Acute Coronary Syndrome

Question 1

What is the difference between UA and AMI?

Answer 1

AMI has necrosis of cardiac muscle

Question 2

In UA, is vessel completely occluded?

Answer 2

Nope

Question 3

What causes a Type I MI?

Answer 3

ASCAD plaque rupture, clot formation, coronary thrombosis; SUPPLY problem

Question 4

What causes a Type 2 MI?

Answer 4

Increased O2 demand or decrease O2 supply (coronary artery spasm, embolism, anemia, arrhythmias, hypertension, hypotension)

Question 5

How long does it take for full necrosis to occur?

Answer 5

6 hours

Question 6

What is ventricular remodeling?

Answer 6

Scarring in heart after MI–doesn’t function as well

Question 7

What agent can reduce scarring post-MI?

Answer 7

ACE Inhibitor!

Question 8

What are the symptoms of ACS?

Answer 8

Chest pain at rest for more than 20 minutes
Feels like angina
Also: N/V, diaphoresis, SOB, impending doom

Question 9

How long do you have to do ECG after MI/

Answer 9

Within 10 minutes of presentation

Question 10

In STEMI, ST is ____ and ___ wave appears

Answer 10

ST is elevated; Q wave appears

Question 11

What are the cardiac enzymes that indicate MI?

Answer 11

Troponin T and Troponin I–elevation corresponds with size of MI

Question 12

When should Cardiac Troponin be measured?

Answer 12

In ED and 3-6 hours after symptoms (and maybe later)

Question 13

What are the TIMI Risk factors?

Answer 13

Age > 65
3 or more risk factors
Known CAD
>2 episodes of chest discomfort within 24 hours
>0.5 mm ST-segment depression
\+ biochemical marker

Question 14

What does the TIMI score mean?

Answer 14

0-2: Low
3-4: Medium
5-7: High

Question 15

What is the difference between Unstable angina, NSTEMI, and STEMI?

Answer 15

UA: maybe relieved by NTG; No ECG unusualy; negative cardiac markers
NSTEMI: Not usually relieved by NTG; no STE, rarely Q waves; POSITIVE cardiac markers
STEMI: Not usually relieved by NTG; STE; Q waves present; POSITIVE cardiac markers

Question 16

How are all ACS’s treated initially?

Answer 16

MONA!
Morphine
Oxygen
Nitrates
Aspirin

Question 17

Dosing for Morphine in ACS?

Answer 17

2-4 mg IV q5-30 minutes

Question 18

When do you give oxygen?

Answer 18

if O2 sat <90%

Question 19

When do you NOT use nitrates?

• SBP:
• ___ change from baseline
• HR between __ and __
• Use of ___ within 24-48 hours

Answer 19

• SBP <90
• 30 mmHg change from baseline
• HR between 50-100 bpm
• Use of PDEIs within 24-48 hours

Question 20

How often to monitor BP and HR when using nitrates?

Answer 20

q2h

Question 21

Dose of IV nitrates during ACS?

Answer 21

5-10 mcg/min titrated to 75-100 mcg/min (for symptom relief or limiting side effects)

Question 22

Which class of meds should NOT be used for pain management during MI?

Answer 22

NSAIDs!!! (APAP, morphine sulfate, NTGs a-okay!)

Question 23

What drug classes are used to treat STEMI w/PCI (after MONA therapy)?

Answer 23

• Antiplatelets (P2Y12 inhibitors or GPIIb/IIIa)

- Anticoagulants

Question 24

Which antiplatelets are used for STEMI w/PCI?

Answer 24

Clopidogrel, Prasugrel, or ticagrelor

Prasugrel or ticagrelor preferred

Question 25

When is prasugrel contraindicated??

Answer 25

History of TIA/stroke

Question 26

When are all P2Y12 inhibitors contraindicated?

Answer 26

History of hemorrhagic stroke Concurrent use of anticoagulants Moderate-severe liver disease

Question 27

When is prasugrel used w/extreme caution?

Answer 27

Pts under 60 kg | Pts older than 75 years

Question 28

How long are P2Y12 inhibitors used after STEMI w/PCI?

Answer 28

12 months

Question 29

How long before elective CABG should prasugrel b d/ced?

Answer 29

7 days

Question 30

How long before elective CABG should clopidogrel and ticagrelor be d/ced?

Answer 30

5 days

Question 31

What are the GPIIb/IIIa inhibitors?

Answer 31

Eptifibitide Abciximab Tirofiban

Question 32

What are Contraindications to GPIIb/IIIa Inhibitors?

Answer 32

-Internal bleeding, major surgery, stroke w/in 30 days -Hx of hemorrhagic stroke -Intracranial neoplasm, AV malformation Acute pericarditis Uncontrolled HTN THROMBOCYTOPENIA

Question 33

Which of the anticoags is administered as a bolus only?

Answer 33

Enoxaparin

Question 34

What anticoags are used for STEMi w/PCI?

Answer 34

Bivalirudin Enoxaparin Heparin

Question 35

When are fibrinolytics used for medical reperfusion?

Answer 35

When patients can't be transferred and treated within 120 minutes (PCI)

Question 36

How does fibrinolytic therapy work (MoA)?

Answer 36

It activates plasminogen to plasmin, which dissolves fibrin clots

Question 37

What is the dosing for reteplase?

Answer 37

10 units IV then 10 units IV 30 minutes later

Question 38

What is the dosing for alteplase?

Answer 38

15 mg bolus, then 0.75 mg/kg over 30 minutes, then 0.5 mg/kg over 1 hour

Question 39

What is the dosing for tenecteplase?

Answer 39

``` <60 kg: 30 mg IV 60-69.9 kg: 35 mg IV 70-79.9 kg: 40 mg IV 80-89.9 kg: 45 mg IV >90 kg: 50 mg IV ```

Question 40

What are the contraindications to fibrinolytics?

Answer 40

- Malignant IC neoplasm - Active bleeding - Severe uncontrolled HTN - TIA w/in 3 months - Facial trauma or head trauma w/in 3 months - Aortic dissection - Cerebral vascular lesion - Hemorrhagic stroke - SK: not used within 6 months, or previous allergy

Question 41

What are MPs for fibrinolytics?

Answer 41

- Evidence for reperfusion (symptoms relief, ECG normalizing, Reperfusion arrhythmia possible) - Signs of bleeding - Baseline CBC, platelet count, INR/aPTT - Mental status changes q2h

Question 42

What antiplatelets are used for STEMI w/out PCI?

Answer 42

ASA & clopidogrel (300 mg LD on day 1)

Question 43

How long to administer DAPT after STEMI w/out PCI?

Answer 43

14 days to 1 year

Question 44

What anticoags are used for STEMI w/out PCI?

Answer 44

Heparin LMWH (enoxaparin) fondaparinux

Question 45

How long should anticoag therapy last for STEMi w/out PCI?

Answer 45

2-8 days

Question 46

What is the maximum dose for heparin?

Answer 46

Bolus: 4000 units Infusion: 1000 units/hr

Question 47

What is the rate of infusion for heparin dose?

Answer 47

12 units/kg /hr

Question 48

What is the bolus dose of heparin?

Answer 48

60 units/kg

Question 49

How is enoxaparin dosed?

Answer 49

30 mg IV bolus | 1 mg/kg SC q12h

Question 50

How long should Beta-blockers be used?

Answer 50

3 years

Question 51

How long should beta-blockers be used if LEF <40%?

Answer 51

still 3 years?

Question 52

How does Beta blocker help after MI/

Answer 52

Limits myocardial damage and mortality; reduces risk of reinfarction, makes it harder to develop V fib

Question 53

When should IV Beta-blocker not be used?

Answer 53

Unstable blood pressure (low)

Question 54

When should IV beta-blocker be used?

Answer 54

High blood pressure

Question 55

Which patients benefit the most from ACEI therapy post-MI/

Answer 55

Pts with DM, CKD, LVEF <40

Question 56

Should ACEI be given IV or oral?

Answer 56

ORAL - not IV within 24 hours

Question 57

How long is ACEI used if LVEF <40%?

Answer 57

forever

Question 58

What patients may benefit from aldosterone antagonists?

Answer 58

LVEF <40% w/HF symptoms or diabetes

Question 59

When is aldosterone antagonist contraindicated?

Answer 59

Cr >2.5 in men or >2 in women | K >5 mEq/L

Question 60

Which antiplatelets are used for UA/NSTEMI?

Answer 60

Clopidogrel or ticagrelor

Question 61

Which anticoags are used for UA/NSTEMI with PCI?

Answer 61

Heparin Bivalirudin LMWH Fondaparinux

Question 62

Which anticoags are used for UA/NSTEMI w/out pCI?

Answer 62

Heparin LMWH fondaparinux

Question 63

When should fondaparinux be avoided?

Answer 63

CrCl <30mL/min