs) needed for bivalirudin?

A

Monitor SCr (to renally dose adjust), Hgb, Hct, platelets; Note: does not need monitoring for adjustments during PCI

63
Q

Dosing for bivalirudin during early invasive strategy, PCI, STEMI +/- PCI and for CrCl <30 mL/min.

A

(1) Early invasive strategy/NSTE-ACS: 0.1-mg/kg LD followed by 0.25 mg/kg per hour (only
in patients with planned PCI), continued until diagnostic angiography or PCI

(2) PCI dosing: 0.75-mg/kg intravenous bolus, 1.75 mg/kg/hour intravenously continued
throughout the procedure (D/C at end of PCI or cont up to 4hrs after procedure); hold UFH 30 min before giving bivalirudin

(3) STEMI +/- PCI: 0.75 mg/kg IV, then 1.75 mg/kg/hr IV

(4) CrCl <30 mL/min: 1 mg/kg/hour or Hemodialysis: 0.25 mg/kg/hour

Can extend duration of infusion for up to 4 hours after procedure for prolonged antiplatelet protection

64
Q

When is anticoagulant therapy discontinued for PCI?

A

D/C after PCI unless there is compelling reason to continue

65
Q

Fondaparinux dosing in NSTE-ACS, STEMI +/- PCI?

A

NSTE-ACS: 2.5mg SQ daily
STEMI +/- PCI: 2.5mg IVB, then 2.5mg daily
Note: do not use as sole anticoagulant in PCI; must use with enoxaparin or GP 2b/3a + enoxaparin

66
Q

List recommended anticoagulants when fibrinolytics are used in reperfusion strategy?

A

UFH
Enoxaparin
Fondaparinux

67
Q

Alteplase dose in fibrinolytic therapy for pts <67kg vs. >67kg?

A
  1. < 67kg: 15mg IVP over 1-2 min, then 0.75 mg/kg IV over 30 min (max 50 mg), then 0.5 mg/kg (max 35 mg) over 60 min
  2. > 67kg: 15 mg IVP over 1-2 min, then 50 mg over 30 min, then 35mg over 1 hr (max total dose 100mg)
68
Q

Reteplase dose in fibrinolytic therapy?

A

10un IVP, repeat 10un IV in 30 min

69
Q

Tenecteplase dose in fibrinolytic therapy?

A

<60 kg: 30mg IVP
60-90 kg: 35mg IVP
70-79 kg: 40mg IVP
80-89 kg: 45mg IVP
>90 kg: 50mg IVP (~0.5 mg/kg)

70
Q

List absolute contraindications for fibrinolytic therapy in ACS (8).

A
  1. Prior hemorrhagic stroke
  2. Ischemic stroke w/i 3 mo
  3. Intracranial neoplasm, ateriovenous malformation
  4. Active internal bleeding
  5. Aortic dissection
  6. Facial trauma or closed-head trauma in past 3 mo
  7. Intracranial/instraspinal surgery w/i 2 mo
  8. Severe uncontrolled HTN (unresponsive to emergency tx)
71
Q

Duration of DAPT therapy after ACS?

A

At least 12 months
-DAPT reduces mortality regardless of stent placement

Continue aspirin 81mg indefinitely in ALL pts

72
Q

Duration of DAPT with ischemia-guided therapy? Available DAPT treatments?

A

Up to 12 months

Give Aspirin + clopidogrel 75 mg daily OR ticagrelor 90mg daily

73
Q

Duration of DAPT after PCI treatments? Available DAPT Treatments?

A

At least 12 months

Aspirin + CLO 75 mg daily, PRA 10mg daily, or TIC 90mg daily

74
Q

When should early discontinuation of DAPT be considered? Duration?

A

Consider shorter duration in stable ischemic heart disease who have undergone PCI with ELECTIVE stent place’t

Duration: 6 months for elective PCI

Note: generally shorter duration DAPT for lower ischemic risk and high bleeding risk; longer-duration for higher ischemic risk and lower bleed risk

Give w/ PPI to reduce GI bleed risk in DAPT

75
Q

When is long-term DAPT, beyond 12mo, a consideration?

A

When pts are at higher ischemic risk w/ lower bleeding risk

Note: continued DAPT is not associated w/ decreased CV or total mortality

76
Q

When DAPT is given beyond 12 mo, what is the ticagrelor dose that can be used?

A

1 year DAPT w/ ticagrelor 90mg BID, then reduce to TIC 60mg BID

77
Q

Who gets Beta-blockers treatment? Duration to give?

A

Indicated in all patients unless contraindicated

Initiate w/i first 24 hrs if possible. If not, re-evaluate to start before discharge

Continue for at least 3 yrs when EF >40%

Continue indefinitely for EF <40%

78
Q

Who gets ACE-i (or ARB) after ACS? Contraindications (List 3)?

A

Indicated in ALL pts w/ LVEF <40%, HTN, DM, or stable CKD

CI: hypotension, pregnancy, bilateral renal artery stenosis

79
Q

Who gets lipid-lowering therapy after ACS? When should it be started? What is the goal LDL level/reduction?

A

Give high-intensity statins to all pts after ACS

Start w/i first 24 hours

Goal: LDL <70 mg/dL

80
Q

When should non-statin therapy be considered in pts who need lipid-lowering post-ACS?

A

Consider in high-risk pts when statins have <50% reduction in LDL or in statin-intolerant pts

In high-risk pts start ezetimibe or PCSK9 inhibitors + statin to reduce CV end points

81
Q

Preferred agents to treat pain after ACS?

A

Acetaminophen
Non-acetylated salicylates
Tramadol
Narcotics

2nd line: Non-selective NSAIDs (ex. naproxen), IF initial therapy is insufficient
*Monitor: HTN, edema, worsening renal function, or GI bleed

82
Q

Non-preferred agents for pain management? Why?

A

Avoid NSAIDs and selective COX-2 inhibitors- D/C at time of presentation bc may be associated w/ increased risk of major CV events.

83
Q

Antiplatelet recommendations in patients going to CABG.
1. Should aspirin be discontinued?
2. Elective CABG- when should P2Y12 inhibitor be discontinued?
3. Urgent CABG- when should P2Y12 inhibitor be discontinued?
4. Pts referred for CABG- when should GP 2b/3a inhibitors be discontinued?

A
  1. No, don’t D/C aspirin. Continue pre-operatively. Aspirin 81 mg -325 mg.
  2. D/C clopidogrel and ticagrelor 5 days, D/C prasugrel 7 days before CABG
  3. D/C CLO and TIC for at least 24hrs to reduce risk major bleeding
  4. D/C Eptifibatide and tirofiban at least 2 hrs pre-surgery
84
Q

What is the consensus on using triple therapy in A.fib pts undergoing PCI?

A

Triple therapy: low-dose ASA + P2Y12 inhibitor + anticoagulant- increases bleeding risk; use should be limited to 1-3 months if used beyond hospital discharge
*D/C aspirin at time of discharge or cont. 1-3 mo.s depending on risk

New AF guidelines prefer P2Y12 inhibitor + anticoagulant (DOAC [preferred] or warfarin)

85
Q

What is the preferred P2Y12 inhibitor in A.fib pts undergoing PCI? When should tx be D/C’d?

A

Clopidogrel is preferred, but can use TIC in high ischemic/thrombotic and low bleeding risk (AVOID prasugrel)

D/C antiplt therapy at 1 year in most pts

86
Q

Which direct antithrombin inhibitor is preferred in Age >75yo with ACS?

A

Bivalirudin&raquo_space;> GP 2b/3a inhibitor + UFH - similar efficacy but less bleed risk

Cardiology- Acute Care (6 decks)

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