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NAPLEX Review > Acute Coronary Syndromes > Flashcards

Acute Coronary Syndromes Flashcards

1
Q

Risk factors for plaque buildup that cause ACS

A 
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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2
Q

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

A

Percutaneous coronary intervention (PCI)

10 minutes

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3
Q

What is the most sensitive and specific biomarkers for ACS?

A

Cardiac troponins I and T

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4
Q

Symptoms, cardiac enzymes, ECG changes, and blockage in

Unstable angina

A

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

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5
Q

Symptoms, cardiac enzymes, ECG changes, and blockage in

NSTEMI

A

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

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6
Q

Symptoms, cardiac enzymes, ECG changes, and blockage in

STEMI

A

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

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7
Q

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

A

decrease myocardial oxygen demand

Morphine, nitrates, beta-blockers

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8
Q

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

A

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

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9
Q

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

A

UFH, LMWH, bivalirudin

inhibit clotting factors to prevent clot formation/growth

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10
Q

What drugs are used to treat ACS?

A 
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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11
Q

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

A

Enteric coated –> avoid because it has delayed effects

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12
Q

What drugs are GPIIb/IIIa receptor antagonists?

A

adciximab, eptifibatide, and tirofiban

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13
Q

What drugs are P2Y12 inhibotors?

A

clopidogrel, prasugrel, and ticagrelor

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14
Q

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

A

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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15
Q

What medications should not be given in the ACS?

A

NSAIDS (except ASA) and immediate-release nifedipine

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16
Q

ASA MOA

A

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

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17
Q

P2Y12 inhibitor MOA

A

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

18
Q

GPIIb/IIIa receptor antagonist MOA

A

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

19
Q

Vorapaxar MOA

A

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

20
Q

Difference between clopidogrel, prasugrel and ticagrelor

A

Clopidogrel and prasugrel: prodrugs that irreversibly bind

Ticagrelor: NOT prodrug, reversibly binds

21
Q

P2Y12 dosing strategy

A

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

22
Q

Prasugrel BBW and contraindications

A

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

23
Q

Ticagrelor BBW and contrindications

A

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

24
Q

Clopidogrel BBW and contrindications

A

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

25
Q

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

A

Ticagrelor

26
Q

What is the only IV P2Y12 inhibitor?

A

Cangrelor - switch to oral after P2Y12 inhibitor after PCI

Effects are gone 1 hour after drug discontinuation

27
Q

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

A

NSAIDs, Warfarin, SSRIs, SNRIs

28
Q

What medications do clopidogrel interact with?

A

CYP2C19 inhibitors esomeprazole and omeprazole

29
Q

When to use eptifibatide, tirofiben, and abciximab

A

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

30
Q

What medication are GPIIb/IIIa recpetor antagonists given with?

A

heparin

31
Q

GPIIb/IIIa antagonist contraindications, side effects

A

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

32
Q

Fibrinolytics MOA

A

bind to fibrin and convert plasminogen to plasmin causing clot breakdown

33
Q

What ACS are fibrinolytics used in?

A

STEMI

34
Q

In what time frame should PCI be performed

A 
90 minutes (door to balloon)
120 minutes of first medical contact
35
Q

When should a fibrinolytic be used in STEMI?

A

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

36
Q

Fibrinolytic contrindications, monitoring, notes

A

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

37
Q

Alteplase dosing when used for STEMI

A

> 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

38
Q

Tenecteplase dosing for STEMI

A

Single IV bolus dose based on weight

30-50 mg

39
Q

What drugs are used for secondary prevention of ACS

A 
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
40
Q

Pain relief in ACS patients

A

Use APAP, tramadol, or narcotics before NSAIDs

If NSAID is unavoidable, use naproxen

41
Q

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

A

Naproxen because it is nonselective and and has lowest CV risk

42
Q

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

A

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

NAPLEX Review (79 decks)

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