Acute Coronary Syndromes Flashcards by Grace Whitham

Risk factors for plaque buildup that cause ACS

Age: men>45 or women>55
Family history
Smoking
HTN
Known CAD
Dyslipidemia
Diabetes
Chronic angina
Lack of exercise
Excessive alcohol

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Patients with an acute MI should be transported to a hospital with _____ capability and a 12 lead EKG should be performed within ____ minutes of medical contact

Percutaneous coronary intervention (PCI)

10 minutes

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What is the most sensitive and specific biomarkers for ACS?

Cardiac troponins I and T

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Symptoms, cardiac enzymes, ECG changes, and blockage in

Unstable angina

Symptoms: chest pain
Cardiac enzymes: negative
ECG changes: none or transient
Blockage: partial

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Symptoms, cardiac enzymes, ECG changes, and blockage in

NSTEMI

Symptoms: chest pain
Cardiac enzymes: positive
ECG changes: none or transient
Blockage: partial

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Symptoms, cardiac enzymes, ECG changes, and blockage in

STEMI

Symptoms: chest pain
Cardiac enzymes: positive
ECG changes: ST elevation
Blockage: complete

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How do antianginals cause benefit in ACS? What meds are used?

decrease myocardial oxygen demand

Morphine, nitrates, beta-blockers

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How do antiplatelets cause benefit in ACS? What meds are used?

inhibit platelet aggregation and prevent clot formation/growth
ASA, P2Y12 inhibitiors, glycoprotein IIb/IIIa inhibitors

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How do anticoagulants cause benefit in ACS? What meds are used?

UFH, LMWH, bivalirudin

inhibit clotting factors to prevent clot formation/growth

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What drugs are used to treat ACS?

MONA-GAP-BA
Morphine
Oxygen
Nitroglycerine
ASA
GPII/IIIa antagonists
Anticoagulants
P2Y12 inhibitors
Beta-blockers
ACE inhibitors

NSTEMI/UA: MONA-GAP-BA +/- PCI
STEMI: MONA-GAP-BA + PCI or fibrinolytic

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What type of ASA should NOT be given during an ACS episode?

Enteric coated –> avoid because it has delayed effects

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What drugs are GPIIb/IIIa receptor antagonists?

adciximab, eptifibatide, and tirofiban

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What drugs are P2Y12 inhibotors?

clopidogrel, prasugrel, and ticagrelor

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What beta blockers and ACE inhibitors are used in ACS? When should BB and ACEi be used?

BB: start within 24 hours unless CI; metoprolol, atenolol, esmolol (if HF use metoprolol, bisoprolol, or carvedilol)
ACEi: start if LVEF <40%, HTN, DM, stable CKD and continue indefinitely unless CI; use any ACEi

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What medications should not be given in the ACS?

NSAIDS (except ASA) and immediate-release nifedipine

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ASA MOA

inhibits platelet aggregation/clot formation by inhibiting production of thromboxane AT (TXA2) via irreversible COX 1 and COX 2 inhibition

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P2Y12 inhibitor MOA

bind to adenosine diphosphate (ADP) P2Y12 receptor on platelet surface which prevents ADP-mediated activation of the GPIIb/IIIa receptor complex, thereby reducing platelet aggregation

GPIIb/IIIa receptor antagonist MOA

blocks platelet glycoprotein IIb/IIIa receptor which is the binding site for fibrinogen, von Willebrand factor and other factor and other ligands thereby reducing platelet aggregation and further thrombosis

Vorapaxar MOA

protease-activated receptor 1 (PAR-1) angatonist that reversibly binds to PAR-1 expressed on platelets, preventing thrombin-induced and thrombin receptor agonist peptide-induced platelet aggregation

Difference between clopidogrel, prasugrel and ticagrelor

Clopidogrel and prasugrel: prodrugs that irreversibly bind

Ticagrelor: NOT prodrug, reversibly binds

P2Y12 dosing strategy

Loading dose x 1 followed by daily maintenance dose
Ticagrelor BID
Clopidogrel and prasugrel daily

Prasugrel BBW and contraindications

BBW: not recommended for >75 years old
Stop 7 days before surgery
CI: Hx of TIA or stroke, active bleeding

Ticagrelor BBW and contrindications

BBW: do not exceed ASA 100mg for maintenance dose
Stop 5 days before surgery
CI: hx of intracranial hemorrhage, active bleeding

Clopidogrel BBW and contrindications

BBW: prodrug dependent on CYP2C19 activity
Stop 5 days prior to surgery
CI: active bleeding

Which P2Y12 inhibitor can cause dyspnea in >10% of patients?

Ticagrelor

What is the only IV P2Y12 inhibitor?

Cangrelor - switch to oral after P2Y12 inhibitor after PCI | Effects are gone 1 hour after drug discontinuation

What drugs, when given with P2Y12 inhibitors can cause increased risk of bleeding?

NSAIDs, Warfarin, SSRIs, SNRIs

What medications do clopidogrel interact with?

CYP2C19 inhibitors esomeprazole and omeprazole

When to use eptifibatide, tirofiben, and abciximab

Eptifibatide and tirofiban: reversible blockade of GPIIb/IIIa receptor - can use in ACS or patients undergoing PCI +/- stent Abciximab: irreversible blockade of receptor - indicated for PCI +/- stent

What medication are GPIIb/IIIa recpetor antagonists given with?

heparin

GPIIb/IIIa antagonist contraindications, side effects

Contraindications: thrombocytopenia, hx of stroke in last 30 days or any hemorrhagic stroke or HD dependence (eptifibatide) SE: bleeding, thrombocytopenia

Fibrinolytics MOA

bind to fibrin and convert plasminogen to plasmin causing clot breakdown

What ACS are fibrinolytics used in?

STEMI

In what time frame should PCI be performed

``` 90 minutes (door to balloon) 120 minutes of first medical contact ```

When should a fibrinolytic be used in STEMI?

If unable to complete PCI within 120 minutes of first medical contact, use fibrinolytic within 30 minutes of hospital arrival

Fibrinolytic contrindications, monitoring, notes

CI: active internal bleeding, hx of recent stroke, hx of ICH, recent intracranial surgery or trauma (2-3 months), severe uncontrolled HTN Monitoring: Hgb, Hct, s/sx of bleeding Notes: alteplase contraindications differ when used for ischemic stroke

Alteplase dosing when used for STEMI

>67 kg: 15 mg bolus, 50mg over 30 minutes, 35 mg given over 1 hour <67: 15mg bolus, 0.75 mg/kg over 30 mins, 0.5 mg/kg over 1 hour ***Max dose 100mg for both dosing schedules

Tenecteplase dosing for STEMI

Single IV bolus dose based on weight | 30-50 mg

What drugs are used for secondary prevention of ACS

``` Aspirin indefinitely (81 mg) unless CI P2Y12 inhibitor: with ASA for 12 months after event Nitroglycerine: indefinitely Beta blocker: 3 years, continue if HF or HTN ACEi: indefinitely if EF<40%, HTN, CKD, DM Aldosterone antagonist: indefinitely if EF<40% and receiving target dose of ACEi or BB Statin: indefinitely; high intensity or moderate-high if >75 years ```

Pain relief in ACS patients

Use APAP, tramadol, or narcotics before NSAIDs | If NSAID is unavoidable, use naproxen

NSAIDs should be avoided in ACS patients, but if unavoidable, which one should be used and why?

Naproxen because it is nonselective and and has lowest CV risk

Anticoagulation in patients with ACS and afib How many agents and for how long? What other medications should be used?

Can use triple therapy Use clopidogrel, antiplatelet (ASA), and medication for afib Switch to duel antiplatelet therapy after 4-6 weeks (clopidogrel and ASA) Use proton pump inhibitors in patients on triple antithrombotic therapy