Acute Coronary Syndromes (ACS)

Question 1

ACS definition

Answer 1

sudden, reduced blood flow causing an imbalance between oxygen supply and demand of the heart

Question 2

ACS conditions

Answer 2

non-ST segment elevation acute coronary syndromes (NSTE-ACS) - unstable angina and NSTEMI
ST-elevated myocardial infarction (STEMI)

Question 3

Classic symptoms of ACS

Answer 3

chest pain (can be radiating to arms, neck, back, jaw)
severe dyspnea
diaphoresis
syncope 
palpitations

Question 4

Pts that may not experience classic ACS symptoms

Answer 4

women
elderly
diabetics

Question 5

ACS risk factors

Answer 5

Men > 45, women > 55
1st degree relative with early ACS event (Men < 55, women < 65)
smoking
HTN
Dyslipidemia
diabetes
CAD/angina
lack of exercise
excessive alcohol

Question 6

ACS diagnosis/workup

Answer 6

ECG asap
Cardiac enzymes (troponins) asap and 3-6 hrs after onset of symptoms
CK-MB and myoglobin (less sensitive)

Question 7

What conditions will cardiac enzymes be positive?

Answer 7

NSTEMI and STEMI

Question 8

Drug treatment options for ACS (acronym)

Answer 8

MONA-GAP-BA
Morphine
Oxygen
Nitrates
ASA

GPIIb/IIIa antagonist
anticoagulants
P2Y12 inhibitors

Beta blockers
ACE inhibitors

Question 9

Morphine’s role in ACS

Answer 9

arterial/venous dilation –> decr oxygen demand

pain relief

Question 10

When to use oxygen

Answer 10

use if SaO2 < 90% or in respiratory distress

Question 11

When to not use NTG

Answer 11

SBP < 90, HR < 50

Question 12

What aspirin should be used for 1st dose?

Answer 12

Non-enteric coated, chewable 325 mg

Question 13

What are the preferred beta blocker in ACS and when should it be admin?

Answer 13

Beta-1 selective w/o ISA (metoprolol, bisoprolol, etc)

w/in 24 hrs

Question 14

Meds to avoid in acute setting of ACS

Answer 14

NSAIDs

IR nifedipine

Question 15

P2Y12 inhibitors that are prodrugs and irreversibile

Answer 15

clopidogrel

prasugrel

Question 16

Loading dose for clopidogrel

Answer 16

300-600 mg (600 for PCI)

do not give load dose if pt recieved firbrinolytics for STEMI and is > 75 y/o

Question 17

Clopidogrel is metabolized by….

Answer 17

CYP2C19

Question 18

How many days should Plavix be stopped prior to most surgeries?

Answer 18

5 days

Question 19

Rare but serious adverse effects associated with Plavix

Answer 19

thrombotic thrombocytopenic purpura (TTP)

Question 20

Plavix side effects

Answer 20

bleeding, pruritis

Question 21

Prasugrel contraindications

Answer 21

serious bleeding

hx of TIA/stroke

Question 22

Stop prasugrel how many days before surgery?

Answer 22

7 days

Question 23

Prasugrel loading dose

Answer 23

60 mg (before or up to 1 hr after PCI)

Question 24

Prasugrel maintenance dose

Answer 24

10 mg daily

5 mg daily (< 60 kg)

Question 25

Prasugrel age cut-off

Answer 25

75 years or older; not recommended unless high risk

Question 26

ticagrelor loading dose

Answer 26

180 mg

Question 27

ticagrelor maintenance dose

Answer 27

90 mg BID x 1yr, can give 60 mg BID after that

Question 28

Stop ticagrelor how many days prior to surgery?

Answer 28

5 days

Question 29

Max dose of ASA w/ ticagrelor

Answer 29

100 mg of ASA | ?100 mg will decrease effectiveness of ticagrelor

Question 30

ticagrelor side effects

Answer 30

bleeding, dyspnea (>10%), incr SCr, incr uric acid

Question 31

Cangrelor use...

Answer 31

adjunct to PCI to decrease risk of periprocedural MI IV infusion transition to oral agent immediately after PCI (use Load dose)

Question 32

Ticagrelor metabolism

Answer 32

CYP3A4

Question 33

GPIIb/IIIa receptor antagonist

Answer 33

ReoPro Integrillin Aggrastat

Question 34

Reopro

Answer 34

Abciximab only use ACS with PCI must be filtered platelet function returns 24-48 hrs after d/c

Question 35

Integrillin

Answer 35

Eptifibatide can't be used in pts on dialysis incr incidence of thrombocytopenia platelet function returns -4-8 hrs after d/c

Question 36

Aggrastat

Answer 36

Tirofiban | platelet function returns 4-8 hrs after d/c

Question 37

When would you use fibrionolytics?

Answer 37

In STEMI pts where PCI cannot be performed PCI must be performed w/in 90 mins of ED arrival fibrinolytics must be given w/in 30 mins of ED arrival

Question 38

Alteplase info

Answer 38

Activase Given as "accelerated infusion" > 67 kg = 100 mg IV over 1.5 hrs, 3 different admins < 67 kg = 15 mg bolus, then weight based

Question 39

Tenecteplase

Answer 39

``` TNKase SIngle IV bolus <60 kg = 30 mg 60-69 = 35 mg 70-79 = 40 mg 80-89 = 45 mg >= 90 kg = 50 mg ```

Question 40

Reteplase

Answer 40

Retavase | 10 units x 1, 10 units 30 mins later

Question 41

Vorapaxar

Answer 41

``` Zontiivty used with ASA and/or clopidogrel Protease-activated receptor 1 antagonist 2.08 mg daily CYP 3A4 substrate ```

Question 42

What NSAID should be used in pts with ACS?

Answer 42

Naproxen (less CV risk)

Question 43

Dual antiplatelet therapy duration

Answer 43

usually 12 months or more for PCI

Question 44

DUration of beta blocker therapy for ACS

Answer 44

3 years | indefinitely if HF/angina/ HTN management