Acute Coronary Syndromes Flashcards
DL is a 77 year old male (6’3”, 315 pounds) who presents to the emergency department with a STEMI. He was given aspirin 325 mg in the field and was started on a nitroglycerin drip at 100 mcg/min. His oxygen saturation is 94% and he has received morphine sulfate 2 mg IV x 2 and metoprolol 5 mg IV in the past 30 minutes. His blood pressure is 164/101, HR is 95 BPM, and his respiratory rate is 22 BPM. Which of the following medications should not be given to the patient due to increased mortality?
Answer
A Procardia B Demadex C Atacand D Cardizem E Vasotec
A
Procardia
Immediate release nifedpine is associated with increased mortality when used in the acute setting
GL is place on aspirin 81 mg PO daily and ticagrelor 90 mg PO BID after PCI with placement of 2 stents. She is now visiting her cardiologist and it has been just over 1 year since her stents were placed. She feels that she is still at risk and would like to continue her regimen. What recommendation regarding her ticagrelor is correct?
Answer
A Continue ticagrelor 90 mg PO BID B Change ticagrelor to 90 mg PO daily C Change ticagrelor to 60 mg PO BID D Change ticagrelor to 60 mg PO daily E Change ticagrelor to 30 mg PO daily
C
Change ticagrelor to 60 mg PO BID
Ticagrelor should be dosed at 60 mg PO BID if continued beyond 1 year.
Patients with acute coronary syndrome may receive a glycoprotein IIb/IIIa receptor antagonist. These may be given in support of a PCI intervention. Choose the correct statement concerning the glycoprotein IIb/IIIa receptor antagonists:
Answer
A
Do not use if patient has a major risk for bleeding
B
They are safe to use within 1 week of major surgery
C
They are safe to use in patients with thrombocytopenia
D
They are safe to use with severe uncontrolled hypertension
E
Do not use if patient has an INR < 1.1
A
Do not use if patient has a major risk for bleeding
The glycoprotein IIb/IIIa receptor antagonists are not safe to use in patients with major risk for bleeding, thrombocytopenia (low platelets), uncontrolled hypertension and within a short period of any major surgery as they can increase bleeding risk. GIIb/IIIa inhibitors are known to cause thrombocytopenia as a side effect, so it is important not to use them in patients who are severly thrombocytopenic at baseline. Many of the contraindications for GIIb/IIIa inhibitors are similar to those of fibrinolytics and relate to bleeding risk.
AH is being discharged from the hospital after a myocardial infarction. Two bare metal stents were placed yesterday. Upon discharge, he will continue taking his Prasugrel therapy which was started yesterday. What is the minimum period of time that AH will need to take Prasugrel?
Answer
A 6 months B 1 year C 2 years D 3 years E Indefinitely
B
1 year
After an MI, patients should receive aspirin and a P2Y12 inhibitor for a minimum of 12 months. The minimum recommendation is the same for patients managed medically or for those stented.
SR is a 61 year old female (5’3”, 115 pounds) who presents to the emergency department with a NSTEMI. Her past medical history is significant for diabetes, hypertension, multiple TIAs and a hip fracture. She was given aspirin 325 mg in the field and was started on a nitroglycerin drip at 50 mcg/min. Her oxygen saturation is 93% and she has received morphine sulfate 1 mg IV x 1 in the past 30 minutes. She is transferred to the cardiac catheterization laboratory and angioplasty confirmed an 85% blockage of her left marginal artery. The cardiac interventionalist wants to start P2Y12 inhibitor therapy prior to starting the PCI. Which of the following regimens would be most appropriate for this patient?
Answer
A Activase 90 mg IV x 1 B Effient 5 mg PO x 1 C Effient 60 mg PO x 1 D Brilinta 180 mg PO x 1 E Brilinta 90 mg PO x 1
D
Brilinta 180 mg PO x 1
This patient has a contraindication to the use of Effient (history of TIA/stroke) and Activase does not work by P2Y12 inhibition. The correct loading dose of Brilinta is 180 mg x 1.
YC is a 77 year old male (6’3”, 315 pounds) who presents to the emergency department with a STEMI. He was given aspirin 325 mg in the field and was started on a nitroglycerin drip that is currently running at 200 mcg/min. His oxygen saturation is 94% and he has received morphine sulfate 2 mg IV x 2 and metoprolol 5 mg IV in the past 30 minutes. The patient still has ongoing ischemia and is going for PCI. The physician plans to start ReoPro for this patient. Which of the following statements are correct regarding ReoPro?
Answer
A
ReoPro is a fibrinolytic.
B
Ticagrelor and prasugrel share the same mechanism of action as ReoPro.
C
ReoPro must be filtered during administration.
D
ReoPro must be shaken upon reconstitution.
E
IV ReoPro should be switched to the oral formulation as soon as possible due to cost.
C
ReoPro must be filtered during administration.
Abciximab (ReoPro) is a GIIb/IIIa inhibitor. It is a protein and should not be shaken during reconstitution. The medication requires filtering during administration and platelets must be monitored. GIIb/IIIa inhibitors are not available orally.
RM is a 56 year old male being discharged from the hospital after a myocardial infarction. One of his discharge medications is Lopressor. According to guidelines, how long will RM need to take Lopressor?
Answer
A 6 months B 1 year C 2 years D 3 years E Indefinitely
D
3 years
Per the ACC/AHA guidelines, beta blocker therapy should be given for 3 years after an MI. If there are other evidence-based reasons to continue the beta blocker (heart failure, atrial fibrillation, etc.), then it may be continued beyond 3 years.
JD is a 54 year old, otherwise healthy female (ht. 5’5’, wt. 168 pounds, SCr 2.2 mg/dL) being discharged from the hospital after a STEMI. Her ejection fraction was 56% before discharge from the hospital. She is being discharged on Lopressor 25 mg PO BID, Altace 5 mg PO daily, aspirin 81 mg PO daily, Crestor 20 mg PO daily and Plavix 75 mg PO daily. Which of the following recommendations should be made regarding her medication therapy?
Answer
A Increase the dose of Plavix B Add on Aldactone C Decrease the dose of Lopressor D Add on Nitrostat PRN E Decrease the dose of Crestor
D
Add on Nitrostat PRN
All patients who have had an MI require a prescription for PRN nitroglycerin (SL tabs or spray). With an EF of 65%, Aldactone is not warranted (but it is contraindicated at this level of SCr anyway). The medications are all dosed appropriately, given the information provided.
What are the 4 P2Y12 inhibitors and what are the available strengths and formulations?
Dosing for PCI and maintenance dosing?
- Clopidogrel (Plavix): PO
- Loading dose for PCI: 300-600 mg PO X 1 dose
- Maintenance dose: 75mg PO daily
- Ticagrelor (Brilinta): PO
- Loading dose for PCI: 180mg PO X 1 dose
- Maintenance dose: 90mg PO BID x 1 year (60mg PO BID if if continued after 1 year)
- Prasugrel (Effient): PO
- Loading dose for PCI: 60mg PO X 1 dose (No later than 1 hour after PCI)
- Maintenance dose: 10mg PO daily (5mg daily if <60kg)
- Cangrelor (Kangreal): IV
- 30mcg/kg IV bolus before PCI, then 4mcg/kg/min X 2 hours
An 87 year old male presents to the Emergency Department with complaints of mid-sternal chest pain. He has had intermittent chest pain for two days with some nausea and diaphoresis. The patient is diagnosed with a Non-ST Segment Elevation Myocardial Infarction (NSTEMI). Which of the following are standard medications that may be used to treat a patient with an acute coronary syndrome characterized as NSTEMI? (Select ALL that apply.)
Answer
A Morphine B Olanzapine C Meperidine D Aspirin E Nitroprusside
Morphine, Aspirin
Look for drugs in the acronym MONA, which represent standard care for a myocardial infarction: Morphine, Oxygen, Nitrates (nitroglycerin in various formulations) and Aspirin (MONA). Additonal medications will be added to MONA depending on the clinical situation.
JB has been taking ticagrelor 90 mg BID for 3 months. Which of the following new orders should not be filled by the pharmacist?
Answer
A Enoxaparin 1 mg/kg every 12 hours B Warfarin 2 mg daily C Metoprolol XL 50 mg daily D Morphine 1 mg IV every 2-4 hours PRN pain E Aspirin 325 mg daily
E
Aspirin 325 mg daily
Correct
Maintenance doses of aspirin > 100 mg reduce the effectiveness of ticagrelor. This is an important distinction to understand. The loading dose of ticagrelor (180 mg) is given with a loading dose of aspirin (325 mg), but the maintenance dose of ticagrelor (90 or 60 mg BID) should be given with an aspirin dose ≤ 100 mg (usually 81 mg in the U.S.). Anticoagulants are sometimes required along with P2Y12 inhibitors (e.g., prior ACS and mechanical valve). Bleeding risk would be increased, but the dual therapy is sometimes required.
Absolute contraindications to using a fibrinolytic during STEMI?
- Prior intracranial hemorrhage
- Active bleeding
- Recent stroke (usually defined as within 3 months)
- Intracranial/intraspinal surgery or trauma in last 2-3 months and others.
- Severe uncontrolled hypertension (usually defined as > 175/110) is considered an absolute contraindication unless it can be controlled emergently before administering the fibrinolytic. Because of the risk of serious bleeding with fibrinolytics, careful risk/benefit assessment must be conducted. Fibrinolytics are also used for acute ischemic stroke. Contraindications differ for that indication.
Which of the following side effects is common with Brilinta?
Answer
A Tachyarrhythmias B Decreased serum creatitine C Hepatic impairment D Dyspnea E Puffy eyes
D
Dyspnea (Occurring >10% of patients)
What is the brand name and mechanism of action for vorapaxar?
Zontivity
It is a protease activated receptor-1 (PAR-1) antagonist expressed on platelets. It has a long half life and is irreversible.
Which of the following medications work by irreversible binding to their target receptor?
Answer
A Integrilin B Brilinta C Lopressor D Aggrastat E ReoPro
E
ReoPro
ReoPro is abciximiab a IIb/IIIa receptor antagonist. It is the only drug in its class that provides irreversible blockade at these receptors.
Eptifibitide (Integrilin) and Tirofiban (Aggrastat) have the same mechanism of action but they are reversible inhibitors of these receptors.
