Chapter 30: Acute Coronary Syndrome

Question 1

Acute Coronary Syndrome

Answer 1

Results from plaque buildup in the coronary arteries (coronary atherosclerosis). The plaque can rupture leading to clot (thrombus) formations and sudden reduced blood flow (ischemia) to the heart. This causes an imbalance between myocardial o2 supply and demand.

Question 2

Risk Factors for ACS

Answer 2

• Age (men >45; women >55 or early hysterectomy)
• Family Hx (1st degree relative with coronary event before 55 yrs (men) or 65 yrs (women)
• Smoking
• Hypertension
• Know coronary artery disease
• Dysplipidemia
• Diabetes
• Chronic Angina
• Lack of exercise
• Excessive alcohol

Question 3

Signs and Symptoms

Answer 3

• chest pain lasting >=10 minutes (pain can radiate to arms, back, neck, jaw or epigastric region)
• severe dyspnea
• diaphoresis

Question 4

Unstable Angina (UA)

Answer 4

• chest pain
• no cardiac enzymes present
• No ECG changes
• Partial blockage

Question 5

NSTEMI

Answer 5

• chest pain
• cardiac enzymes present
• no ECG changes
• partial blockage

Question 6

STEMI

Answer 6

• chest pain
• cardiac enzymes present
• ST segment elevation on ECG
• Complete blockage

Question 7

Drug Tx for ACS (MONA-GAP-BA)

Answer 7

M-morphine
O-oxygen
N-nitroglycerin
A-aspirin

G-GPIIb/IIIa antagonists
A-anticoagulatns
P-P2Y12 inhibitors

B-beta-blockers
A-ace inhibitors

Question 8

PCI

Answer 8

Involves inflating a small balloon inside a coronary artery to widen it and improve blood flow, usually a stent is placed into the artery afterward to keep it open
Should be performed within 90 minutes (door-to-balloon time) or 120 minutes of first medical contact.

Question 9

CABG

Answer 9

Coronary artery bypass graft

Question 10

Antianginals MOA in ACS Tx

Answer 10

Decrease myocardial oxygen demand

morphine, nitrates, BBs

Question 11

Antiplatelets MOA in ACS Tx

Answer 11

Inhibit platelet aggregation to prevent clot formation/growth

(aspirin, p2y12 inhibitors, GPIIb/IIIa inhibitors)

Question 12

Anticoagulants MOA in ACS Tx

Answer 12

Inhibit clotting factors to prevent clot formation

UFH, LMWH, bivalirudin

Question 13

MONA drugs

Answer 13

Give these drug immediately
Morphine- produces arterial and venous dilation (decreases preload and afterload)
oxygen
Nitrates- dilate coronary arteries, improve cardiac blood flow, decrease preload, reduces chest pain
Aspiring 325mg chewed

Question 14

GAP drugs

Answer 14

Give these next
GPIIb/IIIA antagonists- abciximab, eptifibatide, tirofuban
Anticoagulants- LMWHs, UFH, bivalirudin
P2Y12is- clopidogrel, prasugrel, ticagrelor

Question 15

BA drugs

Answer 15

Give within 24 hours prn and continue as outpatient
Beta-blockers- increases long term survival, start within 24 hours
ACEis- start within 24 hours and continue indefinitely

Question 16

Prasugrel

Answer 16

Effient

CI with serious bleeding, Hx of TIA or stroke

Question 17

Ticagrelor

Answer 17

Brillinta
90mg bid for 1 year then 60mg bid
CI with active serious bleeding, hx of intracranial hemorrhage

Question 18

Cangrelor

Answer 18

Kengreal

Injection

Question 19

Abciximab

Answer 19

Reopro
GPIIb/IIIa receptor antagonist
SE: bleeding, thrombocytopenia

Question 20

Eptifibatide

Answer 20

Integrillin

GPIIb/IIIa receptor antagonist

Question 21

Fibrinolytics MOA

Answer 21

Cause fibrinolysis by bidning to fibrin and converting plasminogen to plasmin.

Are only used for STEMI, should be given within 30 minutes of arrival to hospital

Question 22

Alteplase

Answer 22

Activase
Recombinant tissue plasminogen activator (tPA)
CI: active internal bleeding, hx of recent stroke, severe uncontrolled htn

Question 23

Tenecteplase

Answer 23

TNKase

CI: active internal bleeding, hx of recent stroke, severe uncontrolled htn

Question 24

NSAIDs

Answer 24

Avoid all, except naproxen if other options are not sufficient