Cardio 2 Flashcards
What is the definition of cardiovascular disease?
any disorder of the heart of blood vessels
What is included in atherosclerotic disease?
Coronary artery disease
Stroke
Aortic aneurysm
Peripheral vascular disease
What is athero?
artery
What is sclerosis?
hardening
Coronary artery disease includes:
Acute coronary syndrome (CCD)
Angina
What is the leading cause of ischemic heart disease?
coronary artery disease (CAD)
CAD is the result of __ in coronary vessels leading to myocardial oxygen supply/demand mismatch
atherosclerotic plaques
What is ischemia?
deficiency of blood supply
What is infarct?
Complete cut off of blood supply leading to cell death
Clinical ASCVD includes:
Stroke, TIA
Carotid artery stenosis
Peripheral vascular disease
Aortic aneurysm
Atherosclerosis is a result of __ cell dysfunction, inflammation, and an increase in __
endothelial cell
lipoproteins
Plaques generally develop in the __, or the innermost layer of the arterial wall
intima
What are unmodifiable risk factors for CAD?
age
sex
family history
genetics
What are modifiable risk factors for CAD?
smoking
comorbidities (HTN, HLD, DM)
obesity
stress
sedentary lifestyle
Ischemia and angina result from a(n) INCREASE/DECREASE in oxygen demand and a(n) INCREASE/DECREASE in oxygen supply
increase in demand
decrease in supply
What are common causes of ischemia?
atherosclerotic plaque**
emboli
vasospasm
trauma
hypoxia
hypotension
medications
What is included in Acute Coronary Syndrome?
STEMI
NSTEMI
Unstable angina
What is included in Chronic Coronary Disease?
Chronic stable angina
How does the heart adapt to lack of oxygen? Can it adapt acutely?
Cannot adapt acutely
Extracts more oxygen from hemoglobin in RBCs
Collateral circulation (new coronary vessel formation around blockage)
An increase in what requires an increase in coronary flow to maintain adequate oxygen supply to the heart and leads to angina?
heart rate
myocardial contractility
myocardial wall tension
The __ of the arterial lumen determines the reduction of blood flow
diameter
Coronary plaques occupying 50-70% of the lumen are usually considered __
non-obstructive
Coronary plaques occupying 70% or more of the lumen are considered __
obstructive
Coronary plaques occupying 90% or more of the lumen are considered __
critical stenosis
Plaque build up in coronary arteries causes __ and __ blood flow
narrowing
decreased
Plaques can rupture and cause __ and __
thrombus
ischemia
Imbalance between __ and __ leads to an infarct
oxygen supply and demand
PAR-1 receptor is for __
thrombin
P2Y12 receptor is for __
ADP
Thrombin converts __ to __ which stabilizes PLT plug leading to blockage
fibrinogen to fibrin
-
-
-
-
-
collagen
thrombin
TXA2
ADP
serotonin
COX-1
Platelet activation leads to expression of __ receptors
GPIIb/IIIa receptors
GPIIb/IIIa receptors link platelets together with fibrinogen causing __
platelet aggregation
What are symptoms of acute coronary syndrome?
chest pain/pressure >10 min
severe dyspnea
diaphoresis
syncope
palpitations
What are atypical symptoms of ACS?
indigestion
stabbing chest pain
increasing exertion dyspnea
Typical ACS chest pain is described as _/3
3
Atypical ACS chest pain is described as _/3
2
What are the three factors to determine typical, atypical, or non-cardiac chest pain?
substernal chest discomfort
provoked by exertion or emotional stress
relieved by rest or nitro
Are there physical exam findings specific for ACS? If so, what are they?
no
What are signs of ACS?
ECG changes
Elevated troponin (I and T)
Elevated CK-MB
Elevated myoglobin
Arrythmias
Troponin I is related to __
muscle contraction
Troponin C is related to __
conformational change due to Ca
Troponin T is related to __
anchors troponin to tropomyosin
What is a normal Hs-cTnT?
<14 ng/L
What is a normal Troponin T?
0-0.04 ng/mL
Unstable Angina:
-ECG?
-Troponins?
-Blockage?
Normal, ST depression, T wave inversions
Not elevated
Partial (no myocardial injury)
NSTEMI:
-ECG?
-Troponins?
-Blockage?
ST depression, T wave inversions, nonspecific changes
Elevated
Partial (myocardial injury)
STEMI:
-ECG?
-Troponins?
-Blockage?
ST elevation, hyper acute T waves
Elevated
Complete (myocardial necrosis)
Ventricular remodeling happens from __ and __ activation
Sympathetic nervous system
Renin-angiotensin aldosterone system
An activated sympathetic nervous system leads to __
increased contractility and heart rate
An increase in RAAS system leads to __
retention of sodium and water, vasoconstriction
increased perfusion and blood volume
In ACS which happens first, SNS or RAAS activation?
SNS activation
What is the definition of CCD?
Stable angina
not an acute event
predictable chest pain exacerbated by physical exertion or emotional stress
relieved by rest or with medications
ACS or SIHD?
thin fibrous cap
ACS
ACS or SIHD?
Thicker fibrous cap
SIHD
ACS or SIHD?
Cholesterol-rich core more likely to erode/rupture
ACS
ACS or SIHD?
Calcified core
SIHD
ACS or SIHD?
Often 70% or greater degree of stenosis
ACS
ACS or SIHD?
Non-obstructive (<70% luminal diameter)
SIHD
What is shown on the PE of CCD?
No specific findings
Elevated BP
Signs of HF, + JVD, pulmonary edema, S3 gallop
What labs are shown with CCD?
troponins NOT typically elevated
Lipid panel (increased TC and LDL)
What are symptoms of CCD?
similar to ACS by predictable/resolve with rest
How is CCD diagnosed?
EKG
exercise stress test
coronary angiography
cardiac MRI
cardiac biomarkers (troponin)
What is the pathophysiology of peripheral artery disease?
plaque development and decreased nitric oxide impairs vasodilatory response and increases artery stiffness
leads to chronic occlusion
PAD most commonly affects which arteries?
medium and large arteries in the lower extremities
Atherosclerosis causing PAD is most commonly due to endothelial cell injury such as __ and __
smoking
diabetes
What is the clinical presentation of PAD?
highly variable
asymptomatic
lower extremity pain at rest
intermittent claudication
chronic limb threatening ischemia (CLTI)/critical limb ischemia (CLI)
non healing wounds/gangrene
What is seen on the PE to diagnose PAD?
Cool, dry, cyanotic extremities
bruits
hypertrophic toenails
lack of hair on calf, feet
diminished tibial, pedis pulse
What score is used for diagnosing PAD?
ABI score
An ABI score of what indicates PAD?
less than or equal to 0.9
ABI score is obtained while patient is in the __ position
supine
ABI score uses the SYSTOLIC/DIASTOLIC blood pressure on the arms and legs
Systolic
What are complications that can happen with PAD?
Impaired blood flow and vascular dysfunction
Nonhealing wounds
Skin/limb necrosis
CLTI
Amputations
Temporary interruption of cerebral blood flow that leads to transient focal neurological deficits
TIA
TIA has a __ onset, lasts ___, and DOES/DOES NOT have evidence of acute infarction
sudden onset
last seconds to minutes
no evidence of acute infarction
What is a TIA caused by?
focal spinal cord, brain, or retinal ischemia within the pertinent artery
What is the clinical presentation of a TIA?
*slurred speech or aphasia
*facial dropp
*paralysis, weakness, or *numbness of one or more limbs
Visual disturbances
ataxia
clumsiness
parasthesia
vertigo or syncope
TIAs are risk factors for __
strokes
Significant interruption of cerebral blood flow that generally leads to a persistent or permanent neurological deficit
Stroke
What are the three classifications of stroke neurological deficits?
Stable
Improving
Progressing
Stable, improving, or progressing?
permanent deficit will not improve or deteriorate
Stable
Stable, improving, or progressing?
Neurologic deficit is recovering, may take days to weeks
Improving
Stable, improving, or progressing?
Neurologic deficit deteriorates after its onset
Progressing
What is the clinical presentation of a stroke?
Similar to TIAs but to a greater magnitude and the deficits are generally permanent
What are the types of stroke?
Ischemic
Hemorrhagic
Which type of stroke is due to an obstruction of cerebral blood flow?
ischemic
Which type of stroke is due to bleeding into an area of the brain and surrounding structures?
hemorrhagic
Most strokes are ISCHEMIC/HEMORRHAGIC
Ischemic
Are hemorrhagic or ischemic strokes more lethal?
hemorrhagic
What are unmodifiable risk factors for cerebral infarction strokes?
age
men
family history of stroke
African American
Low birth weight
What are modifiable risk factors for cerebral infarction strokes?
Hypertension
DM
DLP
Smoking
AFib
Presence of carotid stenosis
Lifestyle
Sickle cell disease
Use of oral contraceptives
Post-menopausal hormone therapy
What is primary prevention for stroke?
Reduce risk factors
Antithrombotic therapy
Procedures if cardiac bruit
For primary prevention of stroke and patient has afib, what is antithrombotic prevention?
Use CHA2DS2-VASc score
For primary prevention of stroke and patient doesn’t have afib what is antithrombotic prevention?
DO NOT use aspirin
What procedures are used for primary prevention of stroke if carotid bruit is heard?
Carotid endarterectomy
Carotid angioplasty
What are causes of stroke due to obstructed blood flow?
Plaque rupture
Embolism
How is stroke due to obstructed blood flow diagnosed?
PE
Brain imaging
NIH stroke scale
mRS
Differential diagnosis
What are two approaches that have improved morbidity and mortality of cerebral infarctions?
Rapid initiation of acute treatment
The establishment of stroke teams and stroke units
What should be done in all patients with cerebral infarction to see if thrombolytic therapy can be given?
Non-contrast CT scan or MRI of the brain
Blood glucose
Achieve blood pressure control
What should be done for all patients with cerebral infarction soon after admission?
CBC
Routine coagulation tests
Routine clinical chemistries
Oxygen saturation
Cardiac markers
EKG
If the stroke is mild and non-disabling, is thrombolytic therapy recommended?
No
What is the benefit of Alteplase for stroke?
Decrease severity of neurological impairment
What is a risk of using alteplase in stroke?
increased risk of intracranial hemorrhage
Do not use alteplase in stroke if:
Symptoms are mild
Symptoms are rapidly improving
What is the window of opportunity for alteplase in stroke patients?
3 hours from onset of event
The window of opportunity for alteplase in stroke can be extended if all the following are present:
Age less than 80
NIH 25 or less
Does not have both DM and prior stroke
Not using oral anticoagulant
No evidence of ischemic injury associated with >1/3 of middle cerebral artery territory
What is the goal of alteplase administration in stroke?
receive medication within 60 minuted of arrival to hospital
What is the dose of alteplase for stroke?
0.9mg/kg max 90mg
Can alteplase be given with heparin?
no
Alteplase should be stopped Dif the patient develops:
severe headache
actue HTN
nausea/vomiting
worsening neurological exam
If intracranial bleed occurs while patient is on alteplase, what should be done?
Stop med
Give tranexamic acid or aminocaproic acid
What are contraindications of alteplase?
Bleeding
Uncontrolled HTN
BG <50
Seizure at onset of stroke
Endocarditis
What are complications of alteplase?
Intracranial bleeding
angioedema
severe headache
acute HTN
worsened neurological findings
nausea/vomiting
If agiokedema occurs while patient is on alteplase what should be dome?
Stop med
Stop ACEI if being used
Administer Medrol, Benadryl, Pepcid
Administer epinephrine if angioedema worsens
When are intraarterial thrombolytics used?
Specialized centers
Unable/ineligible to receive IV therapy
Disorder is related to large vessel with a heavy clot
What is the window of opportunity of intraarterial thrombolytics for stroke?
within 6 hours
What is the preferred tPA if thrombectomy is being performed?
tenecteplase
If stroke is due to atherosclerosis patient should be started on a __ statin
high-intensity
What antiplatelet therapy is used in stroke?
Aspirin
If alteplase is given, how long should you wait to give aspirin?
24 hours
What antiplatelet therapy should be given in stroke for patients allergic to aspirin?
clopidogrel
If anticoagulation is needed for stroke patient with low risk for hemorrhagic conversion, when should it be given?
2-14 days after the event
If anticoagulation is needed for stroke patient with high risk for hemorrhagic conversion, when should it be given?
at least 14 days after the event
For DVT prophylaxis in stroke patient what medications can be given and when?
48 hours after stroke onset
EPC cuffs
Heparin BID or TID
Enoxaparin
What medications should not be used in stroke patients?
Corticosteroids for cerebral edema
Prophylactic anticonvulsant therapy
What are complications of cerebral infarction strokes?
Seizures
Pneumonia
DVTs
Depression
What is secondary prevention of cerebral infarction strokes?
Reduce risk factors
Blood pressure and blood glucose control
Endartectomy or stenting if >70% stenosis
Aggressive statinization
Antiplatelet therapy
The ABCD Score determines risk for __
subsequent stroke
What is secondary prevention for TIAs?
Reduce risk factors
Blood pressure reduction
Aggressive statinization
Antiplatelet therapy
Anticoagulation
When is combination therapy of aspirin and clopidogrel considered?
TIAs (ABCD 4 or higher)
Minor stroke (NIHSS 3 or lower)
Hemorrhagic strokes are often due to __
severe hypertension
arteriovenous malformations
aneurysms
trauma
medications
Risk of bleed into cerebral tissue is increased with uncontrolled __
blood pressure
Symptoms of bleed into cerebral tissue are due to __
blood directly irritating brain tissue
Bleed into the subdural cavity between dura mater and arachnoid are related to __
head and or skull trauma
Hemorrhagic stroke can be caused by bleeds in what three areas?
-Into cerebral tissue
-Into the subdural cavity between the dura mater and arachnoid
-Into space between arachnoid and pia mater
For hemorrhagic strokes, antithrombotic therapy can be stopped in __
1-2 weeks
What antithrombotic are used in hemorrhagic stroke?
Warfarin
Xa inhibitors
Thrombin Inhibitors
Heparin
LMWH
When is antihypertensive therapy used in hemorrhagic stroke?
cerebral bleed
SBP 150-220
Subarachnoid hemorrhage is a bleed into __
space between arachnoid and pia mater
Subarachnoid hemorrhage is caused by __
Aneurysm (Polycystic kidney disease)
Trauma
Arteriovenous malformations
What is the clinical presentation of subarachnoid hemorrhage?
“Worst headache of my life”
Feel a popping sensation at onset
Altered consciousness and/or confusion
Photophobia
Muscle aches
Nausea and/or vomiting
What is seen in the PE for subarachnoid hemorrhage?
stiff neck
decreased eye movement
neurologic deficit
How is a subarachnoid hemorrhage diagnosed?
Cerebral angiogram
CT angiogram
CT scan of the head
What are complications that occur from a subarachnoid hemorrhage?
Rebleeding
Hydrocephalus
Delayed ischemia
Seizures
What is hydrocephalus?
Accumulation of CSF within ventricular system of the brain
How is hydrocephalus managed?
Surgical placement of ventriculoperitoneal shunt
How is delayed ischemia due to subarachnoid hemorrhage prevented?
Volume expansion with NS
Fludrocortisone
Nimodipine
What are the two treatment considerations for subarachnoid hemorrhage?
Bleeding
Control BP
How should bleeding be managed of a subarachnoid hemorrhage?
Reverse anticoagulation
Surgical clipping
What are suggested medications to control BP in subarachnoid hemorrhage?
Nicardipine
Clevidipine
What is the Coronary angiography and PCI difference between a STEMI and NSTE-ACS?
STEMI:
-Emergent
-Preferred over thrombolytic therapy
-Primary PCI
NSTE-ACS:
-Early vs Late
-Generally early is preferred
-No mortality difference
What is non-pharm treatment in STEMI and NSTE-ACS?
Heart healthy diet
A1c <7
BMI 18.5-24.9
Waist circumference <35F, <40M
Aerobic activity 150 min/wk
Smoking cessation
Limiting alcohol 1F, 2M
What is the acronym for immediate drug therapy in STEMI/NSTE-ACS?
MONA-B
What is the acronym for at hospital drug therapy in STEMI/NSTE-ACS?
GAP
What is the acronym for prior to discharge for STEMI/NSTE-ACS?
BA2S2
What does MONA-B stand for?
Morphine
Oxygen
Nitrates
Aspirin
Beta-Blocker (CCB potentially)
What does GAP stand for?
GPIIb/IIIa antagonists
Anticoagulants
P2Y12 Inhibitors
What does BA2S2 stand for?
Beta-blocker
Ace-Inhibitor (or ARB)
Antiplatelets (ASA and P2Y12)
Statin/Smoking cessation
SL nitro PRN chest pain
When is should morphine be avoided?
Hypotension
Bradycardia
Lethargic
What is a clinical pearl with morphine?
May reduce oxygen demand but increased risk of mortality and decreases absorption of other oral ACS drugs
When should Oxygen be avoided?
COPD (88-92%)
When is oxygen indicated in STEMI/NSTE-ACS patients?
O2 Sat <90%
When should nitroglycerin be avoided?
SBP <90mmHg
PDE5 Inhibitors
RV infarct
What is a clinical pearl associated with nitroglycerin?
Useful in ACS related to vasospasms (cocaine-induced)
When should aspirin be avoided?
Severe bleeding
Allergy
If pt is already on baby aspirin, should a loading dose be given for STEMI?
yes
Which formulation of aspirin for loading dose should be given for STEMI/NSTE-ACS?
chewable
When should beta blockers be avoided?
Acute decompensated HF
Cardiogenic shock
AV block
What are clinical pearls of beta blockers for STEMI/NSTE-ACS?
Mortality benefit
Avoid IV (increased shock)
Can use any beta blocker
When should CCBs be used for STEMI/NSTE-ACS?
If beta blockers are contraindicated
Coronary vasospasms
When should CCBs be avoided?
Acute decompensated HF
Cardiogenic shock
AV block
Hypotension
Non-DHP CCBs are contraindicated in __
EF <40%
What CCB should be avoided for STEMI/NSTE-ACS?
IR Nifedipine
When are fibrinolytics indicated?
STEMI
If cannot do PCI within 120 minutes
Symptom onset past 12 hours
What is door-to-needle time for fibrinolytics in STEMI?
30 minutes
What are relative contraindications to fibrinolysis?
Ischemic stroke>3 months ago
Recent major surgery <3 weeks
Trauma
Recent internal bleed <4 weeks
BP >180/110 mmHg
What are absolute contraindications to fibrinolysis?
Any prior hemorrhagic stroke
Ischemic stroke <3 months
Intracranial neoplasm
Active internal bleed
Aortic dissection
Facial/head trauma <3 months
Intracranial/spine surgery <2 months
Severe hypertension
What should be given with fibrinolytics?
Antiplatelets
Anticoagulation
What anticoagulation can be given prior to PCI?
UFH
Bivalirudin
LMWH
Fondaparinux
What anticoagulation should be given for STEMI patients during PCI?
UFH
Bivalirudin
LMWH
If UFH or bivalirudin are to be continued after PCI when should it be stopped?
48 hours
If LMWH or Fondaparinux are continued after PCI when should they be stopped?
8 days or at discharge
Anticoagulation dosing for STEMI undergoing PCI is LOWER/HIGHER than for a DVT
lower
What labs should be monitored for anticoagulation?
CBC (Hbg, HCT, PLTs)
How should heparin be monitored?
aXa-UFH
aPTT
ACT
How should Bivalirudin be monitored?
aPTT
ACT
How should Enoxaparin be monitored?
aXa-LMWH
ACT
During PCI the STEMI patients must have at least __ antiplatelets
two
What are antiplatelet choices during PCI?
Aspirin and oral P2Y12 inhibitor
Aspirin and IV cangrelor
Aspirin allergy: P2Y12 inhibitor and IV GIIb/IIIa inhibitor
What are reversible P2Y12 inhibitors?
Cangrelor
Ticagrelor
What are irreversible P2Y12 inhibitors?
Clopidogrel
Prasugrel
What are GIIb/IIIa inhibitor options?
Eptifbitide
Tirofiban
What drug can be used to bridge patients to surgery?
Cangrelor
GIIb/IIIa inhibitors are guideline recommended for __ use
bailout
What is dosing for Clopidogrel?
75mg 3-5 days
300mg 6-8 hours
600mg 2-4 hours
What is dosing for Prasugrel?
10mg 3 days
60mg 30-60 min
What is dosing for Ticagrelor?
90mg 2-3 dawys
180mg 60 min
Ticagrelor is contraindicated in __
intracrannial hemorrhage
What medications can decrease concentrations of clopidogrel?
Esomeprazole, omeprazole
Fluconazole, voriconazole
Fluoxetine
Fluvoxamine
Prasugrel is contraindicated in patients with history of __
stroke or TIA
Prasugrel dose is reduced to 5mg QD in which patient populations?
> 75 yo
<60kg
What dose of aspirin should be used with ticagrelor?
75-100mg
What are the preferred P2Y12 inhibitors?
Prasugrel
Ticagrelor
__ is the P2Y12 of choice in patients needing to be maintained on an oral anticoagulant
Clopidogrel
__ has not been studied in patients who are medically managed (no revascularization/PCI) or in combination with fibrinolytic therapy
Prasugrel
Loading dose is always needed when switching antiplatelet sin the EARLY/LATE phase
early
How do you switch from Ticagrelor to Clopidogrel?
600mg Clopidogrel loading dose 24 hours after last Ticagrelor dose
How do you switch from Ticagrelor to Prasugrel?
60mg Prasugrel loading dose 24 hours after last Ticagrelor dose
How do you change from Clopidogrel to Ticagrelor in early phase?
180mg Ticagrelor loading dose
How do you change from Clopidogrel tp Ticagrelor in late phase?
90mg BID Ticagrelor maintenance dose 24 hours after last Clopidogrel dose
How do you change from Prasugrel to Ticagrelor in early phase?
180mg Ticagrelor loading dose 24 hours after last Prasugrel dose
How do you change from Prasugrel to Ticagrelor in late phase?
90mg BID Ticagrelor maintenance dose 24 hours after last Prasugrel dose
How do you change from Prasugrel to Clopidogrel in early phase?
600mg Clopidogrel loading dose 24 hours after last Prasugrel dose
How do you change from Prasugrel to Clopidogrel in late phase?
75mg Clopidogrel maintenance dose 24 hours after last Prasugrel dose
How do you change from Clopidogrel to Prasugrel in early phase?
60mg Prasugrel loading dose
How do you change from Clopidogrel to Prasugrel in late phase?
10mg Prasugrel maintenance dose 24 hours after last Clopidogrel dose
What is considered early phase?
Within first 30 days
How do you switch from oral to IV P2Y12 Inhibitors?
Initiate within 72 hours from discontinuation fro a minimum of 48 hours and max of 7 days
How do you switch from Cangrelor to Clopidogrel?
600mg Clopidogrel immediately after Cangrelor discotinuation
How do you switch from Cangrelor to Prasugrel?
60mg Prasugrel immediately after Cangrelor discontinuation
How do you switch from Cangrelor to Ticagrelor?
180mg at start of Cangrelor up to immediately after discontinuation
What is included in DAPT?
Aspirin
and
Clopidogrel or Ticagrelor or Prasugrel
What’s Clopidogrel dosing in DAPT therapy?
600mg load
75mg daily
What’s Ticagrelor dosing in DAPT therapy?
180mg Load
90mg BID
60mg BID after 1 year
What’s Prasugrel dosing in DAPT therapy?
60mg load
10mg daily
5mg daily in select patients
When is DAPT therapy considered?
CABG (Clopidogrel only)
PCI
Medical Management (No Prasugrel)
Fibrinolytics (Clopidogrel preferred)
What is the duration of DAPT therapy? In high bleed risk patients?
Aspirin indefinitely, P2Y12 at 12 months
P2Y12 at 6 months
What is the duration for triple antiplatelet therapy?
Aspirin: 1 week
P2Y12: 12 months
OAC: indefinitelty
A higher DAPT score indicates __
longer DAPT therapy
What are the two purposes of statins post ACS events?
Hyperlipidemia
Plaque stabilization
What statins should be used post ACS event?
Atorvastatin 40-80mg
Rosuvastatin 20-40mg
What is the purpose of beta blocker use post ACS event?
Reduce likelihood of ventricular arrhythmias, recurrent ischemia/infarction, ventricular remodeling
Improve survival
When are beta blockers contraindicated post ACS?
Signs/symptoms of cariogenic shock (Low BP, bradycardia)
How long should beta blockers be continued post ACS?
minimum of 3 years
How long should beta blockers be continued post ACS in patients with a preserved EF?
1 year
RAAS inhibitors are suggested post ACS event in patients with which compelling indications?
HFrEF (<40%)
Hypertension
DM
Stable CKD
What nitrate should be given post ACS event?
Nitro SL tablet
Nitro TL spray
Nitro SL powder
PRN for immediate relief
When should nitroglycerin be avoided post ACS?
If recent use of PDE-5 inhibitor
