Acute Coronary Syndromes

Question 1

TIMI Risk Calculation

Answer 1

• predicts risk of death or MI in the next 14 days

- risk varies from 5-41%

Question 2

What are the 3 goals of therapy for unstable angina/NSTEMI?

Answer 2

1. diminish coagulability
2. relieve pain
3. decrease workload of the heart

Question 3

What meds are used to diminish coagulability in UA/NSTEMI pts?

Answer 3

• anti platelets: ASA, P2Y12, IIbIIIa inhibitors

- anti coagulants: heparinoids, bivalrudin

Question 4

What meds are used to relieve pain in UA/NSTEMI pts?

Answer 4

• SL and IV nitro
• morphine
• BB

Question 5

What meds are used to decrease the workload of the heart in UA/NSTEMI pts?

Answer 5

BB

Question 6

UA/NSTEMI Aspirin Therapy

Answer 6

-162-325 mg unless CI or already taken

Question 7

What are the P2Y12 Inhibitors and what are they used for?

Answer 7

• clopidogrel (Plavix)
• ticagrelor (Brilinta)
• prasugrel (Effient)
• used to diminish coagulability (anti platelet agents)

Question 8

Who should receive a high dose clopidogrel regimen? What is considered a “high dose?”

Answer 8

• 300 mg vs 600 mg load

- hx MI, stent placement, ACS, DM

Question 9

In what patients should prasugrel be avoided?

Answer 9

• hx of TIA or stroke
• 75 y.o
• undergoing surgical procedure (CABG)
• CrCl < 60 mL/min
• warfarin pts

Question 10

Prasugrel should be used in what types of pts?

Answer 10

-in high risk MI patients (DM or hx of MI) getting PCI

Question 11

When should IIaIIIb inhibitors be used before PCI?

Answer 11

• DM or STEMI or elevated troponins and low bleed risk

- recurrent pain on ASA, P2Y12, and heparin

Question 12

What is the dosing of sublingual nitro?

Answer 12

-0.4 mg SL q5 minutes for 3 doses

Question 13

When is IV nitro contraindicated?

Answer 13

• hypotension (SBP < 100)
• tachycardia > 100 bpm
• phosphodiesterase inhibitor within 24-48 hrs

Question 14

When is IV morphine sulfate indicated?

Answer 14

-uncontrolled chest pain despite IV NTG

Question 15

When is IV morphine sulfate contraindicated?

Answer 15

• hypotension SBP < 100

- tachycardia > 100 bpm

Question 16

What is the indication for oral beta blockers?

Answer 16

First 24 hours for all patients who do not have:

• signs of active HF
• evidence of low output state/cardiogenic shock
• PR interval greater than 0.24 seconds
• 2nd or 3rd degree heart block
• active asthma

Question 17

Signs and Sxs of Uncompensated Heart Failure

Answer 17

• orthopnea
• PND
• DOE
• ascites
• 2-3+ pitting edema

Question 18

What patients should receive oral ACE-I/ARBs?

Answer 18

in first 24 hrs to pts w/ pulmonary congestion or LVEF < 40% unless contraindicated

Question 19

What are the CIs for ACE-I/ARBs?

Answer 19

• hypotension (SBP < 100)
• BL renal artery stenosis
• hx angioedema
• 2 or 3 trimester pregnancy

Question 20

What are the goals of therapy for treating STEMI?

Answer 20

• relieve pain
• re-perfuse
• diminish coagulability

Question 21

When are lytics used?

Answer 21

• given if the 90 minute PCI window is not met

- most effective within 12 hours of symptom onset

Question 22

Absolute CI of Lytics

Answer 22

• active bleeding or hx of intracranial hemorrhage

- ischemic (thrombotic) stroke within 3 months

Question 23

Relative CI of Lytics

Answer 23

• uncontrolled HTN
• current anticoagulant use (warfarin)
• pregnancy
• surgery <3 weeks

Question 24

At discharge, how long should pts be kept on BBs?

Answer 24

• at least 6 months, ideally 3 years

- in pts with low EF, indefinitely

Question 25

What discharge meds should pts be on?

Answer 25

- BB - PRN SL NTG - statins for all - ACE-I for EF <40%, DM, CKD