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NAPLEX > Acute Coronary Syndrome > Flashcards

Acute Coronary Syndrome Flashcards

0
Q

What usually causes the imbalance seen in ACS?

A

Plaque build up in the coronary arteries

Plaque ruptures -> clot forms -> reduction in blood flow -> ischemia -> compromising proper cardiac functioning

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1
Q

What is ACS?

A

ACS refers to a set of clinical disorders that result from an IMBALANCE btw myocardial oxygen demand and supply

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2
Q

What biochemical markers are released into the blood stream as a result of ischemia?

A 
Troponins I and T
Creatinine kinase (CK) myocardial band (MB)
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3
Q

What clinical conditions encompasses ACS?

A

Unstable angina (UA)
Non-segment elevation myocardial infarction (NSTEMI)
Segment elevation myocardial infarction (STEMI)

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4
Q

What are the common clinical xtics of UA/NSTEMI?

A

Transient ST-segment DEPRESSION
T-wave INVERSION
NO changes seen in ECG

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5
Q

What are the clinical symptoms of ACS?

A

Chest pain that feels like pressure or tightness
SOB
Pain in other areas such as left upper arm or jaw
Pain usually not relieved by nitroglycerin sublingual tablets/ spray/ rest

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6
Q

Once a person experiences sx of ACS, what must they do first?

A

Immediately call 911

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7
Q

What must be performed on the patient at the site of FIRST medical contact?

A

12-lead ECG

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8
Q

What must the hospital have for a pt with ACS to be transported there?

A

Percutaneous coronary intervention (PCI)

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9
Q

Risk factors for ACS

A 
Age (men > 45; women > 55 years or early hysterectomy)
FH of coronary event before 55yrs (men); 65yrs (women)
Smoking
HTN
Hyperlipidemia
Diabetes
Chronic angina
Known coronary artery dx
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10
Q

What factors may precipitate ACS?

A 
Exercise
Cold weather
Extreme emotions
Stress
Sexual intercourse
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11
Q

Diagnosis of UA

A

Chest pain

NEGATIVE cardiac enzymes

No or transient ECG changes

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12
Q

Diagnosis of NSTEMI

A

Chest pain

POSITIVE cardiac enzymes (Troponins, CK-MB)

No or transient ECG changes

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13
Q

Diagnosis of STEMI

A

Chest pain

Positive cardiac enzymes (Troponins, CK-MB)

ST elevation or NEW left bundle branch block (LBBB) (>= 0.1 mV of ST segment elevation in 2 or more contiguous ECG leads)

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14
Q

What’s the difference btw UA and NSTEMI diagnosis?

A

Same (chest pain, no or transient ECG changes) EXCEPT

UA - negative cardiac enzymes

NSTEMI - positive cardiac enzymes

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15
Q

What’s the difference btw NSTEMI and STEMI diagnosis?

A

Same (chest pain, positive cardiac enzymes - Troponins and CK-MB)
Except

NSTEMI - no or transient ECG changes

STEMI - ST segment changes or new left bundle branch block (LBBB) of >= 0.1 mV of ST segment elevation of >= 2 contiguous ECG leads

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16
Q

What’s the aim of acute tx of ACS?

A

Stabilizing pt’s condition

Relieving pain from ischemia

Reducing myocardial damage and further ischemia

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17
Q

What’s meds are given to stabilize pt and treat pain with all ACS?

A

MONA =

Morphine

Oxygen

Nitroglycerin

Aspirin

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18
Q

What’s initiated to reduce myocardial damage and prevent further ischemia in ACS?

A

Anti-thrombotic therapy, usually dual oral Antiplatelet + anticoagulant with heparin, LMWH OR bivalirudin

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19
Q

What meds may be given in select pts?

A

GP IIb/IIIa antagonist (Tirofiban, Eptifibatide, Abciximab) TEA

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20
Q

What must all pts receive within 24 hrs of presentation, if no contraindication?

A

Beta blocker + ACE I

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21
Q

What may be given to pts presenting with STEMI? When must this be done?

A

Fibrinolytic

Done when pt can’t be transferred to a PCI capable hospital

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22
Q

When is a fibrinolytic given?

A

STEMI pt

Done when pt can’t be transferred to a PCI capable hospital

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23
Q

What’s the tx for UA and NSTEMI?

A

MONA + GAP-BA

Morphine
Oxygen
Nitrates
Aspirin

GP IIb/IIIa receptor antagonists (Tirofiban, Eptifibatide, Abciximab) TEA
Anti-coagulants (heparin, LMWH eg Enoxaparin, Dalteparin,
fondaparinux, bivalirudin
P2Y-12 inhibitors (Clopidogrel/ prasugrel - if pt is going for PCI)
(Ticagrelor - for ALL pts except those going for
CABG surgery)

Beta blockers
ACE-I

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24
Q

MOA of morphine used in ACS?

A

Arterial and venous DILATION -> reduction in myocardial O2 demand

Pain relief

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25
Q

Dosing of morphine

A

2 to 8 mg IV repeated at 5 to 15 minutes intervals PRN

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26
Q

Antidote of Morphine

A

Naloxone (Narcan)

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27
Q

When should supplement oxygen be admin in ACS?

A

SaO2 < 90%

OR

Respiratory distress

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28
Q

MOA of nitrates

A

DILATES coronary arteries and improves collateral blood flow -> reduce cardia O2 demand by reduced PRELOAD

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29
Q

Dose of nitrates

A

NTG (SL tabs or spray) = 0.4mg (1 dose) Q 5 mins…max 3 doses

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30
Q

What’s the indication for NTG IV?

A

Relief of ongoing ischemia discomfort
HTN
Mgt of pulmonary congestion

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31
Q

C/I to nitrates use

A

SBP < 90 mmHg

HR < 50 BPM OR > 100 BPM (tachycardia)

Pt on PDE-5 inh for erectile dysfunction (w/in 24 hrs of sildenafil/vardenafil; OR 48 hrs of tadalafil OR 12 hrs of Avanafil)

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32
Q

What meds may C/I the use of nitrates?

A

PDE-5 inh

Not within 12 hrs Avanafil

Not within 24 hrs for sildenafil/vardenafil

Not within 48 hrs for tadalafil

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33
Q

How soon after using the ff meds can one use nitrates?

Tadalafil
Sildenafil
Avanafil
Vardenafil

A

Tadalafil - 48 hrs

Sildenafil/vardenafil - 24 hrs

Avanafil - 12 hrs

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34
Q

What’s the dose of the initial Aspirin given?

What’s the maintenance dose?

A

LD: 162 - 325mg (2-4 tabs of 81mg)

MD: 81mg daily

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35
Q

If pt is intolerant to aspirin, what’s the alternative?

A

Clopidogrel (Plavix)

Prasugrel (Effient)

Ticagrelor (Brilinta)

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36
Q

MOA of GP IIb/IIIa receptor antagonist?

A

Blocks fibrinogen binding to GP IIa/IIIb receptors on platelets, preventing PLT aggregation

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37
Q

What agents make up GP IIa/IIIb?

A

TEA

Tirofiban (Aggrastat)

Eptifibatide (Integrilin)

Abciximab (ReoPro)

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38
Q

Uses of GP IIa/IIIb rec antagonists?

A

Medical mgt or those going for PCI +/- stent

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39
Q

Which GP IIa/IIIb is to be given ONLY if PCI is planned?

A

Abciximab

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40
Q

What agents make up P2Y-12 inh?

A

Clopidogrel

Prasugrel

Ticagrelor

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41
Q

Which P2Y-12 inhibitor is given to ALL pts? C/I?

A

Ticagrelor

CABG surgery

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42
Q

Which P2Y-12 inh are used for ONLY PCI?

A

Clopidogrel

Prasugrel

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43
Q

MOA of beta blockers?

A

DECREASE oxygen demand due to reductions in BP, HR, and contractility

May reduce the magnitude of infarction

44
Q

In UA/NSTEMI - What are the C/I that may prevent staring beta blockers (usu started within 24 hrs of presentation)?

A

Signs of HF

Evidence of low output state

Increased risk for cardiogenic shock

Other relative C/I to B-B e.g. PR interval > 0.24 secs, 2nd and 3rd degree heart block

45
Q

When is it reasonable to use oral long acting non-dihydropyridine calcium antagonists?

A

Pts with recurrent ischemia w/o C/I AFTER B-b and nitrates have been fully used

46
Q

MOA of ACE-I?

A

Inh ACE and blocks pdt of Angiotensin II

Prevents cardiac remodeling

Reduce preload and afterload

47
Q

C/I to use of ACE-I within 24 hrs of pt presentation?

A

Hypotension (SBP < 100)

Intolerance to ace-I (use ARB in this case)

48
Q

Why is it recommended to NOT use IV ACE-I within the first 24hrs?

A

Due to risk of hypotension

49
Q

What meds should be avoided in ACS pt in an acute setting?

A

All NSAIDs except Aspirin

Immediate release form of dihydropyridine Ca channel blocker eg Nifedipine

IV fibrinolytic therapy (unless pt has STEMI/LBBB)

50
Q

List the agents that make up GP IIb/IIIa

A

Tirofiban (Aggrastat)

Eptifibatide (Integrilin)

Abciximab (ReoPro)

51
Q

What’s the brand name of Abciximab?

A

ReoPro

52
Q

What’s the brand name of Eptifibatide?

A

Integrilin

53
Q

What’s the brand name of Tirofiban?

A

Aggrastat

54
Q

Name the C/I to GP IIb/IIIa receptor antagonists.

A

Thrombocytopenia (platelets < 100,000)

Hx of bleeding diathesis (predisposition)

Active internal bleeding

Recent (within 6 weeks) of surgery

Increased Prothrombin time (PT)

Hx of stroke

Severe uncontrolled HTN

55
Q

What time frame is considered wrt hx of stroke and GP IIb/IIIa?

A

Abciximab (ReoPro) = hx of stroke w/in 2 years

Eptifibatide (Integrilin) and = hx of stroke w/in 30 DAYS
Tirofiban (Aggrastat) OR any hx of hemorrhagic stroke

56
Q

What C/I is unique to Abciximab (ReoPro)?

A

Hypersensitivity to murine proteins

57
Q

Name the main SE of GP IIb/IIIa

A

Bleeding

Thrombocytopenia

Hypotension

58
Q

Name monitoring parameters for GP IIb/IIIa

A

Hgb

Hct

Platelets

S/sx of bleeding

Scr

59
Q

Which GP IIb/IIIa has the highest risk for thrombocytopenia?

A

Abciximab (ReoPro)

60
Q

What’s peculiar about Abciximab (ReoPro)?

A

Must filter with administration

61
Q

How soon do platelet count return after d/c of GP IIb/IIIa?

A

Eptifibatide (Integrilin) = 2-4 hours

Tirofiban (Aggrastat) = 4-8 hrs

Abciximab (ReoPro) = 24-48 hrs

62
Q

Which GP IIb/IIIa binds IRREVERSIBLY to block platelet aggregation?

A

Abciximab (ReoPro)

Others (Eptifibatide and Tirofiban) bind reversibly

63
Q

Name the drugs that make up P2Y-12 inhibitors

A

Clopidogrel (Plavix)

Prasugrel (Effient)

Ticagrelor (Brilinta)

64
Q

Which P2Y-12 inh are prodrugs? Implication?

A

Clopidogrel (Plavix) and prasugrel (Effient)

IRREVERSIBLE binding

65
Q

Which P2Y-12 inh is NOT a prodrug? Implication?

A

Ticagrelor (Brilinta)

Faster onset and offset (faster offset b/c it’s NOT a prodrug)

66
Q

What’s the dosing of Clopidogrel (Plavix)?

A

LD - 300 to 600mg

MD - 75mg PO daily

67
Q

What’s the dosing of Clopidogrel (Plavix ) for PCI?

A

600mg

68
Q

What’s the alternative dosing for Clopidogrel (Plavix)?

A

LD: 600 mg

150mg daily for 6 days

Then 75 mg daily

69
Q

When is no LD req for Clopidogrel (Plavix) use?

A

If ACS is managed medically w/o stenting

70
Q

What determines effectiveness of Clopidogrel (Plavix)?

A

Activation to active metabolite by CYP 2C19 (Plavix is a prodrug)

71
Q

Which allele is considered to be fully functional metabolism?

A

CYP2C19*1

*2 and *3 (have reduced functions)

72
Q

C/I of all P2Y-12 inh

A

Active bleeding

Hx of TIA or stroke

Hx of ICH

Severe hepatic impairment

73
Q

SE of both Clopidogrel (Plavix) and Prasugrel (Effient)?

A

Bleeding

Bruising

Rash

TTP (rare)

74
Q

Which P2Y-12 inh has the higher risk for bleeding?

A

Clopidogrel (Plavix)

75
Q

When is prasugrel (Effient) used in pts >= 75years?

A

Only in high risk pts eg DM and prior MI

76
Q

Are P2Y-12 inh used in CABG pts?

A

All - don’t start in pts likely to undergo CABG surgery

D/c 5 days prior to any major surgery (Clopidogrel and ticagrelor)
D/c 7 days (prasugrel)

77
Q

What’s the recommended aspirin dose to be used with Ticagrelor (Brilinta)?

A

75-100 mg daily (81mg)

> 100mg of Aspirin reduces effectiveness of ticagrelor (Brilinta)

78
Q

What SE are unique to ticagrelor (Brilinta)?

A

Dyspnea (> 10%)

Increased Scr, Uric acid

Bradyarrhythmias

79
Q

Which NSAID is used with P2Y-12 inh?

A

81mg aspirin

80
Q

How to manage bleeding on P2Y-12 inhibitors?

A

Avoid d/c, if possible (stopping p2y-12 inh, esp w/in first few months after ACS increases risk of subsequent cardiovascular events)

81
Q

What meds should be avoided with use of Clopidogrel?

A

Strong/ moderate 2C19 inhibitors

Omeprazole and Esomeprazole

82
Q

What dose of simvastatin and lovastatin should be avoided with p2y-12 inh?

A

> 40mg

83
Q

What’s the tx for STEMI?

A

MONA + GAP-BA + PCI or Fibrinolytic therapy

84
Q

What’s the preferred tx btw PCI and fibrinolytic therapy?

A

PCI, if facilities are available

85
Q

What’s the timeframe to perform a PCI, if the facilities exist?

A

Within 90 mins, (door to balloon time)

86
Q

What’s the timeframe to perform fibrinolytics, if the facilities to perform PCI doesn’t exist?

A

30 mins (door to needle).

Guidelines find that fibrinolytics is still beneficial when given 12-24 hours

87
Q

List agents that are called fibrinolytics.

A

Fibrinolytics RATS

Reteplase (r-PA) (Retevase)

Alteplase (t-PA, rt-PA, Activase)

Tenecteplase (TNKase)

Streptokinase (Streptase)

88
Q

SE of fibrinolytics

A

Bleeding

Hypotension

Intracranial hemorrhage

Fever

89
Q

List meds that are used for long-term medical mgt (secondary prevention MI).

A

Aspirin

P2Y-12 (Clopidogrel, prasugrel, ticagrelor)

NTG (PRN)

B-B (daily for 3 years)

ACE-I

High intensity statin (Atorvastatin 80mg is preferred)

Warfarin. (If req)

Pain relief (avoid NSAIDs)

Lifestyle

90
Q

What’s the time frame for receiving high doses of aspirin (162-325mg)?

Bare metal stent

Sirolimus-eluting stent

Paclitaxel-eluting stent

A

BMS - 1 month

SES - 3 months

PES - 6 months

All these then cont on low dose aspirin (81mg) indefinitely

91
Q

What’s the dose and duration for P2Y-12 inh?

A

Plavix (Clopidogrel) - 75 mg QD

Ticagrelor - 90mg BID (for at least a month and up to 1 yr)

92
Q

When do u consider using p2y-12 inh for longer than 12 months?

A

In pts ff drug eluting stent placement (Sirolimus or Paclitaxel)

93
Q

What Grp of pts MUST have ACE-I?

A

EF < 40%

HTN

CKD

Diabetes

94
Q

What’s the target INR for

Warfarin alone?

Warfarin + Aspirin / W + A + p2y-12 inh?

A
  1. 5-3.5

2. 0-2.5

95
Q

What’s NOT recommended for pain post ACS?

A

NSAIDs (risk of reinfaction and death)

96
Q

Gen recommendations for lifestyle post-mi?

A

Control HTN, DM, smoking cessation

Phy activities (30-60 mins/day for 5-7 days a week)

New guideline just recommends weightloss only (NOT to limit fat intake)

97
Q

Can Clopidogrel (Plavix) be taken with food?

A

Can be taken with or without food

98
Q

List the meds to CONTINUE when pts goes for CABG surgery?

A

Aspirin

UFH

99
Q

When is Plavix and ticagrelor DISCONTINUED when pts goes for CABG surgery?

A

5 days b4

100
Q

When is Prasugrel DISCONTINUED when pts goes for CABG surgery?

A

7 days b4

101
Q

When is Eptifibatide/Tirofiban DISCONTINUED when pts goes for CABG surgery?

A

4 HRs b4

102
Q

When is Abciximab DISCONTINUED when pts goes for CABG surgery?

A

12 HRs b4

103
Q

When is enoxaparin DISCONTINUED when pts goes for CABG surgery?

A

12-24 hrs b4 …. Dose with UFH

104
Q

When is fondaparinux DISCONTINUED when pts goes for CABG surgery?

A

24 hrs b4 …. Dose with UFH

105
Q

When is bivalirudin DISCONTINUED when pts goes for CABG surgery?

A

3 hrs b4 …. Dose with UFH

106
Q

Describe s/sx of TTP (rare SE of p2y-12 inh)

A

Extreme skin paleness

Purplish spots or skin patches (purpura)

Jaundice

Mental status changes

107
Q

Can alcohol be drank with Plavix? Why/why not?

A

No

Alcohol can increase risk of bleeding

NAPLEX (73 decks)

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