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Cardio 1228 > Acute Coronary Syndrome (edited) > Flashcards

Acute Coronary Syndrome (edited) Flashcards

1
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 (reduced blood flow)-> compromising proper cardiac functioning may lead to cardiac muscle cell death (myocyte necrosis)

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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>=10 min
  • SOB-severe dyspnea
  • diaphoresis
  • syncope/pre-syncope
  • palpitations
  • Pain can radiate to arms, back, neck, jaw, or epigastric (females, diabetic, elderly may not experience classic symptoms)
  • Pain usually not relieved by nitroglycerin sublingual tablets/ spray/ rest - if not relieved after 1st dose or worse 5 minutes after dose (Call 911)
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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) capability

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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
dyslipidemia
Diabetes
Chronic angina
Known coronary artery dx
lack of exercise
excessive alcohol
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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 (neg troponin I & T TnI, TnT)

None or transient ECG changes(ST depression or T inversion)

=partial blockage

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12
Q

Diagnosis of NSTEMI

A

Chest pain

POSITIVE cardiac enzymes (Troponins, CK-MB-creatine kinase myocardial enzyme-less sensitive markers-might be monitored though)

None or transient ECG changes(ST depression or T inversion)
=partial blockage

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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)

=complete blockage

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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-prevent MI expansion
  • prevent death
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17
Q

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

A

MONA (given prn)

Morphine- decreases O2 demand=pain relief

Oxygen when SaO2<90% on room air

Nitroglycerin-decrease O2 demand IV for persistent pain

Aspirin- inhibits platelet agg (non-enteric chewable 162-325 immediately; maintenance 81-162 indefinitely)

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18
Q

What meds may be given in select pts?

A

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

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19
Q

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

A

Beta blocker w/o ISA (unless low output state, cariogenic shock risk, or HR<45; if HFrEF- use bis, carve, metoprolol succ)

+ ACE I

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20
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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21
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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22
Q

What’s the tx for UA and NSTEMI?

A

UA/NSTEMI: MONA + GAP-BA +/- PCI
STEMI: MONA + GAP-BA + PCI or Fibrinolytic

Morphine
Oxygen
Nitrates
Aspirin

GP IIb/IIIa receptor antagonists (Tirofiban-P, Eptifibatide, Abciximab) TEA
Anti-coagulants: heparin, LMWH (Enoxaparin, Dalteparin, fondaparinux) bivalirudin are preferred in STEMI
P2Y-12 inhibitors: prasugrel - if pt is going for PCI; Ticagrelor or clopidogrel - med management +/- PCI

Beta blockers
ACE-I

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23
Q

MOA of morphine used in ACS?

A

Arterial and venous DILATION -> reduction in myocardial O2 demand

Pain relief

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24
Q

Dosing of morphine

A

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

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25
Q

Antidote of Morphine

A

Naloxone (Narcan)

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26
Q

When should supplement oxygen be admin in ACS?

A

SaO2 < 90%

OR

Respiratory distress

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27
Q

MOA of nitrates

A

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

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28
Q

Dose of nitrates

A

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

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29
Q

What’s the indication for NTG IV?

A

Relief of ongoing ischemia discomfort
HTN
Mgt of pulmonary congestion

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30
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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31
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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32
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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33
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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34
Q

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

A

Clopidogrel (Plavix)

Prasugrel (Effient)

Ticagrelor (Brilinta)

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35
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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36
Q

What agents make up GP IIa/IIIb?

A

TEA

Tirofiban (Aggrastat)

Eptifibatide (Integrilin)

Abciximab (ReoPro)

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37
Q

Uses of GP IIa/IIIb rec antagonists?

A

Medical mgt or those going for PCI +/- stent

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38
Q

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

A

Abciximab

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39
Q

What agents make up P2Y-12 inh?

A

Clopidogrel (Plavix)

Prasugrel (Effient)

Ticagrelor (Brillinta)

Cangrelor (Kangreal)

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40
Q

Which P2Y-12 inh are used for ONLY if undergoing PCI?

A

Prasugrel

Cangrelor-only if P2Y12 naive and not getting GP IIb/IIIa inhibitor

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41
Q

MOA of beta blockers?

A

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

May reduce the magnitude of infarction

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42
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

brady (HR<45)

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43
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

44
Q

MOA of ACE-I?

A

Inh ACE and blocks pdt of Angiotensin II

Prevents cardiac remodeling

Reduce preload and afterload

45
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)

46
Q

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

A

Due to risk of hypotension

47
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)

48
Q

List the agents that make up GP IIb/IIIa

A

Tirofiban (Aggrastat)

Eptifibatide (Integrilin)

Abciximab (ReoPro)

49
Q

What’s the brand name of Abciximab?

A

ReoPro

50
Q

What’s the brand name of Eptifibatide?

A

Integrilin

51
Q

What’s the brand name of Tirofiban?

A

Aggrastat

52
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) surgery

Increased Prothrombin time (PT)

Hx of stroke (2yrs Reopro, 30days Integrillin)

Severe uncontrolled HTN

53
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) hx of stroke w/in 30 DAYS OR any hx of hemorrhagic stroke
Tirofiban (Aggrastat) any stroke hx

54
Q

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

A

Hypersensitivity to murine proteins

55
Q

Name the main SE of GP IIb/IIIa

A

Bleeding, Thrombocytopenia (both highest in Reopro)

Hypotension

56
Q

Name monitoring parameters for GP IIb/IIIa

A

Hgb

Hct

Platelets

S/sx of bleeding

Scr

57
Q

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

A

Abciximab (ReoPro)

58
Q

What’s peculiar about Abciximab (ReoPro)?

A

Must filter with administration

59
Q

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

A

Eptifibatide (Integrilin), Tirofiban (Aggrastat) = 4-8 hours

Abciximab (ReoPro) = 24-48 hrs

60
Q

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

A

Abciximab (ReoPro)

Others (Eptifibatide and Tirofiban) bind reversibly

61
Q

Name the drugs that make up P2Y-12 inhibitors

A

Clopidogrel (Plavix)

Prasugrel (Effient)

Ticagrelor (Brilinta)

cangrelor (Kengreal)

62
Q

Which P2Y-12 inh are prodrugs? Implication?

A

Clopidogrel (Plavix) and prasugrel (Effient)
Both are prodrugs- classified as thienopyradines
IRREVERSIBLE binding

63
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)

64
Q

What’s the dosing of Clopidogrel (Plavix)?

A

Loading D - 300 to 600mg

MD - 75mg PO daily

65
Q

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

A

600mg

66
Q

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

A

STEMI treated with fibrinolytic in pt>75 yrs

67
Q

What determines effectiveness of Clopidogrel (Plavix)?

A

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

avoid with omeprazole & esomeprazole

68
Q

Which allele is considered to be fully functional metabolism?

A

CYP2C19*1

*2 and *3 (have reduced functions)

69
Q

C/I of all P2Y-12 inh

A

Active bleeding-all

Hx of TIA or stroke-prasugrel

Severe hepatic impairment-ticagrelor

70
Q

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

A

Bleeding-more with prasugrel

Bruising

Rash

TTP (rare)-clopidogrel

71
Q

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

A

Prasugrel (Effient)

72
Q

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

A

Only in high risk pts (DM and prior MI)

73
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)
cangrelor effects gone 1 hr after D/C

74
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) and should be avoided

75
Q

What SE are unique to ticagrelor (Brilinta)?

A

Dyspnea (> 10%)

Increased Scr, Uric acid (hyperuricemia)

76
Q

Which NSAID is used with P2Y-12 inh?

A

81mg aspirin

77
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)

However be careful because there is no antidote for P2Y12 inhibitors

78
Q

What meds should be avoided with use of Clopidogrel?

A

Strong/ moderate 2C19 inhibitors

Omeprazole and Esomeprazole

79
Q

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

A

> 40mg

80
Q

What’s the tx for STEMI?

A

MONA + GAP-BA + PCI or Fibrinolytic therapy

81
Q

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

A

PCI, if facilities are available

82
Q

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

A

Within 90 mins, (door to balloon time)

83
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

84
Q

List agents that are called fibrinolytics.

A

Fibrinolytics RAT- only given for STEMI when PCI can’t be done within 120 minutes of 1st medical contact

Reteplase (r-PA) (Retevase)

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

Tenecteplase (TNKase)

Fibrinolytics should be given 30 minutes of hospital arrival (door to needle)

85
Q

SE of fibrinolytics

A

Bleeding

Hypotension

Intracranial hemorrhage

86
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

87
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

88
Q

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

A 
Med Manage: Take for at least 12 months
Plavix (Clopidogrel) - 75 mg QD
OR
Ticagrelor - 90mg BID
\+ 81mg aspirin 
PCI: Take for at least 12 months
clopidogrel OR ticagrelor OR prasugrel
\+81 mg aspirin
89
Q

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

A

Handling DAPT, not at high risk of bleeding, AND had coronary stent placed

90
Q

What Grp of pts MUST have ACE-I?

A

EF < 40%

HTN

CKD

Diabetes

91
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

92
Q

What’s NOT recommended for pain post ACS?

A

NSAIDs (risk of reinfarction and death)
Use tylenol, nonacetylated salicylates, tramadol, or low dose narcotics first. If not sufficient…naproxen has lowest CV risk

93
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)

94
Q

Can Clopidogrel (Plavix) be taken with food?

A

Can be taken with or without food

95
Q

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

A

Aspirin

UFH

96
Q

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

A

5 days b4

97
Q

When is Prasugrel DISCONTINUED when pts goes for CABG surgery?

A

7 days b4

98
Q

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

A

4 HRs b4

99
Q

When is Abciximab DISCONTINUED when pts goes for CABG surgery?

A

12 HRs b4

100
Q

When is enoxaparin DISCONTINUED when pts goes for CABG surgery?

A

12-24 hrs b4 …. Dose with UFH

101
Q

When is fondaparinux DISCONTINUED when pts goes for CABG surgery?

A

24 hrs b4 …. Dose with UFH

102
Q

When is bivalirudin DISCONTINUED when pts goes for CABG surgery?

A

3 hrs b4 …. Dose with UFH

103
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

104
Q

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

A

No

Alcohol can increase risk of bleeding

105
Q

What is ACS?

A

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

106
Q

cangrelor transition

A

cangrelor given bolus prior to PCI, then infused for 2 hrs or duration of procedure (whichever is longer)

  • -> ticagrelor 180mg given during o immediately after stopping cangrelor infusion
  • ->prasugrel 60mg or clopidogrel 600mg given immediately AFTER stopping cangrelor infusion (DO NOT give prior to stopping)
107
Q

vorapaxar

A

Zontivity

Protease activated receptor 1 antagonist (PAR-1)
Reversibly binds PAR1 receptor on platelets (long t1/2 makes it essentially irreversible)

indicated to reduce thrombotic CV events in pts with MI Hx or PAD

In trials it was used in combo with clopidogrel and/or aspirin but it is not yet incorporatedinto clinical guidelines

Cardio 1228 (17 decks)

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