Acute Coronary Syndrome Part 2

Question 1

What different life factors give points in the TIMI risk scores?

Answer 1

• over 65 y/o
• more than 3 risk factors for CAD
• prior coronary stenosis
• > 50% ST deviation on an ECG
• more than 2 anginal events in prior 24 hours
• use of aspirin in prior 7 days
• elevated cardiac biomarkers

Question 2

What are some other high risk factors for ACS?

Answer 2

• hemodynamic instability
• refractory angina
• recurrent angina or ischemia at rest
• signs and symptoms of HF
• sustained VT
• ECG changes (new ST depression)
• prior PCI/CABG

Question 3

What patients are generally referred for a CABG?

Answer 3

• high risk patients with multi-vessel disease may be referred for a CABG (hold DAPT 5-7 days prior to surgery if possible)

Question 4

When is an angiography/PCI revascularization indicated in patients?

Answer 4

for high risk patients with a TIMI risk score of >2, or in the presence of other high risk characteristics

Question 5

UN/STEMI patients who underwent early invasive strategy with PCI should receive what?

Answer 5

• DAPT (as would a STEMI patient receive)

Question 6

How long should DAPT therapy be recommended in all ACS patients?

Answer 6

• recommend DAPT therapy for 1 year in all ACS patients

over 1 year therapy is controversial

Question 7

How long should DAPT therapy be recommended in all ACS patients?

Answer 7

• recommend DAPT therapy for 1 year in all ACS patients

over 1 year therapy is controversial

Question 8

If a patient is at very high risk of having another infarction, what should be used: clopridogrel or ticagrelor?

Answer 8

• ticagrelor

there is a reduction in endpoint death from CV causes, nonfatal MI or stroke in the ticagrelor group

Question 9

What are GP IIb/IIIa inhibitors?

Answer 9

they are potent anti-platelet agents

Question 10

Describe the action of GP IIb/IIIa agents?

Answer 10

• they block the binding of fibrinogen to GP IIb/IIIa receptors on the platelet surface, therefore inhibiting platelet aggregation

Question 11

What are examples of the GP IIIb/IIIa receptor antagonists?

Answer 11

• abciximab, epifibatide, tirofiban

Question 12

When do GP IIb/IIIa inhibitors have benefit?

Answer 12

• they have demonstrated benefit in reducing death/MI in patients who have undergone PCI (early invasive strategy)

Question 13

What anticoagulant is the standard to give?

Answer 13

• LMWH is the standard to give in patients (long acting and has renal elimination however- disadvantage)

Question 14

What needs to be monitored in patients receiving anticoagulant therapy?

Answer 14

• need to monitor signs of bleeding, Hbg and platelets

Question 15

What is the action of fondaparinux?

Answer 15

• indirect acting factor Xa inhibitor

- we do not usually give this unless the person is at a very high risk of bleeding

Question 16

What are the goal of adding adjunct therapy to anticoagulants?

Answer 16

• reduce the risk short term and long term complications associated with ACS
• slow the progression of coronary heart disease and minimize the risk of future cardiovascular events and other morbidities
• improve mortality and quality of life

Question 17

What medications generally have to be used for life after an MI?

Answer 17

• ASA, ticagrelor/clopridogrel and ACE inhibitors are all for life

Question 18

How long do beta blockers need to be taken after an event?

Answer 18

• for 3-4 years

Question 19

What 4 medications should be started before a person leaves the hospital for long term risk reduction?

Answer 19

• ASA, beta blockers, statins, ACEI (all 4 provide a cumulative risk reduction of 75%)

Question 20

What is the role of omega-3 fatty acids in risk reduction?

Answer 20

• unclear if omega 3 fats alter the total mortality, combined cardiovascular events or cancers in people with, or at high risk of, cardiovascular disease or in the general population

Question 21

What vitamins/supplements are NOT recommended in preventing heart disease

Answer 21

• vitamins A,C,E and beta caroteine

- folic acid either alone or in combination with vitamin B6 or vitamin B12

Question 22

Hormone therapy is not recommended in post menopausal women post MI because of what?

Answer 22

• they may increase CV risk

Question 23

What else should be avoided post MI?

Answer 23

• NSAIDs, including selective COX2 inhibitors should be avoided if possible

Question 24

What medication should be avoided in those that are active, ongoing users of cocaine or methamphetamine?

Answer 24

• beta blockers (should be avoided due to the risk of potentiating coronary spasm)