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Naplex > Acute Coronary Syndromes > Flashcards

Acute Coronary Syndromes Flashcards

1
Q

What is ACS?

A

•Plague buildup in the coronary arteries (coronary atherosclerosis)
•Plague can rupture, leading to clot (thrombus) and sudden, reduced blood flow (ischemia)
•This causes imbalance between myocardial oxygen supply and demand

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2
Q

Risk Factors

A

•Age: men >45 years, women >55 years (or early hysterectomy
•Family hx: 1st degree relative with coronary event before 55 years (men) or 65 years (women)
•Smoking
•HTN
•Known coronary artery disease
•Dyslipidemia
•Diabetes
•Chronic angina
•Lack of exercise
•Excessive alcohol

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3
Q

S/Sx

A

*Chest pain (pressure, squeezing) lasting >=10 min
*Severe dyspnea, diaphoresis
*Chest pain can radiate to the arms, back, neck, jaw or epigastric region

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4
Q

Diagnosis

A
  • Non-segment elevation acute coronary syndromes (NSTE-ACS)
    • Unstable angina (UA)
    • non-ST segment elevation MI (NSTEMI)
  • ST-segment elevation myocardial infarction (STEMI)
  • 12-lead ECG (first medical contact)
  • Patients should be transported to a hospital with percutaneous coronary intervention (PCI) capability
  • Cardiac troponins I and T (TnI/TnT) are the most sensitive cardiac enzymes;
    • obtained at presentation and 3-6 hrs after symptom onset in all patients with ACS symptoms
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5
Q

Compare UA, NSTEMI, STEMI

A
  • UA
    *Symptoms: chest pain
    *Cardiac enzymes: negative
    *ECG changes: none or transient ischemic changes
    *Blockage: partial
  • NSTEMI
    *Symptoms: chest pain
    *Cardiac enzymes: positive
    *ECG changes: none or transient ischemic changes
    *Blockage: partial
  • STEMI
    *Symptoms: chest pain
    *Cardiac enzymes: positive
    *ECG changes: ST segment elevation
    *Blockage: complete
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6
Q

Drug Treatment

A
  • NSTE-ACS
    *Medications alone or PCI
  • STEMI
    *Needs to be opened quickly
    *PCI; if not at the reasonable time frame, fibrinolytics given
    *Multiple vessel disease: CABG surgery

PCI: revascularization procedure that involves inflating a balloon inside a coronary artery to widen it and improve blood flow; usually a stent is placed afterward to keep the artery open

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7
Q

Drug Treatment

A
  • Immediate relief of ischemia and preventing MI expansion is aimed;
    *Antianginals: decrease O2 demand
    *Antiplatelets: prevent clot formation/growth
    *Anticoagulants: prevent clot formation/growth

Antianginals: morphine, nitrates, BBs
Antiplatelets: aspirin, P2Y12 inhibitors, glycoprotein IIb/IIIa inhibitors
Anticoagulants: UFH, LMWH, bivalirudin

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8
Q

MONA-GAP-BA

A
  • Morphine
  • Oxygen
  • Nitrates
  • Aspirin
  • GPIIb/IIIa antagonists
  • Anticoagulants
  • P2Y12 inhibitors
  • BBs
  • ACE inhibitors

NSTE-ACS: MONA-GAP-BA +/- PCI
STEMI: MONA-GAP-BA + PCI or fibrinolytic (PCI preferred)

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9
Q

MONA - drug effects

A
  • Morphine
    *Antianginal: arterial and venous dilation, pain relief
  • Oxygen
  • Nitrates
    *Antianginal: dilate arteries, improve blood flow by decreasing preload (reduces chest pain)
    *Sublingual NTG (0.4 mg)
    *Reduces BP
    *PDE-5 inhibitors are contraindicated
  • Aspirin
    *Non-enteric coated, chewable (162-325 mg)
    *Given all patients asap
    *A maintenance dose 81-162 mg daily should continued indefinitely

Give these ASAP (PRN)

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10
Q

GAP - drug effects

A
  • GPIIb/IIIa Receptor Antagonist
    *Abciximab, eptifibatide and tirofiban
  • Anticoagulants
    *LMWHs, UFH, bivalirudin
  • P2Y12 Inhibitors
    *Clopidogrel, prasugrel and ticagrelor

Give these next

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11
Q

BA - drug effects

A
  • BBs
    *Increases long term survival
    *Beta-1 selective without ISA is preffered
  • ACE Inhibitors
    *Should be continued indefinitely in all patients with LVEF <=40%
    *Use ARB if intolerant

Give within 24 hrs (PRN); continue as an outpatient

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12
Q

Medications to avoid in the acute setting

A
  • NSAIDs
    *Whether nonselective or COX-2 selective
  • Immediate release nifedipine
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13
Q

P2Y12 Inhibitors - MOA

A
  • Clopidogrel and prasugrel bind to the ADP P2Y12 receptor
  • Classified as thienopyridines
  • Prodrugs that irreversibly bind to the receptor
  • Commonly used with aspirin after an ACS; DAPT
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14
Q

P2Y12 Inhibitors - Clopidogrel

A
  • Clopidogrel (Plavix)
    *MD:75 mg PO daily
  • BW: prodrug converted to its active metabolite by CY450 2C19;
    *tests to check CYP2C19 genotype
  • CIs: serious bleeding
  • Warnings: bleeding risk;
    *stop 5 days prior to elective surgery, do ot use with omeprazole or esomeprazole
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15
Q

P2Y12 Inhibitors - Prasugrel

A
  • Prasugrel (Effient)
    *Dispense in original container
  • BW: Stop at least 7 days prior to elective surgery
  • CIs: serious bleeding, Hx of TIA or stroke
  • Warnings: bleeding risk
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16
Q

P2Y12 Inhibitors - Ticagrelor

A
  • Ticagrelor (Brilinta)
    *MD: 90 mg PO BID for 1 year, then 60 mg BID
  • BW: do not exceed aspirin 10o mg for maintenance doses, stop 5 days before any surgery
  • CIs: serious bleeding
  • Warnings: bleeding risk
  • SEs: bleeding, dyspnea
17
Q

P2Y12 DDIs

A
  • NSAIDs, warfarin, SSRIs, SNRIs increase the bleeding risk
18
Q

GPIIb/IIIa Receptor Antagonists

A
  • MOA: blocks platelet GPIIb/IIIa receptor
  • Abciximab (ReoPro)
  • Eptifibatide (Integrillin)
    *SEs: bleeding, thrombocytopenia
19
Q

Protease-Activated Receptor-1 Antagonist

A
  • MOA: binds to the PAR-1
  • Vorapaxar
20
Q

Fibrinolytics - MOA

A
  • MOA: cause clot breakdown by binding to fibrin and converting plasminogen to plasmin
  • Used only for STEMI
  • PCI is preferred; within 90 min (optimal door-to-balloon time) or within 120 min of first medical contact
  • If PCI not possible, fibrinolytic therapy should be given within 30 min of hospital arrival (door-to-needle time)
21
Q

Fibrinolytic - drug effects

A
  • Alteplase (Activase)
    *Recombinant tissue plasminogen activator
  • Tenecteplase (TNKase)
  • CIs: active internal bleeding, Hx of recent stroke, severe uncontrolled HTN
  • SEs: bleeding (including ICH)
  • Monitoring: Hgb, Hct, s/sx of bleeding

Alteplase contraindication adn dosing differ when used for ischemic stroke

22
Q

Drugs for secondary prevention after ACS

Aspirin, P2Y12 Inhibitors, Nitroglycerin, BBs

A
  • Aspirin
    *Indefinitely (81 mg daily)
  • P2Y12 Inhibitor
    *Medical Therapy Patients (fibrinolytics): ticagrelor or clopidogrel with aspirin 81 mg for at least 12 months
    *PCI: clopidogrel, prasugrel or ticagrelor with aspirin 81 mg daily for at least 12 months; may continue beyond if tolerating and are not at risk of bleeding
  • Nitroglycerin
    *Indefinitely
  • BBs
    *3 years; continue indefinitely if HF or if needed for management of HTN
23
Q

Drugs for secondary prevention after ACS

ACE Inhibitors, Aldosterone Antagonists, Statins

A
  • ACE Inhibitor
    *Indefinitely if EF <40%, HTN, CKD or diabetes; consider for all MI patients
  • Aldosterone Antagonist
    *Indefinitely if EF <=40% and either symptomatic HF or DM receiving target doses of an ACE inhibitor and BBs
    *CIs: renal impairment (SCr >2.5 in men, SCr >2 in women) or hyperkalemia (K>5)
  • Statin
    *Indefinitely
    *High-intensity statin
    *Patients >=75 yeas: consider moderate or high intensity
24
Q

Other Considerations

Pain relief, ACS+Afib

A
  • Pain relief
    *Naproxen can be used if nothing works (less CV risk)
    *COX-2 selective NSAIDs shuld be avoided
  • ACS+Afib
    *PPIs should be used if patient has a hx of GI bleeding while taking triple antithrombotic therapy

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