Acute Coronary Syndromes

Question 1

ACS encompasses st segment

Answer 1

non-ST segment elevation (NSTE-ACS)
- can describe both unstable angina (UA) or NSTEMI
ST-segment elevation (STEMI)

Question 2

Comparing UA, NSTEMI, and STEMI
UA

Answer 2

UA
Symptoms: chest pain
Cardiac Enzyme: negative
ECG changes: none or transient ischemic change
Blockage: Partial

Question 3

Comparing UA, NSTEMI, and STEMI
NSTEMI

Answer 3

NSTEMI
Symptoms: chest pain
Cardiac Enzyme: Positive
ECG changes: none or transient ischemic change
Blockage: Partial

Question 4

Comparing UA, NSTEMI, and STEMI
STEMI

Answer 4

STEMI
Symptoms: chest pain
Cardiac Enzyme: positive
ECG changes: ST segment elevation
Blockage: complete blockage

Question 5

PCI

Answer 5

Percutaneous coronary intervention
coronary revascularization procedure
- inflating a small ballon inside a coronary artery and widening it and improving blood flow… usually a stent is placed to keep the artery open

Question 6

NSTE-ACS

Answer 6

can be tx with medications

STEMI requires a blocked artery to be replaced

Question 7

PCI timing

Answer 7

90min door- to balloon time
120min- first medical contact (ambulance)

if PCI not possible fibrinolytic therapy… should be given 30 min of hospital arrival (door to needle time)

Question 8

Drug TX opiton for ACS

Answer 8

MONA- GAP- BA

Morphine
Oxygen
Nitrates
Aspirin

GPIIb/IIa anatagonists
Anticoagulats
P2Y12 inhibitors

Beta-blockers
ACE inhibitors

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

Question 9

MONA

Answer 9

morphine
- 2-5mg/ IV repeat 5-30 min PRN
Oxygen
- admin in pt with O2 saturation < 90% or res distress
Nitrates
- sublingual 0.4mg every 5min x 3 doses, do not use if SBP <90 mmHG
Aspirin
- non-enteric coated chewable aspirin 325mg all pt immediately- maintances dose 81mg

Question 10

GAP

Answer 10

depends on PCI vs CABG vs medical management
GPIIb/IIa antagonists
- abciximab, eptifibatide, and tirofiban
Anticoagulants
- LMAHs (enoxaparin, etc.), UFH and bivalirudin
P2Y12
- clopidogrel, prasugrel and ticagrelor

Question 11

BA

Answer 11

beta-blockers
- increase long time survival, start within 24 hrs unless contra
ACE inhibitors
- start first 24hrs and continue indefinitely if LVEF <40%, if contra use ARB.

Question 12

Clopidogrel

Answer 12

Plavix
test for CYP2C19
stop 5 days prior to surgery
prodrug
LD: 300-600mg PO (600mg for PCI)
MD: 75mg PO daily
- P2Y12 inhibitors

Question 13

Prasugrel

Answer 13

Effient
protect for moisture, keep in original packaging
stop 7 days prior to surgery
LD: 60mg no later than 1 hr after PCI
MD: 10mg daily w/ ASA
contra: History of TIA or stroke
- P2Y12 inhibitors

Question 14

Ticagrelor

Answer 14

Brilinta
LD: 180mg
MD 90mg BID for one year, then 60mg BID
tab can be crushed and mixed with water, swallowed or given NG tube
after initial ASA dose of 162-325mg, do not exceed maintenance 100mg
- P2Y12 inhibitors

Question 15

Abciximab

Answer 15

ReoPro
contra: thrombocytopenia (platelets <100,000), history of stroke within 2 years
- within 6 weeks a risk of GI or GU bleeding
- increase prothrombin time
- hypersensitivity to murine proteins
- intracranial neoplasms
- do not shake the vial
- platelet function returns to normal 24-48 hr
- GPIIb/IIa antagonists

Question 16

Eptifibatide

Answer 16

Integrillin
- dependency on renal dialysis
- adjust maintenance dose if CrCl< 50ml/min
platelet function return to normal after 4-8hrs
- contra: in pt with history of stroke within 30 days or any history of hemorrhagic stroke

Question 17

Alteplase

Answer 17

Activase
- tissue plasminogen activator (tPA)
Cathflo Activase
- single-use 2mg vial

> 67kg 100mg IV over 1.5 hr, 15mg bolus, 50mg over 30min, then 35mg over 1hr

<= 67kg 15mg bolus, 0.75 mg/kg (max 50mg) over 30min, then .5 mg/kg (max 35mg) over 1hr, max 100mg total

contra: active internal bleeds, history of recent stroke, prior ICH (inter-cranial hemorrhage)
severe uncontrolled hypertension

dose differ in ischemic stroke