Acute Coronary Syndromes Flashcards
What is a Type I Acute Coronary Syndrome (ACS)?
vascular occlusion ischemia (blockage)
What is a Type II Acute Coronary Syndrome (ACS)?
demand ischemia, “overworking” (wall tension, heart rate, contractility)
What are the indicators of unstable angina?
no ST elevation and no biomarkers
What are the indicators of NSTEMI?
no ST elevation(usually) with biomarkers
What are the indicators of STEMI?
ST elevation and maybe biomarkers
What are the cardiac biomarkers?
TROPONIN, myoglobin, creatine kinase(CK)
Describe NSTEMI vs STEMI
-NSTEMI= ST depression, white clots, partial coronary occlusion, reperfusion, not urgent
-STEMI= ST elevation, red clots, total coronary occlusion, reperfusion urgently needed
What is the PQEST of Angina?
-Precipitating factors= pain at rest with NO exertion
-Palliative measures= rest and nitrates won’t relieve pain
-Quality of pain= crushing chest tightness
-Region of pain= substernal (right in the middle)
-Radiation of pain= arms, jaw, neck, abdomen, or back
-Severity of pain= 8-10/10
-Temporal pattern= > 20 minutes
What does MONA stand for?
-Morphine
-Oxygen
-Nitroglycerin
-Aspirin
What is the concern with morphine for initial treatment of acute coronary syndromes?
studies showed increased death and length of hospitalizations so not generally given unless symptoms persist despite therapy
When would oxygen be considered for acute coronary syndromes (ACS) pt?
SaO2 < 90%
What is the MOA of Nitroglycerin?
increased nitric oxide release resulting in venous dilation and arterial dilation (decrease afterload= decrease BP= decrease demand and coronary vasodilation = increased coronary supply)
What is the indication of Nitroglycerin?
-SL preferred for acute angina
-IV preferred for unstable refractory angina
What drug should every patient with ACS receive once admitted to the hospital?
aspirin
What is the benefit of Aspirin in ACS pt?
reduce death, MI, or stroke by up to 50%
What dose of Aspirin should be given to pt initially upon admittance into the hospital for ACS?
160-325mg chewed and swallowed
What does THROMBINS2 stand for?
-Thienopyridine
-Heparin
-RAAS
-Oxygen
-Morphine
-Beta blocker
-Intervention (PCI)
-Nitroglycerin
-Statin
-Salicylate (aspirin)
Describe TIMI:
used to score patients to assist on deciding whether a pt is a candidate for percutaneous coronary intervention (PCI) aka “cardiac catheterization”
How does the point system work for TIMI?
one point for each of the following risk factor predictors:
-age > 65
-3 or more CAD risk factors
- > 50% stenosis of major coronary artery
-ST segment elevation
-2+ angina episodes in past 24h
-ASA used within past 7 days
-elevated biomarkers
What pt would be a candidate for early invasive therapy (PCI)?
-TIMI score > 3
-recurrent angina/ischemia with low activity
-elevated troponin levels
-new ST depression on EKG
-angina/ischemia + HF
-hemodynamic instability
-sustained ventricular tachycardia
Describe Coronary Patency
dye is injected into coronary artery and blood flow is assessed (angiogram/angiography) and is graded:
-3= normal
-2= moderate
-1= minimal
-0= none
What are examples of percutaneous coronary intervention (PCI)?
-balloon angioplasty
-cardiac stenting
What is the MOA of P2Y12 Inhibitors?
prevent platelet aggregation by irreversibly blocking P2Y12 component of the ADP receptor -> preventing platelet activation
What drugs are P2Y12 Inhibitors?
-clopidogrel
-prasugrel
-ticagrelor
-cangrelor
What should be given to pt before PCI?
aspirin 162-325mg and P2Y12 Inhibitor ASAP
What drugs should be given to pt after PCI?
-aspirin 81mg INDEFINITELY
-P2Y12 inhibitor should be given for at least 12 months if not on oral anticoagulant
What are the benefits of Prasugrel?
-more potent antiplatelet effects
-not limited by genetic polymorphisms
-reduction in ischemic outcomes (w/ PCI)
What are the limitations of Prasugrel?
-not indicated for “medically treated”
-higher life-threatening bleed rates
-CONTRAINDICATED in previous stroke or TIA
What drugs are Glycoprotein IIb/IIIa Inhibitors?
tirofiban and eptifibatide
What are the benefits of using Glycoprotein IIb/IIIa inhibitors in ACS?
reduce risk of death, reduce revascularization, reduce major adverse cardiac events
What are the adverse effects of Glycoprotein IIb/IIIa Inhibitors?
-thrombocytopenia
-occult bleeding
-hypotension
-chest pain
What is the place in ACS therapy of Glycoprotein IIb/IIIa Inhibitor?
-combined with anticoagulation (heparin), but not given with bivalitudin
-generally reserved for higher risk patients with high troponin
-in NSTEMI/STEMI: adjunct when P2Y12 inhibitor therapy is not adequate
What are the contraindications of Glycoprotein IIb/IIIa Inhibitors?
-thrombocytopenia
-active bleed
-stroke within 2 years
What are the monitoring parameters for Unfractionated Heparin (UFH)?
-activated clotting time in cath lab
-activated partial thromboplastin time (aPTT) every 6 hours when medically managing (1.5-2x control (roughly 50-65 sec)
What is the duration of therapy of Unfractionated Heparin (UFH)?
-PCI: discontinue after procedure is completed
-medical management: 2-5 days
What is the unique use of Enoxaparin?
STEMI with a fibrinolytic
What are the indications of Bivalirudin?
-preferred over heparin + GPIIb/IIIa inhibitor in PCI STEMI patients at high risk for bleeding
-in patients with heparin induced thrombocytopenia
What are non-anticoagulant/antiplatelet therapy for ACS medication management?
-beta blocker
-ACEI
-statin
-aldosterone blockers
When should a beta blocker be started for ACS?
ASAP or with 24h
What is the benefit of using beta blockers in ACS?
decreases myocardial O2 demand (decrease HR, decrease contractility, decrease BP)
How long should beta blockers be used after ACS event?
3 years
What is the goal HR using beta blockers for ACS?
50-60bpm
What are the contraindications of beta blockers?
-SBP < 90mmHg
-HR < 50 bpm
-acute heart failure
-heart block
What is the benefit of using an ACEI for ACS?
-prevent venticular remodeling
-reduce venticular dilation after infarction
-reduce venticular hypertrophy
-reduce arrhythmias
-improve LV function
What patients should receive an ACEi in ACS?
all, but especially if evidence of HFrEF
What is the indication of Aldosterone blocker, Eplerenone?
patients with MI in past 10 days and HFrEF < 40%
What is the adverse effect of Aldosterone blocker, Eplerenone?
hyperkalemia
What statin should patients be given post ACS event?
high intensity statin
When should a CCB be considered for ACS?
if BB is contraindicated but DO NOT use in HF because CCB of choice is verapamil and diltiazem
Which fibrinolytic is most fibrin specific?
tenecteplase
What are the adverse effects of fibrinolytics?
-occult bleeding= check all stools, avoid unnecessary sticks
-ICH (brain bleed)
-hypotension
When should PCI be preformed once admitted?
60-90 mins
When should fibrinolytics be administered once admitted?
30 mins
