Acute Coronary Syndromes (ACS) intervention

Question 1

Non-pharm therapies

Answer 1

bed rest
continuous EKG monitoring (ST-segment elevations)
frequent vital sign measurements
procedures and surgery

Question 2

Non-pharm therapies

Answer 2

bed rest
continuous EKG monitoring (ST-segment elevations)
frequent vital sign measurements
procedures and surgery

Question 3

Angiography (aka cardiac catheterization)

Answer 3

patient is consciously sedated. a guide wire and catheter inserted into femoral, brachial, or radial artery and fed into aorta. contrast dye injected through catheter. x-ray cameras allow interventionalist to visualize coronary arteries and determine where obstruction is.

Question 4

Angioplasty

Answer 4

occurs during angiography. mechanical widening of narrowed or occluded coronary arteries via balloon inflation.

Question 5

Percutaneous coronary intervention (PCI)

Answer 5

occurs during angiography. mechanical widening of narrowed or occluded coronary artery via balloon inflation and stent placement.

Question 6

what is the door-to-ballon time?

Question 7

what is the door-to-ballon time?

Question 8

Angiography (aka cardiac catheterization)

Answer 8

patient is consciously sedated. a guide wire and catheter inserted into femoral, brachial, or radial artery and fed into aorta. contrast dye injected through catheter. x-ray cameras allow interventionalist to visualize coronary arteries and determine where obstruction is.

Question 9

Angioplasty

Answer 9

occurs during angiography. mechanical widening of narrowed or occluded coronary arteries via balloon inflation.

Question 10

Percutaneous coronary intervention (PCI)

Answer 10

occurs during angiography. mechanical widening of narrowed or occluded coronary artery via balloon inflation and stent placement.

Question 11

Coronary artery bypass graft (CABG)

Answer 11

usually occurs following an angiography that reveals substantial blockage in more than or equal to 3 coronary arteries. surgical procedure grafting veins from another part of the patient’s body to the coronary vasculature.

Question 12

Glycoprotein IIb/IIIa inhibitors

Answer 12

Efficacy: prevents reinfarction, recurrent ischemia, and salvages myocardial tissue. decreases mortality
Indication: consider for use in early invasive strategy in patients with excessive clot burden or continual ischemia despite other treatments.

Question 13

Antiplatelet Therapies

Answer 13

P2Y12 inhibitors

Glycoprotein IIb/IIIa inhibitors

Question 14

P2Y12 receptor inhibitor

Answer 14

Efficacy: decreases the rate of stent thrombosis, MI, stroke, and CV death. decreases mortality
Indication: all patients. only Clopidogrel and Ticagrelor approved for ischemia-guided strategy

Question 15

GP IIb/IIIa inhibitors contraindications

Answer 15

active bleed within 30 days
h/o ischemic stroke within 30 days
h/o hemorrhagic stroke
hypertensive urgency/emergency
major surgery within 6 weeks
GI/GU bleed within 6 weeks

Question 16

Effient (prasugrel)

Answer 16

Loading dose: 60 mg

only used in cath lab!

Question 17

Brillinta (ticagrelor)

Answer 17

Loading dose: 180 mg

Question 18

Glycoprotein IIb/IIIa inhibitors

Answer 18

Efficacy: prevents reinfarction, recurrent ischemia, and salvages myocardial tissue. decreases mortality

Question 19

Reopro (abciximab)
Integrillin (eptifibatide)
Aggrastat (tirofiban)

Answer 19

Dose: continuous IV infusion

Question 20

GP IIb/IIIa inhibitors cautions

Answer 20

thrombocytopenia (platelets

Question 21

GP IIb/IIIa inhibitors contraindications

Answer 21

active bleed within 30 days
h/o ischemic stroke within 30 days
h/o hemorrhagic stroke
hypertensive urgency/emergency
major surgery within 6 weeks

Question 22

Monitoring:
bleeding signs/symptoms
H/H
Platelets
SCr

Answer 22

Medications: 
all
all
all
eptifibatide, tirofiban
Frequency:
every shift
daily
4 hours after initiation, then daily
daily

Question 23

who should be on anticoagulants?

Answer 23

all patients should receive 1 anticoagulant

Question 24

Unfractionated Heparin (UFH)

Answer 24

Efficacy: reduces MI refractory angina when used with ASA. decreases mortality
Indication: ischemia-guided or early invasive strategy

Question 25

Ischemic-guided strategy (low risk) | Early invasive strategy (high-moderate risk)

Answer 25

Dose: 60 IU/kg bolus, then 12 IU/kg/hour infusion

Question 26

UFH cautions

Answer 26

malignant hypertension | thrombocytopenia (

Question 27

UFH contraindications

Answer 27

active bleed h/o HIT thrombocytopenia (

Question 28

Low Molecular Weight Heparin (LMWH)

Answer 28

Efficacy: greater or equal reduction in MI and death compared to UFH. decreases mortality Indication: ischemia-guided or early invasive strategy

Question 29

Lovenox (enoxaparin)

Answer 29

Dose: 1 mg/kg q 12 hours SQ | CrCl

Question 30

LMWH cautions

Answer 30

malignant hypertension | thrombocytopenia (

Question 31

Angiomax (bivalirudin)

Answer 31

Dose: IV bolus, then continuous infusion

Question 32

Factor X Inhibitors

Answer 32

Efficacy: similiar reduction in death and MI compared to enoxaparin. similiar efficacy/safety compared to UFH when used with fibrinolytics. decreases mortality Indication: UA/NSTEMI patients treated with ischemia-guided strategy. STEMI patients when using a fibrinolytic (ischemia-guided)

Question 33

Reperfusion therapy | STEMI patients

Answer 33

Efficacy: decreases mortality by 20% via myocardial salvage. greater benefit with earlier administration. Indication: STEMI patients ONLY! presenting to hospital within 12 hours of symptom onset --> initiate within 30 minutes of hospital arrival (door-to-needle time) -->preferred method of perfusion if: * (door-to-balloon time)- (door-to-needle time) > 60 mins * delay in PCI availability: door to balloon > 90-120 mins

Question 34

Factor X inhibitor Cautions

Answer 34

age > 75 yo | thrombocytopenia (

Question 35

Factor X inhibitor contraindications

Answer 35

active bleeding | CrCl

Question 36

Activase (alteplase t-PA) Retevase (reteplase r-PA) TNKase (tenecteplase TNK) Streptase (streprokinase SK)

Answer 36

Dose: IV

Question 37

Angiomax (bivalirudin)

Answer 37

Dose: IV bolus, then continuous infusion

Question 38

Direct Thrombin inhibitor contraindications

Answer 38

active bleeding

Question 39

Reperfusion therapy | STEMI patients

Answer 39

Efficacy: decreases mortality by 20% via myocardial salvage. greater benefit with earlier administration. Indication: STEMI patients ONLY! presenting to hospital within 12 hours of symptom onset --> initiate

Question 40

Direct Thrombin inhibitor contraindications

Answer 40

``` active internal bleeding suspected aortic dissection h/o hemorrhagic stroke h/o ischemic stroke within 3 months known intracranial neoplasm ```

Question 41

Direct Thrombin inhibitor cautions

Answer 41

age > 75 yo uncontrolled HTN (SBP > 180 mmHg and/or DBP >110 mmHG) h/o CVA anticoagulant therapy or an INR greater than or equal to 2 known bleeding diathesis trauma within 2-4 weeks major surgery with

Question 42

Activase (alteplase t-PA) Retevase (reteplase r-PA) TNKase (tenecteplase TNK) Streptase (streprokinase SK)

Answer 42

Dose: IV