Acute Coronary Syndrome

Question 1

What causes ACS?

Answer 1

the build up of plaque in arteries and then they rupture, leading to thrombus

Question 2

duration and severity of ACS?

Answer 2

occurs at rest, increasing in severity and can last longer for example > 20 minutes

Question 3

ECG readings in ACS

Answer 3

S-T elevation if STEMI
S-T depression in NSTEMI or T-wave inversion

In someone who has MI, they will always have a Q-wave. (Rules in/out past MI)

Question 4

cardiac biomarkers

Answer 4

troponin
creatinine kinase
-they are high within a few hours of chest pain in MI, it shows sign of myocardial necrosis (cell death) = ACS

Question 5

when does chest pain occur in STEMI or NSTEMI?

Answer 5

at rest

Question 6

Goals of therapy

Answer 6

-restore blood flow in occluded artery
-prevent re-occlusion, complications, and death
-treat chest pain

Question 7

Early therapy for STEMI

Answer 7

1. Oxygen
2. Nitroglycerin (SL)
3. Morphine
4. ASA
5. Second antiplatelet agent
6. Anticoagulant (IV unfractionated heparin)
7. Reperfusion: PCI or fibrinolytic

Question 8

For reperfusion, what is the preferred strategy?

Answer 8

PCI - more effective than fibrinolytic therapy but PCI needs to be done in a timely way and its not always available

Question 9

Indication for fibrinolytic therapy

Answer 9

STEMI < 12 hrs of symptom onset

Question 10

What are the contraindications of fibrinolytic therapy?

Answer 10

1. prior intracranial hemorrhage or ischemic stroke within 3 months
2. intracranial malignant neoplasm
3. facial trauma within 3 months
4. active bleeding

Fib tx = increased risk of intracranial hemorrhage, so avoid if pt is already at risk of bleeding

Question 11

example of fibrinolytic therapy

Answer 11

tPA (alteplase)
TNK (tenecteplase)

Question 12

Dosing for ASA in acute MI

Answer 12

162-325 mg to chew x 1, then 81 mg daily INDEF

Question 13

Ticagrelor vs. Clopidogrel comparison

Answer 13

efficacy: T> C
side effects: T> C
DDI: T = cyp3a4 interactions, C = 2c19 interactions
T = quicker onset

Question 14

What is the benefit of using DAPT post-ACS?

Answer 14

to avoid stent thrombosis and future recurrent plaque rupture

Question 15

How long should DAPT be used with ASA + ticag or clopidogrel?

Answer 15

atleast 1 year

*A+T = if bleeding risk is not high x 1 year
*A+C = if pt had fibrinolytic treatment in acute STEMI (bc lower bleeding risk) x 1 year

Question 16

Total time from FMC to first device
activation (for primary PCI)

Answer 16

• within 90 minutes of first medical contact (FMC) at a PCI-capable hospital.
• within 120 minutes of FMC if the patient must be transferred from a non-PCI hospital.

Question 17

What happens if PCI can not be performed in time?

Answer 17

If PCI cannot be performed within these time frames, fibrinolytic therapy should be initiated within 30 minutes of arrival, and PCI can follow later if needed.

Question 18

AEs of antiplatelets

Answer 18

bleeding
dyspepsia (ASA)
diarrhea, rash (clopido)
dyspnea (ticagrelor)

Question 19

AEs of anticoagulants (UGH, enoxa, fondaparinux)

Answer 19

bleeding
heparin-induced thrombocytopenia (heparin & enoxaparin)

Question 20

What are the clinical signs of bleeding?

Answer 20

-CBC (hemoglobin)
-melena
-hemoptysis hematemesis
-bruising

Question 21

Other drugs to start after ACS?

Answer 21

ACEi, BB, statins

Question 22

how long to space apart PDE5 inhibitors from nitrates?

Answer 22

sildenafil and vardenafil - 24 hours
tadalafil - 48 hrs

Question 23

contraindications of beta blockers?

Answer 23

• reactive airway disease
• bradycardia (HR< 50)
• 2nd or 3rd degree heart block without a functioning pacemaker
• hypotension (SBP < 100)

Question 24

What is the role of CCBs in NSTEMI?

Answer 24

-used if BB and nitrate max dose reached + need further symptom relief
- or used if pt can not tolerate BB and has variant angina (coronary spasm)
-non DHP CCB - use with caution if also using BB

Question 25

What is the interaction between non-DHP CCB and BBs?

Answer 25

heart block
-left ventricular dysfunction
-severe bradycardia
-increased AV nodal block

Question 26

Efficacy of ace inhibitors

Answer 26

reduce mortality in pts with LV systolic dysfunction, HF, diabetes, or recent MI
-ideally start within 24 hours of presentation

Question 27

optimal duration of heparin therapy in NSTEMI?

Answer 27

2-5 days

Question 28

T/F - heparin is usually not administered after successful PCI.

Answer 28

true

Question 29

Amongst anticoagulants, when is enoxaparin vs, UFH used?

Answer 29

enoxaparin- preferred in NSTEMI, used in CrCl > 30 mL/min
UFH - appropriate if CrCl </= 30 mL/min

Question 30

what are the advantages of LMWH?

Answer 30

-easy of administration
-no need to monitor anticoagulant effect.
-predictable response

Question 31

which population of patients have increased bleeding events with Prasugrel?

Answer 31

> 75 y/o
body weight < 60 kg
history of stroke or TIA

Question 32

how many days prior to surgery should prasugrel be held?

Answer 32

7 days prior

Question 33

prasugrel vs ticagrelor

Answer 33

same risk of bleeding
P = lower risk of death, MI, and stroke

Question 34

what genetic polymorphism affects the efficacy of clopidogrel?

Answer 34

cyp2c19 - requires activation

Question 35

clopidogrel should be held for a minimum of __ days before non-urgent bypass surgery

Answer 35

5 days

Question 36

what is a side effect of ticagrelor that may require switching to a thienopyridine (clopido, prasu)

Answer 36

dyspnea (SOB)