Acute Coronary Syndromes

Question 1

Stable angina

Answer 1

chest or arm discomfort brought on by exertion or emotional stress, relieved within 5-15 min by rest or ntg

Question 2

anginal equivalents

Answer 2

women/diabetes/elderly

dyspnea, nausea, fatigue faitness

Question 3

MI Classification

Answer 3

type 1- spontaneous- plaque rupture
type 2- MI secondary to imbalance- spasm, pul embolism, anemia
type 3- sudden unexpected cardiac death before biomarkers
type 4- a. ass. PCI b. stent thrombosis
type 5- MI ass with CABG

Question 4

integrelin

Answer 4

eptifibatide
must be adjusted for renal
CrCl <50, decrease infusion to 1mcg/kg/min
max 7.5mg/hr

Question 5

stemi platelet function:

Answer 5

adhesion- mediated by vWF
activation- adp (thrombin induced)- express GP 2b3a
aggregation- fibrinogen links platelet
amplifications

Question 6

ntg contraindications

Answer 6

hypotensive
severe aortic stenosis
rv infarction
pde for ed <24 hrs

Question 7

UA/NSTEMI class 3

Answer 7

thrombolytic rx
nitrates if 100
iv ace in 1st 24 hr
iv b blocker if chf/ shock
NSAID

Question 8

TIMI risk score

Answer 8

age 65, >3 risk factors, prior cad >50%, asa < 7 days, >2 angina events, st deviation, elevated markers

markers of highest risk st deviation and elevated markers

Question 9

first step usa or nstemi

Answer 9

asa or clopidogrel if asa intolerant

prasugrel if going to pti strategy

Question 10

Immediate angio/revascularization

Answer 10

persistant ischemic discomfort p meds
hemo unstable
severe lv dysfuntion or chf
worsening mr or vsd
sustained vent arrhythmia

Question 11

volume of contrast causing contrast induced nephropathy

Answer 11

volume/CrCl > 3.7 is high risk for CIN

Question 12

diabetic revascularization

Answer 12

cabg with lima guideline preferred over pci with multivessel disease

Question 13

normal coronary art with ua/nstmi

Answer 13

9-14% 
mechanisms
thrombolysis on nonobstructive plaque
vasospasm
pul embolism, myocarditis, hypertensive emergency

Question 14

platelet in acs

Answer 14

adhesion: collagen, vWF
activation: ADP (most important) thienopyridine/ ticagrelor (brilanta)
thrombin, and thromboxane
amplification:
aggregation: plt express Gp2b 3a receptor

Question 15

ADP platelet therapy

Answer 15

thienopyridines (clopidogrel, prasugrel) irreversible P2Y12 receptor blocker for inhibiting ADP production
ticagrelor (reversible)

Question 16

ASA action platlets

Answer 16

blocks tromboxin production

Question 17

Final pathway of platelet aggregation

Answer 17

GP 2b3a receptor
abciximab (repro)
eptifibatide (integrelin) irreversible
tirofiban (aggrastat)

Question 18

asa intolerant

Answer 18

clopidogrel, prasugril ( if invasive anticipated) or ticagrelor

Question 19

clopidogrel metabolism

Answer 19

drug in pro form:
needs to be oxidized 2x in liver: cyp 2c19
TRITON study

Question 20

prasugrel

Answer 20

pro drug: more efficient mechanism than clopidigrel in conversion
more efficient absorption-
1 oxidative step

Question 21

abciximab

Answer 21

guidelines only in cath lab

Question 22

platetet rx in ER

Answer 22

clopidigrel with load or
2b3a inhibitor (eptifibatide, tirofaban)
integrlin or aggrastat (repro (abciximab) in labs)
at time of pci: clopidigrel, prasugrel or 2b3a

Question 23

bleeding with prasugrel

Answer 23

triton timi 38
groups @ higher risk
tia/cva hx
age >75 yo
wt < 60kg

Question 24

prasugrel contraindication

Answer 24

prior stroke or tia

Question 25

ticagrelor

Answer 25

brilanta- p2y12 receptor like clopidigrel/prasugrel but not pro drug and irreversible depends on plasma concentration plasma concentration takes 3-5 days for platelet activity side effects: dry cough, and mild dyspnea, brady

Question 26

anti-platelet rx washout for cabg

Answer 26

clopidigrel - 5-7 days ticagrelor- 5 days prasugrel- 7-10 days

Question 27

GB2b3a inhibitors

Answer 27

abciximab (repro) monoclonal ab- irreversible blocker not upstream use eptifibatide (integrelin) reversible, but longer t1/2, needs renal adjustment tirofiban (aggrastat) reversible

Question 28

bivalrudin

Answer 28

direct antithrombin | rx alone with low bleeding risk

Question 29

prior to cabg- antithrombotic recs

Answer 29

no not stop ufh (continue) dc eptifabatide >4hr prior to cabg dc clopidogrel >5 day prior to cabg dc prasugrel >7 d prior to cabg

Question 30

triple antithrombotic rx

Answer 30

``` use lowest asa dose standard clopidogrel dose inr 2.0-2.5 ppi rx prophylactically stop asa if risk high, bare metal stents ```

Question 31

MI mimics:

Answer 31

dissection, pericarditis, myocarditis, pul embolism, pneumothorax

Question 32

Contraindication for thrombolytics:

Answer 32

hx of intracranial hemorrhage, vascular cerebral avm or neoplasm, cva <3 mths, aortic dissection, bleeding, closed head, facial trauma

Question 33

DES STEMI benefits

Answer 33

only decreases revasc <1yr

Question 34

STEMI thrombus PCI

Answer 34

Aspiration benefit, protection no benefit

Question 35

Occluded PTCA

Answer 35

``` >23 hr class 3 indication OAT trail with increased mortality ```

Question 36

STEMI b blockers

Answer 36

``` iv b blocker class 3 if signs of hypo-perfusion and chf oral b blockers better ```

Question 37

STEMI theiopyridines

Answer 37

no prasugrel if previous cva or tia

Question 38

lytic therapy and ADP rx

Answer 38

prasugrel not recommended - not tested

Question 39

anticoag > 48 hr

Answer 39

avoid UFH | enaxaparin, fundaparin used