acute coronary syndrome Flashcards

Question

initial anti-ischemic and analgesic medications

Answer 1

**MONA-B. 1. **morphine 1. oxygen 1. nitroglycerine 1. asprin 1. betablocker

Answer 2

1. first-line therapy in ACS regardless of the type (STEMI or NSTEMI). **initial dose**: (Avoid enteric-coated aspirin) 1. **162-325mg** is recommended for patients who haven't been taking aspirin regularly (naive) 2. for **PCI (81-325mg**) depending on their pre-existing aspirin regimen. **Maintenance therapy:** 1. given indefinitely at a preferred dose of **81mg** after ACS with or without PCI. 2. lower doses are generally preferred for long-term use. below 160mg due to higher risk of bleeding

Answer 3

aspirin+p2y12 inhibtor **ischemia-guided strategy**: aspirin+Clopidogrel and ticagrelor **NST-ACS**: asprin + Clopidogrel, prasugurl and ticagrelor **STEMI PCI**: asprin + Clopidogrel, prasugurl and ticagrelor **STEMI Fibrinolytics**: Clopidogrel ## Footnote The efficacy of ticagrelor is decreased in patients treated with higher doses of aspirin (greater than 300 mg daily) compared with lower doses (less than 100 mg daily).

Answer 4

* Patients undergoing reperfusion with fibrinolytic should receive anticoagulant therapy after fibrinolysis: * At least 48 hours with intravenous UFH * intravenous/subcutaneous enoxaparin or fondaparinux during hospitalization, up to 8 days. ## Footnote Anticoagulant Recommendations for pci: 1. ufh and bivalirudin

Answer 5

DAPT betablocker ace statin ## Footnote ABAS= ASPRIN+ BETABLOCKER+ ACE+STATIN

Answer 6

* **duration**:Given at least 12 months after ACS. * Shorter-duration DAPT: for patients with stable ischemic heart disease who have undergone PCI with elective stent placement **benefit**: reduces mortality after ACS, regardless of whether the patient received stenting. **short duration:** high bleeding risk and lower ischemic risk **long duration**:higher ischemic risk and a lower bleeding risk

Answer 7

* Indicated for all patients unless contraindicated. * initiated within the first day, * Continue for at least 3 years (when EF is greater than 40%). * Continue indefinitely in patients with an EF less than 40%. * If moderate or severe LV failure, initiate carvedilol, bisoprolol, or metoprolol succinate with gradual titration.

Answer 8

ACE inhibitors should be initiated and continued indefinitely for all patients with an **LVEF of 40% or less** and in those with hypertension, diabetes mellitus, or stable chronic kidney disease unless contraindicated. ACE inhibitors may be acceptable in all other patients with cardiac or other vascular disease. Angiotensin receptor blockers (ARBs) are indicated if the patient has contraindications to or is intolerant of ACE inhibitors. **Contraindications** include hypotension, pregnancy, and bilateral renal artery stenosis.

Answer 9

High-intensity statins are indicated in all patients after ACS without contraindication and within the first 24 hours. In high-risk patients achieving a less-than-expected response to statins or in those who are completely statin intolerant, non-statin therapy may be considered for CV benefit. either ezetimibe or a PCSK9 inhibitor “Alirocumab and Evolocumab” can be considered in combination with statin therapy in very high-risk patients.

Answer 10

Pain should be treated with acetaminophen, nonacetylated salicylates, tramadol, or narcotics at the lowest dose to control symptoms. It is reasonable to use nonselective NSAIDs, such as Naproxen, if initial therapy is insufficient. ## Footnote Monitor regularly for sustained hypertension, edema, worsening renal function, or GI bleeding. If these occur, consider dose reduction or discontinuation.

Answer 11

**NSAIDs and select cyclooxygenase-2 inhibitors should be discontinued** at the time of presentation because they have been associated with an increased risk of major adverse cardiac events. **Antiemetic + Stool Softener** should be administered to minimize the undesirable effects of morphine and also because straining has negative impact on the CVS. Before discharge, the patient’s **musculoskeletal discomfort should be addressed**, and a stepped-care approach should be used to select therapy.

Answer 12

Relief of ischemic discomfort Return of ECG changes to normal / baseline Absence or resolution of HF signs and symptoms. ## Footnote In general, the most common adverse reactions from ACS therapies include hypotension and bleeding.

Answer 13

Not recommended in patients with NSTE-ACS as thrombi in these patients are not typically fibrin rich, so they are less responsive to therapy.

Answer 14

This is because older clots (>12hrs old) are resistant to lysis & also because cardiac tissue necrosis is already established In MI, intracoronary delivery within 2-6 hours & IV administration after 6 hours (rapid, inexpensive and lower risk)