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Clinical Pharmacy 2 > Acute Coronary Syndrome Part 1 > Flashcards

Acute Coronary Syndrome Part 1 Flashcards

1
Q

What is the difference between NSTEMI and STEMI

A
  • stemi: there is completely occlusion of the artery

- nstemi: lumen is occluded only partly- there is still some coronary blood flow

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2
Q

What is the difference between the thrombus is the NSTEMI and STEMI?

A

stemi: full blown coagulation pathway and see a lot of fibrin here
nstemi: mainly platelets in the thrombus

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3
Q

______ is an enzyme that is released when there is myocardial necrosis

A

troponin

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4
Q

Where is the worst place to have an occlusion in the heart? Why is this?

A
  • left main coronary artery

- this is the worst place because there is a large amount of downstream blockage

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5
Q

Describe a STEMI

A
  • most severe type of ischema in the pathophysiologic continuum of the acute coronary artery syndrome
  • caused by complete occlusion of a coronary artery by clot (rupture of atherosclerotic plaque)
  • STEMI comprises approx. 25-40% of MI presentations
  • in hospital mortality rates are 4.6% vs 2.2% for patients with STEMI and NTEMI, respectively
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6
Q

What are the classic presenting symptoms of coronary artery syndrome?

A
  • central chest paon (typically radiating to shoulder, down the left arm, to the back or the jaw); may be accompanied by SOB, n/v, diaphoresis
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7
Q

What are the symptoms associated with silent type MIs?

A
  • no chest pain or discomfort
  • more often here they describe SOB, indigestion or diaphoresis, other sx like fatigue, faintness, dizziness, light-headedness, anxiety and palpitation
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8
Q

What demographic groups are less likely to have classic symptom presentation?

A
  • elderly, diabetic patients and women
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9
Q

What are the major SIGNS of acute coronary syndrome?

A
  • syncope
  • bradycardia (inferior infarction), tachycardia (increased sympathetic activity, decreased cardiac output), other arrhythmias
  • elevated or low BP
  • diffuse rales, wheezing or respiratory distress usually indicate pulmonary oedema and CHF
  • jugular venous distention indicates right atrial hypertension, usually from RV infarction or elevated LV filling pressure
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10
Q

What are the 2 enzymes that are released into the circulation when cardiac cells are damaged?

A
  • creatinine kinase

- troponins

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11
Q

What can be expected from CK (creatinine kinase) levels after an MI?

A
  • these should be detectable in the serum within 3-5 hours after an MI, peaks in 12-24 hours, stays elevated for 2-3 days
  • this can be elevated in other non-ACS conditions (e.g. pericarditis, myocarditis, rhabdomyolysis, renal failure)
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12
Q

What is the preferred biomarker for detecting an acute coronary syndrome?

A
  • troponins
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13
Q

What can be expected from troponin levels after a coronary artery syndrome?

A
  • troponin T appears in serum within 4-12 hours after an MI onset peaks in 12-48 hours, and stays elevated for 7-10 days
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14
Q

When should biomarker essays be done after an MI?

A
  • should be done stat on presentation, then should be redone every 4-6 hours for the first 12-24 hours, then periodically
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15
Q

What needs to be seen on lab tests for the diagnosis of a STEMI or an NSTEMI?

A
  • at least 2 elevated CK-MB or 1 TnT exceeding the upper reference range is needed (usually 2 successive blood samples)
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16
Q

What are the advantages of an ECG?

A
  • get results immediately
  • can be very indicative of if patient is having a STEMI or something else
  • will give the location of the infarct
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17
Q

What signs on an ECG can be indicative of a STEMI?

A

ST elevation

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18
Q

What signs on an ECG can be indicative of a NSTEMI?

A

ST depression

T wave inversion

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19
Q

What is the main initial management of acute coronary syndrome? (4 things)

A
  1. oxygen at 4 L/min by nasal prong to maintain O2 saturation >90% (preferably 95%)
  2. ASA 162-325 mg po chew/shallow (if not already given by EMS)
  3. Nitroglycerin SL or IV
  4. Morphine 2-5 mg IV q5-30 min prn (could use other analgesics such as fentanyl) -if pain not relieved by nitro

can be described as MONA

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20
Q

What is the main priority in STEMI?

A
  • priority is to quickly reestablish blood flow to the occluded artery as quickly as possible (need to enhance perfusion)
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21
Q

What is the main priority in STEMI?

A
  • priority is to quickly reestablish blood flow to the occluded artery as quickly as possible (need to enhance perfusion)
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22
Q

What are the 2 types of reperfusion strategies in STEMI?

A
  1. primary percutaneous coronary intervention (PCI)

2. Fibronolytics (in STEMI, the thrombus is heavily laced with fibrin)

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23
Q

What are the goals of therapy in reperfusion?

A
  • decrease mortality and complications
  • reduce or contain infarct size
  • salvage functioning myocardium and prevent remodelling
  • re-establish potency of the infarct-related artery (clear occlusion, reestablish flow of coronary blood)
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24
Q

What is the recommended method of reperfusion?

A
  • primary PCI (when it can be performed in a timely fashion)
  • ideal medical contact to device time of <90 minutes should be targeted for primary PCI
  • if fibrinolytic therapy is chosen as the reperfusion strategy, it should be administered within 30 minutes of hospital arrival
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25
Q

Describe the process of a primary PCI?

A
  • diagnostic catheter is placed and advanced through the femoral artery to the aorta and the coronary arteries
  • contrast dye is injected once the catheter is in place. X-rays are taken to locate the exact location of coronary occlusion
  • a balloon catheter (with or without a stent mounted) is advanced to the blockage site. Once at the site, the balloon is inflated for a few seconds to open the blocked coronary
  • the stents are left in place to keep the coronary vessel open
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26
Q

How long should someone be on anti-platelet therapy after a PCI?

A
  • should be on anti-platelet therapy for a minimum of 1 year after a PCI
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27
Q

What is the TIMI grade flow? What TIMI blood flow do we want to achieve?

A
  • adopted scoring system from 0-3 referring to the level of coronary blood flow assessed during a PCI
  • we want to achieve TIMI 3 blood flow for complete perfusion
28
Q

What is the TIMI grade flow? What TIMI blood flow do we want to achieve?

A
  • adopted scoring system from 0-3 referring to the level of coronary blood flow assessed during a PCI
  • we want to achieve TIMI 3 blood flow for complete perfusion
29
Q

Angioplasty without _____ is rarely used in the setting of the ACS now

A

stenting

—- PCI procedures almost always involve a bare metal send or a drug eluting stent

30
Q

What is a drug eluting stent and why is it most commonly used?

A
  • a stent that has anti proliferative drugs coating on the stent scaffold, which is released slowly over time to prevent restenosis
  • — body will naturally want to endotheliaze around the stent- this is why drug coating is important
31
Q

Patients who ave received a DES will require dual-antiplatelet therapy for a minimum of _____

A

1 year

32
Q

What is the timeframe that fibrinolytics need to be given for the greatest mortality benefit

A

needs to be given within 0-2 hours (target time of 30 minutes)

33
Q

Why are fibrinolytics not administered to NATEMI/UA patients?

A
  • this goes back to the pathology of clotting- in STEMI there is a big thrombus made up of heavy fibrin, which is not found in NSTEMI/UA
  • fibrinolytic add risk of bleeding and is not worth this risk in anything but STEMI
34
Q

What fibrinolytic should be given due to its high specificity?

A
  • tenecteplase when possible should be given as a single IV bolus for 5 seconds
35
Q

What are the main benefits of giving tenecteplase over over fibrinolytics?

A
  • there are 20% fewer major non-cerebral bleeds
  • little effect on blood pressure
  • most fibrin-specfic agent
36
Q

What are the absolute contraindications to fibrolytics?

A
  • any prior ICH
  • known structural cerebral vascular lesion
  • known malignant intracranial neoplasm
  • ischemic stroke within 3 months
  • suspected aortic dissection
  • active bleeding
  • significant closed head or facial trauma within 3 months
  • severe uncontrolled hypertension
  • for streptokinase, prior treatment within the previous 6 months
37
Q

______ are the cornerstone therapy in STEMI management

A

antithrombotics (anti platelets and anticoagulants)

38
Q

When is the use of heparin appropriate for use in ACS with someone ?

A
  • usually initiated on presentation and discontinued after PCI
39
Q

What should be given to STEMI patients undergoing primary PCI?

A
  • ASA 162-325 mg po should be given before PCI PLUS
    a loading dose of a P2Y12 receptor inhibitor as early as possible before PCI
    — clopridogrel 600 mg, prasugrel 60 mg or ticagrelor 180 mg —- ticagrelor is the 1st recommended
40
Q

How long should a P2Y12 inhibitor be used after ACS?

A
  • should be used for the minimum of 1 year (can be used even more though)
41
Q

What antithrombotics are appropriate to use in STEMI patients receiving fibrinolytics?

A
  • ASA 162-325 mg po should be given on presentation PLUS

- clopridogrel loading dose along with clopridogrel 75 mg po daily for 14 days

42
Q

What is the appropriate use of heparin in STEMI patients receiving fibrinolytics?

A
  • LMWH or UFH should be initiated at the time of fibrinolysis and continued for a minimum of 48 hours and up to 8 days (or until revascularization)
43
Q

What is enoxaprin?

A
  • most commonly used LMWH
44
Q

What heparin needs to be monitored more regularly?

A

LMWH needs to be monitored more often

- UFH should be used in those that we are not sure of their dose and in renal impairment and the obese

45
Q

Should enoxaprin always be given as an IV bolus?

A
  • NO

- it should only be given as a bolus dose in STEMI patients under the age of 75

46
Q

When is the use of heparin indicated in patients?

A
  • should be used in patients >149 kg (little evidence to support LMWH in these patients)
  • used for those with renal impairment, CrCl <30 mL/min
47
Q

Clinical trials suggest better efficacy profile with what combination of drugs when compared to ASA+clopridogrel in patients with STEMI undergoing primary PCI

A

ASA and prasugrel

ASA and ticagrelor

48
Q

Prasugrel should not be used in what patients?

A

in those with a history of stroke or TIA due to higher rates of major bleeding in these populations

49
Q

Triple therapy of _______ may be indicated in STEMI patients with low ejection fraction or if the patient has a concurrent AF

A

DAPT and warfarin

50
Q

What needs to be monitored in a patient after repercussion therapy is done?

A

Need to monitor for EFFICACY
- signs and sx of ongoing chest pain, ECG changes, serial monitoring of biomarkers
- stent thrombosis
- complications: arrhythmias, HF, pericarditis
Need to monitor for SAFETY
- major and minor bleeding complications
- clinical signs of bleeding include bloody stools, melon, hematuria, hematemesis, bruising, and oozing from arterial or venous puncture sites

51
Q

What are some of the main complications associated with a STEMI?

A
  1. Heart failure
  2. Cardiogenic shock
  3. Arrhythmias
  4. Pericarditis
52
Q

What causes heart failure after an MI?

A
  • LV myocardium may be ischemic, stunned, hibernating or irrevocably injured after MI
53
Q

What is used to assess LV ejection fraction?

A

echocardiography

- intervention is required in those with a LVEF <40%

54
Q

What causes cariogenic shock after an MI?

A
  • decreased cardiac output and evidence of tissue hypoxia in presence of adequate intravascular volume
  • this is often due to an extensive LV infarction
  • can also be due to systolic, diastolic and valvular dysfunction
  • incidence ~10% of hospitalized STEMI patients
55
Q

What causes an arrhythmia to arise post MI?

A
  • due to ischemia and severe HF
  • there will be some rhythm changes as you are re-gaining oxygen to myocardium
  • ventricular arrhythmias are more probable in the peri-infarction period
56
Q

What is the role that beta blockers will play post MI?

A
  • increase myocardial salvage in the infarct area
  • prevent extension of infarction by reducing oxygen consumption/demand
  • decrease cardiovascular mortality, recurrent nonfatal MI and all-cause mortality
57
Q

When are beta blockers indicated after an MI?

A
  • should be initiated within 24 hours post MI
58
Q

What is the goal HR when giving a beta blocker post MI?

A

55-60 bpm

59
Q

What are the contraindications to beta blockers?

A
  • hypotension (systolic BP <90)
  • bradycardia (HR <50 bp)
  • acute HF
  • cardiogenic shock
  • asthma
  • 2nd or 3rd degree AV block
60
Q

What is the role of a ACEI after an event?

A
  • minimize ventricular remodeling
  • reduce oxygen demand and myocardial wall stress by reducing after load or preload
  • reduction in cardiovascular mortality and morbidity
61
Q

The benefit of and ACEI is greatest in what population?

A
  • anterior infarction, HF (LVEF <40%), patients with diabetes or CKD
  • should be initiated win 24 hours of an MI once BP is stabilized
62
Q

What groups are ACEIs CI’ed in?

A
  • in those with renal impairment and hyperkalemia
63
Q

What is important to monitor for with an ACEI?

A
  • SCr, electrolytes, watch for hyperkalemia (K>5.5) especial with concurrent spironolactone
64
Q

What is evolovumab?

A
  • its a monoclonal antibody (biologic) that inhibitrs PCSK9 - lowers the LDL
65
Q

When would an aldosterone antagonist like spironolactone be used?

A
  • may be indicated if the patient has severe LV dysfunction (EF <40%)
66
Q

When would aldosterone antagonists be contraindicated in patients?

A

caution in patients with CrCl <30 ml/min and K 5 mEq

- check the potassium at baseline and within 1 week of initiation

67
Q

What are some of the non-pharamcological things that can be done to help patients manage after ACS?

A
  • cardiac rehab program
  • weight management (BMI 18.5-25, waist circumference, goal of 5-10% weight reduction)
  • physical exercise (goal of 30-60 minutes of moderate activity)
  • implantable cardioverter/defibrillator assessment for patients with ongoing LV dysfunction
  • depression screening/stress management

Clinical Pharmacy 2 (18 decks)

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