Acute Coronary Syndromes

Question 1

Patho phys

Answer 1

Takes decades

Begins with intimal thickening and xanthom fomration

Progression leads to dz extension into media and adeventitia

Stbale plaques

ACS after plaque ruptures and exposes necoritc ocre…then thrombotic event occurs

Question 2

Pathophys of ACS

Answer 2

STEMI - complete coclusion

NSTE - partial…could be NSTEMI and unstable angina

LEads to pump dysfunction and electrical instability

Question 3

Goal of tx

Answer 3

Interrupt platelet aggregation and thrombus formation

Prevent/minimize myocardial damage

Question 4

Sx

Answer 4

Angina - pressurel ike, substernal chest discomfort

Radiates

Diaphoresis, dyspnea, nausau, lighthededness and syncope

Duration exceed 5-10 minutes and may have stuttering or waxing and waning course

Question 5

Guidelines for eval

Answer 5

ECG within 10 minutes and repeat every 5-10

High sensitivity troponin

GRACE or TIMI score

Question 6

Tx

Answer 6

Invasive - medical therapy, catheterization lab within 72 hours

Ischemia guide - medical tx…eval for ischemia despite medical therapy

Question 7

When to give O2

Answer 7

If hypoxic - yes

If not hypoxic - probably

Question 8

Aspirin

Answer 8

Everyone unless contraindication

30-50% reduction in risk of MI

Question 9

Nitrates

Answer 9

Give SL…if still having pain, consider IV

No mortality benefit

Question 10

Morphine

Answer 10

Do not give unless going to the cath lab

Question 11

Heparin and enoxaparin

Answer 11

Hepatin - bolus and drip, higher bleeding rates, reversible, monitoring, control in cath lab

Enox - simple, give IV bolus, less bleeding, better if conservative approach

Bivalirudin - reserved for cath lab

Question 12

P2Y12 inhibitor

Answer 12

Preferred - clopidogrel or ticagrelor

Question 13

B blockers

Answer 13

Do NOT need to be given acutely but can be useful if HTN or tachy…can perpetuate shock as SE

Start oral dose in 24 hours unless contraindication

Question 14

Fibrinolytics

Answer 14

Only given for STEMI

Question 15

GLycoprotein 2b/3a inhibitors

Answer 15

Not routinely used

If used, check platelets…thrombocytopenia

Abciximab eptifibatide, tirofiban

Question 16

Stress testing

Answer 16

No indicaiton for stress testing in someone with ACES and chest discomfort/ischemia

Can be performed AFTER stabiliation ofr risk stratificaiton in pts with conservative approach

Question 17

Angiography

Answer 17

Probably a reasonable option

Mortality benefit in some high risk groups

Question 18

STEMI management

Answer 18

PCI - preferred, esp if sx over 12 hours or shock…door to balloon time 90 minutes

Thrombolytics - if cannot get PCI within 2h ours…given with 30 minutes of walking into ER

Question 19

Odd contraind tot thrombolytcis

Answer 19

High BP…always check BP!!!!!!!!!!

Question 20

STEMI effect on ECG

Answer 20

Acute - ST elevation

Hours - ST elevation, dec R wave with Q wave beginning

1-2 days - T wave inverison and Q wave deepr

Days - ST normalizes, T wave inverted

Weeks later - ST and T noromal and Q wave persists

Question 21

POst ACS event tx

Answer 21

Aspirin and high intesnity statin for life

P2Y12 inhibt and BEta block for 1 year…no B blocker if LVEF low or anginal

SL Nitroglyc

SMoking cessation and exercise

Risk factor reduction - diabetes, HTN, weight

Question 22

Cocaine induced chest pain

Answer 22

Tx like regular ACS

Liberal use of benzos, nitrates and CCBs

Beta blockers are controversial