Acute Coronary Syndrome Flashcards
What usually causes the imbalance seen in ACS?
Plaque build up in the coronary arteries
Plaque ruptures -> clot forms -> reduction in blood flow -> ischemia -> compromising proper cardiac functioning
What biochemical markers are released into the blood stream as a result of ischemia?
Troponins I and T Creatinine kinase (CK) myocardial band (MB)
What clinical conditions encompasses ACS?
Unstable angina (UA)
Non-segment elevation myocardial infarction (NSTEMI)
Segment elevation myocardial infarction (STEMI)
What are the common clinical xtics of UA/NSTEMI?
Transient ST-segment DEPRESSION
T-wave INVERSION
NO changes seen in ECG
What are the clinical symptoms of ACS?
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
Once a person experiences sx of ACS, what must they do first?
Immediately call 911
What must be performed on the patient at the site of FIRST medical contact?
12-lead ECG
What must the hospital have for a pt with ACS to be transported there?
Percutaneous coronary intervention (PCI)
Risk factors for ACS
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
What factors may precipitate ACS?
Exercise Cold weather Extreme emotions Stress Sexual intercourse
Diagnosis of UA
Chest pain
NEGATIVE cardiac enzymes
No or transient ECG changes
Diagnosis of NSTEMI
Chest pain
POSITIVE cardiac enzymes (Troponins, CK-MB)
No or transient ECG changes
Diagnosis of STEMI
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)
What’s the difference btw UA and NSTEMI diagnosis?
Same (chest pain, no or transient ECG changes) EXCEPT
UA - negative cardiac enzymes
NSTEMI - positive cardiac enzymes
What’s the difference btw NSTEMI and STEMI diagnosis?
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
What’s the aim of acute tx of ACS?
Stabilizing pt’s condition
Relieving pain from ischemia
Reducing myocardial damage and further ischemia
What’s meds are given to stabilize pt and treat pain with all ACS?
MONA =
Morphine
Oxygen
Nitroglycerin
Aspirin
What’s initiated to reduce myocardial damage and prevent further ischemia in ACS?
Anti-thrombotic therapy, usually dual oral Antiplatelet + anticoagulant with heparin, LMWH OR bivalirudin
What meds may be given in select pts?
GP IIb/IIIa antagonist (Tirofiban, Eptifibatide, Abciximab) TEA
What must all pts receive within 24 hrs of presentation, if no contraindication?
Beta blocker + ACE I
What may be given to pts presenting with STEMI? When must this be done?
Fibrinolytic
Done when pt can’t be transferred to a PCI capable hospital
When is a fibrinolytic given?
STEMI pt
Done when pt can’t be transferred to a PCI capable hospital
What’s the tx for UA and NSTEMI?
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
MOA of morphine used in ACS?
Arterial and venous DILATION -> reduction in myocardial O2 demand
Pain relief
Dosing of morphine
2 to 8 mg IV repeated at 5 to 15 minutes intervals PRN
Antidote of Morphine
Naloxone (Narcan)
When should supplement oxygen be admin in ACS?
SaO2 < 90%
OR
Respiratory distress
MOA of nitrates
DILATES coronary arteries and improves collateral blood flow -> reduce cardia O2 demand by reduced PRELOAD
Dose of nitrates
NTG (SL tabs or spray) = 0.4mg (1 dose) Q 5 mins…max 3 doses
What’s the indication for NTG IV?
Relief of ongoing ischemia discomfort
HTN
Mgt of pulmonary congestion
C/I to nitrates use
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)
What meds may C/I the use of nitrates?
PDE-5 inh
Not within 12 hrs Avanafil
Not within 24 hrs for sildenafil/vardenafil
Not within 48 hrs for tadalafil
How soon after using the ff meds can one use nitrates?
Tadalafil
Sildenafil
Avanafil
Vardenafil
Tadalafil - 48 hrs
Sildenafil/vardenafil - 24 hrs
Avanafil - 12 hrs
What’s the dose of the initial Aspirin given?
What’s the maintenance dose?
LD: 162 - 325mg (2-4 tabs of 81mg)
MD: 81mg daily
If pt is intolerant to aspirin, what’s the alternative?
Clopidogrel (Plavix)
Prasugrel (Effient)
Ticagrelor (Brilinta)
MOA of GP IIb/IIIa receptor antagonist?
Blocks fibrinogen binding to GP IIa/IIIb receptors on platelets, preventing PLT aggregation
What agents make up GP IIa/IIIb?
TEA
Tirofiban (Aggrastat)
Eptifibatide (Integrilin)
Abciximab (ReoPro)
Uses of GP IIa/IIIb rec antagonists?
Medical mgt or those going for PCI +/- stent
Which GP IIa/IIIb is to be given ONLY if PCI is planned?
Abciximab
What agents make up P2Y-12 inh?
Clopidogrel
Prasugrel
Ticagrelor
Which P2Y-12 inhibitor is given to ALL pts? C/I?
Ticagrelor
CABG surgery
Which P2Y-12 inh are used for ONLY PCI?
Clopidogrel
Prasugrel
MOA of beta blockers?
DECREASE oxygen demand due to reductions in BP, HR, and contractility
May reduce the magnitude of infarction
In UA/NSTEMI - What are the C/I that may prevent staring beta blockers (usu started within 24 hrs of presentation)?
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
When is it reasonable to use oral long acting non-dihydropyridine calcium antagonists?
Pts with recurrent ischemia w/o C/I AFTER B-b and nitrates have been fully used
MOA of ACE-I?
Inh ACE and blocks pdt of Angiotensin II
Prevents cardiac remodeling
Reduce preload and afterload
C/I to use of ACE-I within 24 hrs of pt presentation?
Hypotension (SBP < 100)
Intolerance to ace-I (use ARB in this case)
Why is it recommended to NOT use IV ACE-I within the first 24hrs?
Due to risk of hypotension
What meds should be avoided in ACS pt in an acute setting?
All NSAIDs except Aspirin
Immediate release form of dihydropyridine Ca channel blocker eg Nifedipine
IV fibrinolytic therapy (unless pt has STEMI/LBBB)
List the agents that make up GP IIb/IIIa
Tirofiban (Aggrastat)
Eptifibatide (Integrilin)
Abciximab (ReoPro)
What’s the brand name of Abciximab?
ReoPro
What’s the brand name of Eptifibatide?
Integrilin
What’s the brand name of Tirofiban?
Aggrastat
Name the C/I to GP IIb/IIIa receptor antagonists.
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
What time frame is considered wrt hx of stroke and GP IIb/IIIa?
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
What C/I is unique to Abciximab (ReoPro)?
Hypersensitivity to murine proteins
Name the main SE of GP IIb/IIIa
Bleeding
Thrombocytopenia
Hypotension
Name monitoring parameters for GP IIb/IIIa
Hgb
Hct
Platelets
S/sx of bleeding
Scr
Which GP IIb/IIIa has the highest risk for thrombocytopenia?
Abciximab (ReoPro)
What’s peculiar about Abciximab (ReoPro)?
Must filter with administration
How soon do platelet count return after d/c of GP IIb/IIIa?
Eptifibatide (Integrilin) = 2-4 hours
Tirofiban (Aggrastat) = 4-8 hrs
Abciximab (ReoPro) = 24-48 hrs
Which GP IIb/IIIa binds IRREVERSIBLY to block platelet aggregation?
Abciximab (ReoPro)
Others (Eptifibatide and Tirofiban) bind reversibly
Name the drugs that make up P2Y-12 inhibitors
Clopidogrel (Plavix)
Prasugrel (Effient)
Ticagrelor (Brilinta)
Which P2Y-12 inh are prodrugs? Implication?
Clopidogrel (Plavix) and prasugrel (Effient)
IRREVERSIBLE binding
Which P2Y-12 inh is NOT a prodrug? Implication?
Ticagrelor (Brilinta)
Faster onset and offset (faster offset b/c it’s NOT a prodrug)
What’s the dosing of Clopidogrel (Plavix)?
LD - 300 to 600mg
MD - 75mg PO daily
What’s the dosing of Clopidogrel (Plavix ) for PCI?
600mg
What’s the alternative dosing for Clopidogrel (Plavix)?
LD: 600 mg
150mg daily for 6 days
Then 75 mg daily
When is no LD req for Clopidogrel (Plavix) use?
If ACS is managed medically w/o stenting
What determines effectiveness of Clopidogrel (Plavix)?
Activation to active metabolite by CYP 2C19 (Plavix is a prodrug)
Which allele is considered to be fully functional metabolism?
CYP2C19*1
*2 and *3 (have reduced functions)
C/I of all P2Y-12 inh
Active bleeding
Hx of TIA or stroke
Hx of ICH
Severe hepatic impairment
SE of both Clopidogrel (Plavix) and Prasugrel (Effient)?
Bleeding
Bruising
Rash
TTP (rare)
Which P2Y-12 inh has the higher risk for bleeding?
Clopidogrel (Plavix)
When is prasugrel (Effient) used in pts >= 75years?
Only in high risk pts eg DM and prior MI
Are P2Y-12 inh used in CABG pts?
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)
What’s the recommended aspirin dose to be used with Ticagrelor (Brilinta)?
75-100 mg daily (81mg)
> 100mg of Aspirin reduces effectiveness of ticagrelor (Brilinta)
What SE are unique to ticagrelor (Brilinta)?
Dyspnea (> 10%)
Increased Scr, Uric acid
Bradyarrhythmias
Which NSAID is used with P2Y-12 inh?
81mg aspirin
How to manage bleeding on P2Y-12 inhibitors?
Avoid d/c, if possible (stopping p2y-12 inh, esp w/in first few months after ACS increases risk of subsequent cardiovascular events)
What meds should be avoided with use of Clopidogrel?
Strong/ moderate 2C19 inhibitors
Omeprazole and Esomeprazole
What dose of simvastatin and lovastatin should be avoided with p2y-12 inh?
> 40mg
What’s the tx for STEMI?
MONA + GAP-BA + PCI or Fibrinolytic therapy
What’s the preferred tx btw PCI and fibrinolytic therapy?
PCI, if facilities are available
What’s the timeframe to perform a PCI, if the facilities exist?
Within 90 mins, (door to balloon time)
What’s the timeframe to perform fibrinolytics, if the facilities to perform PCI doesn’t exist?
30 mins (door to needle).
Guidelines find that fibrinolytics is still beneficial when given 12-24 hours
List agents that are called fibrinolytics.
Fibrinolytics RATS
Reteplase (r-PA) (Retevase)
Alteplase (t-PA, rt-PA, Activase)
Tenecteplase (TNKase)
Streptokinase (Streptase)
SE of fibrinolytics
Bleeding
Hypotension
Intracranial hemorrhage
Fever
List meds that are used for long-term medical mgt (secondary prevention MI).
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
What’s the time frame for receiving high doses of aspirin (162-325mg)?
Bare metal stent
Sirolimus-eluting stent
Paclitaxel-eluting stent
BMS - 1 month
SES - 3 months
PES - 6 months
All these then cont on low dose aspirin (81mg) indefinitely
What’s the dose and duration for P2Y-12 inh?
Plavix (Clopidogrel) - 75 mg QD
Ticagrelor - 90mg BID (for at least a month and up to 1 yr)
When do u consider using p2y-12 inh for longer than 12 months?
In pts ff drug eluting stent placement (Sirolimus or Paclitaxel)
What Grp of pts MUST have ACE-I?
EF < 40%
HTN
CKD
Diabetes
What’s the target INR for
Warfarin alone?
Warfarin + Aspirin / W + A + p2y-12 inh?
- 5-3.5
2. 0-2.5
What’s NOT recommended for pain post ACS?
NSAIDs (risk of reinfaction and death)
Gen recommendations for lifestyle post-mi?
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)
Can Clopidogrel (Plavix) be taken with food?
Can be taken with or without food
List the meds to CONTINUE when pts goes for CABG surgery?
Aspirin
UFH
When is Plavix and ticagrelor DISCONTINUED when pts goes for CABG surgery?
5 days b4
When is Prasugrel DISCONTINUED when pts goes for CABG surgery?
7 days b4
When is Eptifibatide/Tirofiban DISCONTINUED when pts goes for CABG surgery?
4 HRs b4
When is Abciximab DISCONTINUED when pts goes for CABG surgery?
12 HRs b4
When is enoxaparin DISCONTINUED when pts goes for CABG surgery?
12-24 hrs b4 …. Dose with UFH
When is fondaparinux DISCONTINUED when pts goes for CABG surgery?
24 hrs b4 …. Dose with UFH
When is bivalirudin DISCONTINUED when pts goes for CABG surgery?
3 hrs b4 …. Dose with UFH
Describe s/sx of TTP (rare SE of p2y-12 inh)
Extreme skin paleness
Purplish spots or skin patches (purpura)
Jaundice
Mental status changes
Can alcohol be drank with Plavix? Why/why not?
No
Alcohol can increase risk of bleeding
What is ACS?
ACS refers to a set of clinical disorders that result from an IMBALANCE btw myocardial oxygen demand and supply
