Acute Coronary Syndrome Flashcards
What is acute coronary syndrome (ACS)?
Range of conditions related to sudden, reduced blood flow to the heart
What conditions are under ACS?
Unstable angina
NSTEMI
STEMI
What does the TIMI score stand for?
Thrombolysis in Myocardial Infarction
Predicts the risk of both death and early recurrent ischemic events
What conditions can TIMI risk score be applied to?
Unstable angina
NSTEMI
What clinical features are in the TIMI risk score?
> 65 years of age
≥3 cardiac risk factors (high cholesterol, hypertension, diabetes, smoker, family history of CAD)
≥50% coronary artery stenosis
Any ASA use within the past 7 days
≥2 episodes of angina within the past 24h
Elevation in cardiac markers (troponin or creatine kinase-myocardial band)
ST segment deviation ≥0.5 mm on ECG
If patient has UA/NSTEMI and are considered high risk, we would take the __________ strategy route.
Invasive
What is the invasive strategy for UA/NSTEMI?
Urgent coronary angiography followed by PCI or bypass if possible
Continuous ECG monitoring
When are patients considered high risk?
Positive cardiac enzymes
ST segment changes
TIMI risk score ≥3
Recurrent ischemic symptoms
Heart failure
Hemodynamic instability
Sustained ventricular tachycardia
Prior CABG or PCI
When is a non-pharm for UA/NSTEMI?
Bed rest while ischemia is ongoing. Gradually mobilize when symptoms stabilize.
If patient has UA/NSTEMI, what’s the first thing we want to do?
Symptom relief
How do we provide symptom relief for patients with UA/NSTEMI?
Nitroglycerin sublingual tablets
Nitroglycerin spray
When do we consider nitroglycerin IV?
If symptoms are not relieved promptly (within 15-20 minutes)
Once patient has been stabilized and is symptom-free, what can we use to prevent recurrent episodes of ischemia?
Topical nitrates like nitrate patches
What is contraindicated interaction with nitrates?
Sildenafil or vardenafil in the previous 24 hours
Tadalafil in the previous 48 hours
Significant hypotension
What therapeutic agents are started for patients with UA/NSTEMI?
Beta blockers or CCB
ACEi
Antiplatelet therapy
When should beta blockers be started for UA/NSTEMI?
Is beta blocker therapy lifetime for UA/NSTEMI?
Start as soon as possible
Not lifetime.
We would typically administer beta blockers orally. When would we administer it IV?
If anginal pain is ongoing, administer IV. Then transition to oral once pain is controlled
When are beta blockers contraindicated?
- Reactive airway disease
- Bradycardia (HR≤50 bpm)
- Second or third degree heart block without pacemaker
- Hypotension (SBP<100)
What do we do if beta blockers are contraindicated?
Calcium channel blockers
When else do we use calcium channel blockers?
When beta blockers are inadequate at optimal doses, we add on CCB
OR
if patient has variant angina (coronary spasm)
What calcium channel blockers are preferred if used?
DHP CCB (amlodipine)
Avoid NDHP CCB with beta blockers (diltiazem and verapamil) to avoid LV dysfunction and severe bradycardia
Avoid immediate release nifedipine
When should ACEi be started?
Are they to be continued for lifetime?
Within 24 hours of presentation
Lifetime
When is anticoagulation therapy used in UA or NSTEMI?
In all patients with UA or NSTEMI and it will be administered again if high risk patient fail PCI/CABG
When does PCI/CABG come into play for UA/NSTEMI?
If they are considered high risk patients.
Recap: What are clinical factors that make the patient high risk?
- Positive cardiac enzymes
- ST segment changes
- TIMI risk score ≥3
- Recurrent ischemic symptoms
- Heart failure
- Hemodynamic instability
- Sustained ventricular tachycardia
- Prior CABG or PCI
How do we pick between LMWH and UFH?
LMWH is easier to administer, predictable response and no need to monitor.
However, LMWH can’t be used if CrCl is <30 mL/min
UFH would require monitoring.
However, UFH can be used if CrCl<30ml/min
How long do we use heparin therapy for?
2-5 days
If we choose to use LMWH, what is the preferred drug?
Enoxaparin
When do we use fondaparinux as anticoagulation therapy?
Lower incidence of major bleeding
When do we initiate ASA?
Is therapy for lifetime?
ASAP
Continued lifetime
When do we use thienopyridines?
Is it for lifetime?
They are started with ASA
Continue for 1 year
What are the three thienopyridines we can use?
Clopidogrel
Prasugrel
Ticagrelor
How do we pick between clopidogrel, prasugrel, and ticagrelor?
Ticagrelor
- First line (more potent and faster onset)
- If dyspnea, switch to clopidogrel
Clopidogrel
- Second line
- If patient has CYP2C19 gene mutation, patient will have diminished effect -> switch to prasugrel
Prasugrel
- Increase risk of bleeds, especially in those older than 75 years of age, body weight <60kg, and those with history of stroke or TIA
- Good for those undergoing stent implantation or are at higher risk for stent thrombosis
If patient is going for non-urgent bypass surgery, how long should we hold ticagrelor for?
5 days
If patient is going for non-urgent bypass surgery, how long should we hold clopidogrel for?
5 days
If patient is going for non-urgent bypass surgery, how long should we hold prasugrel for?
7 days
What is a STEMI?
ST segment elevated myocardial infarction
Medical emergency
What are non-pharm that are required for STEMI?
Bed rest with supplemental oxygen
Continuous ECB monitoring
Gradual mobilization after stabilization
What is the first line therapy for STEMI?
Urgent coronary angiography with PCI
- Preferred in patients >75 or those with cardiogenic shock
When does PCI have to be administered by?
Within 2 hours
If patient is unable to receive PCI within 2 hours, what do we do?
Administer a thrombolytic therapy followed by immediate transfer to a cardiac catheterization centre
If administering thrombolytic, what are the therapies of choice?
Alteplase
Tenecteplase
When is thrombolytic therapy most effective? When does its beneficial effects diminish?
Within 6 hours of symptoms onset
Benefit is much less clear after 12 hours
Heparins are always used in NSTEMI patients, but are they always used in STEMI patients?
If patient got PCI, use of heparin is dependent on the physician
If patient got fibrinolytic therapy, always give UFH
Is there a preference for a specific type of heparin?
If patient used Tenecteplase, we should use enoxaparin
How long should heparin be used in STEMI patients?
For a minimum of 48 hours
What pharmacotherapy should be started for STEMI patients?
ASA
Beta blockers
ACEi/ARBs
Clopidogrel
When should ASA be started? Is it for lifetime?
ASAP
For lifetime
If patient has a history of GI bleeding, what should they take ASA with?
PPI to protect the stomach
When are beta blockers started for STEMI patients?
Is it for lifetime?
Start once hemodynamically stable
Lifetime
When should we hold off on starting beta blockers?
If patient is bradycardic (HR<50)
What is a drug class that we want to avoid in patients with STEMI?
Is there an exception?
Calcium channel blockers increase morbidity and mortality rates in patients with STEMI
Can use cautiously if beta blockers are contraindicated or to relieve ischemia/rate control
If we are using calcium channel blockers, what is the drug of choice?
Diltiazem 90-120 mg daily in divided doses
Nitrates are routinely used in NSTEMI.
Are they routinely used in STEMI?
Only if ischemia is present or recurrent or if patient had large anterior MI, hypertension or heart failure
When do we start ACEi?
Is it for lifetime?
Within 24 hours of STEMI
Yes
When do we delay the start of the ACEi?
If patient is hypotensive (SBP<100 mmHg)
When do we use MRA?
If they have clinical evidence of heart failure (LV ejection fraction <40% or both)
What antiplatelet therapy is used in STEMI patients?
Clopidogrel is started with ASA
-Therapy is started with patient is treated with fibrinolysis
What are complications of STEMI?
Recurrent or ongoing ischemia
Heart failure
Arrhythmias
Pericarditis
How do we treat recurrent ischemia?
Urgent coronary angiography and revascularization
How do we treat heart failure following STEMI?
Aggressively as you would with general heart failure
If the arrhythmias is an asymptomatic premature ventricular contraction, how do we treat?
No treatment needed
If arrhythmia is a symptomatic ectopy, how do we treat?
Beta blocker
Avoid class IC agent, as they are contraindicated
If patient has a.fib, how do we treat?
Control ventricular rate (with a beta blocker or digoxin) and consider oral anticoagulant therapy
Pericarditis is uncommon following STEMI, but if it occurs, how do we treat?
Increase dose of ASA to 650mg QID for 1-2 weeks.
Add-on colchicine if needed
If patient has ACS and is pregnant, which therapies are safe? Which pharmacotherapy should be avoided?
Safe:
Primary PCI is treatment of choice
ASA
Clopidogrel
UFH and LMWH
Beta blockers
Nitrates
Avoid:
ACEi, ARBs, statins
What agent should be started in all ACS patients?
Statin
If patient has ACS and is breastfeeding, how do we manage? What agents are safe in breastfeeding?
Safe:
ASA
UFH
LMWH
Beta blockers
Discontinuation of breastfeeding is preferred for optimal maternal outcomes
What is the door to needle time for thrombolytic treatment?
30 minutes or less
What is the first medical contact to device time for primary PCI?
90 minutes or less
What are some other add-on agents that can benefit patient care?
Stool softeners
-minimizes straining during post MI period
Anxiolytics
- PRN during post MI period
What drug therapy should all patients with ACS be started on to decrease cardiovascular risk?
Statin
What the cholesterol target for those who have had a myocardial infarction?
LDL<1.8 mmol/L
Does clopidogrel need to be renally adjusted?
No
