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NAPLEX 2023 > Chapter 30: Acute Coronary Syndromes > Flashcards

Chapter 30: Acute Coronary Syndromes Flashcards

1
Q

An acute coronary syndrome results from ____ buildup in the _____ (coronary atherosclerosis).

A

plaque

coronary arteries

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2
Q

Plaque buildup can rupture, leading to ____ formation and _____ to the heart.

A

thrombus

ischemia

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3
Q

Risk factors that lead to plaque buildup that causes an ACS

A
  • Age: men > 45 years, women > 55 years (or early hysterectomy
  • Family hx: 1st degree relative w/ coronary event before 55 years (men) or 65 years (women)
  • Smoking
  • HTN
  • Known coronary artery disease
  • Dyslipidemia
  • Diabetes
  • Chronic angina
  • Lack of exercise
  • Excessive alcohol
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4
Q

Classic signs and symptoms of ACS

A

chest pain (pressure and squeezing) lasting > 10 min, severe dyspnea, diaphoresis, syncope/presyncope, and/or palpitations

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5
Q

Pain from ACS can radiate to

A

arms, back, neck, jaw, or epigastric region

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6
Q

Patients with a prescription for SL nitroglycerin should use __ dose(s) every __ min up to ___ doses for relief of chest pain. If the pain is not improved or is worse __ min after the first dose, call 911 immediately

A

one dose every 5 min up to 3 doses

5 min

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7
Q

NSTE-ACS describes which 2 medical conditions

A

Unstable angina & NSTEMI

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8
Q

Cardiac enzymes in unstable angina are (neg/pos)
Cardiac enzymes in NSTEMI are (neg/pos)
Cardiac enzymes in STEMI are (neg/pos)

A

UA - negative
NSTEMI - Positive
STEMI - Positive

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9
Q 
There is (partial/complete) blockage in unstable angina
There is (partial/complete) blockage in NSTEMI
There is (partial/complete) blockage in STEMI
A

UA - partial
NSTEMI - partial
STEMI - complete

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10
Q

___ should be performed and evaluated within 10 minutes at the site of first medical contact after ACS

A

A 12-lead ECG

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11
Q

Patients with STEMI or NSTEMI should be urgently transported to a hospital with _____ capability, if possible

A

percutaneous coronary intervention (PCI)

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12
Q

What are the most sensitive and specific biomarkers for ACS

A

Cardiac troponins I & T (TnI and TnT)

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13
Q

When should cardiac troponin levels be obtained in all patients with ACS symptoms

A

At presentation & 3-6 hours after symptom onset

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14
Q

What is PCI

A

a coronary revascularization procedure that involves inflating a small balloon inside a coronary artery to widen it and improve blood flow. Usually, a metal stent is placed into the artery after to keep it open

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15
Q

In STEMI, the blocked arteries need to be opened how quickly

A

as quickly as possible with PCI (preferred) or fibrinolytics

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16
Q

Acute treatment of ACS is aimed at

A

Immediate relief of ischemia & preventing MI expansion and death

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17
Q

Drug treatment for ACS

A
  • remember MONA-GAP-BA*
  • Morphine
  • Oxygen
  • Nitrates
  • Aspirin
  • GPIIb/IIIa antagonists
  • Anticoagulants
  • P2Y12 inhibitors
  • Beta-blockers
  • ACE inhibitors
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18
Q

Which antianginals are used in ACS

A

Morphine, BB, nitrates

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19
Q

MOA of antianginals in ACS

A

Decrease myocardial O2 demand or increase myocardial O2 supply (blood flow) to relieve ischemia

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20
Q

MOA of antiplatelets in ACS

A

Inhibit platelet aggregation to prevent clot formation/growth

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21
Q

MOA of anticoagulants in ACS

A

inhibit clotting factors to prevent clot formation/growth

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22
Q

NSTE-ACS (i.e, NSTEMI and unstable angina) are treated with:

A

MONA-GAP-BA +/- PCI

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23
Q

STEMI is treated with

A

MONA-GAP-BA + PCI (preferred) or fibrinolytic

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24
Q

When should morphine, O2, nitrates and ASA (MONA) be given

A

Immediately as needed

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25
Q

MOA of morphine in ACS

A

Antianginal; produces arterial and venous dilation (↓ preload and afterload)
Provides pain relief

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26
Q

MOA of nitrates in ACS

A

Antianginal: dilates coronary arteries and improves collateral blood flow; ↓ preload and afterload (modestly); reduces chest pain

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27
Q

Which dose and formulation of NTG should be administered in ACS

A

SL 0.4 mg

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28
Q

Which drug class is CI with nitrates

A

PDE5-i

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29
Q

Which dose and formulation of aspirin should be administered in ACS

A

Non-EC, chewable ASA

162-325 mg

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30
Q

Do not use which formulation of ASA in ACS

A

extended release

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31
Q

What is the maintenance dose of ASA that should be continued indefinitely in ACS

A

81-162 mg daily

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32
Q

Which drugs are GPIIb/IIIa receptor antagonists

A

abciximab, eptifibatide, and tirofiban

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33
Q

Which anticoagulant is preferred for STEMI

A

bivalirudin

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34
Q

Which anticoagulants are used in ACS

A

LMWHs (e.g. enoxaparin, dalteparin), UFH and bivalirudin

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35
Q

Which P2Y12 inhibitors are used in ACS

A

clopidogrel, prasugrel, and ticagrelor

36
Q

Which drugs are given within 24 hrs (as needed) in ACS & continued as outpatient

A

BB and ACEi

37
Q

Why are BB used in ACS

A

they increase long-term survival

38
Q

Which type of BB is preferred in ACS

A

oral low dose BB (B1 selective blocker without intrinsic sympathomimetic activity preferred)

39
Q

Which BB do have ISA & should be avoided post-MI

A

Acebutolol, penbutolol and pindolol

40
Q

Which two drugs are continued indefinitely post ACS

A

BB & ACEi (in pts with LVEF < 40%, HTN, DM, or stable CKD)

41
Q

Which medications should be avoided in ACS

A
  • NSAIDs (except ASA) should not be administered during hospitalization
  • IR nifedipine d/t increased risk of mortality
42
Q

MOA of aspirin

A

inhibits platelet aggregation/clot formation by inhibiting production of TXA2 via irreversible COX1 and COX2 inhibition

43
Q

MOA of P2Y12 inhibitors

A

bind to the ADP P2Y12 receptor on the platelet surface which prevents ADP-mediated activation of the GPIIb/IIIa receptor complex, thereby reducing platelet aggregation

44
Q

GPIIb/IIIa receptor antagonists MOA

A

block the platelet glycoprotein IIb/IIIa receptor, which is the binding site for fibrinogen, vWf and other ligands, thereby ↓ plt aggregation and further thrombosis

45
Q

Vorapaxar MOA

A

PAR-1 antagonist that reversibly binds to the PAR-1 expressed on platelets, preventing thrombin-induced and thrombin receptor agonist peptide-induced platelet aggregation

46
Q

Which two P2Y12 inhibitors are prodrugs that irreversibly bind to the receptor

A

Clopidogrel and prasugrel

47
Q

Clopidogrel and prasugrel are classified as

A

thienopyridines

48
Q

P2Y12 inhibitors are commonly used with ___ after ACS

49
Q

Clopidogrel maintenance dose

A

75 mg PO daily

note: a much higher loading dose is required either prior to PIC or at the time of dx if PCI is not performed

50
Q

Clopidogrel effectiveness depends on the conversion to _____, mainly by which CYP enzyme?

A

an active metabolite

2C19

51
Q

Clopidogrel CI

A

active serious bleeding

52
Q

Clopidogrel should be stopped ___ days prior to elective surgery

53
Q

Do not use clopidogrel with these 2 drugs d/t severe drug interaction

A

Omeprazole and esomeprazole

54
Q

All P2Y12 inhibitors can cause

A

Thrombotic thrombocytopenic purpura (TTP)

55
Q

Prasugrel brand name

56
Q

Which P2Y12 inhibitor must be dispensed in its original container to protect from moisture

57
Q

Ticagrelor brand name

58
Q

Which P2Y12 inhibitor comes as an injection

59
Q

Ticagrelor maintenance dose

A

90 mg PO BID for 1 year, then 60 mg BID

60
Q

Prasugrel CI

A

Active serious bleeding, history of TIA or stroke

61
Q

Prasugrel should be stopped ___ days prior to elective surgery

62
Q

If using Ticagrelor, after the initial dose of 162-325 mg of ASA, do not exceed aspirin ___ mg for maintenance doses because higher daily doses can reduce the effectiveness of ticagrelor

63
Q

Ticagrelor should be stopped ___ days prior to any surgery

64
Q

Besides bleeding, what is another side effect of ticagrelor

A

Dyspnea

think of a tiger chasing you and you’re out of breath

65
Q

Which drugs can increase the risk of bleeding and should be avoided with P2Y12 inhibitors

A

NSAIDs, SSRI, SNRI, and warfarin

66
Q

Abciximab brand name

A

ReoPro (a pro with abs)

67
Q

Eptifibatide brand name

A

Integrilin

68
Q

Side effect of GPIIb/IIIa receptor antagonists

A

Bleeding, thrombocytopenia

69
Q

MOA of fibrinolytics

A

cause fibrinolysis (clot breakdown) by binding to fibrin and converting plasminogen to plasmin

70
Q

Fibrinolytics are only used for

71
Q

PCI for STEMI is preferred if it can be performed within __ minutes (optimal door-to-balloon time) or within __ minutes of first medical contact (which could be in an ambulance)

72
Q

If PCI is not possible, fibrinolytic therapy is recommended for STEMI and should be given within __ min of hospital arrival (door-to-needle time)

73
Q

Which drugs are fibrinolytics

A

Alteplase (tPA) and tenecteplase

74
Q

Alteplase brand name

A 
Activase
Cathflo Activase (single-use 2 mg vial)
75
Q

tenecteplase brand name

76
Q

Fibrinolytic CI

A

Active internal bleeding
history of recent stroke
severe uncontrolled HTN

77
Q

Alteplase CI and dosing differ for which condition

A

ischemic stroke

78
Q

Drugs used for secondary prevention after ACS & duration

A
  • Aspirin 81 mg/day indefinitely
  • P2Y12 inhibitor
  • NTG indefinitely
  • BB: 3 years; indefinitely if HF or if needed for HTN
  • ACEi indefinitely if EF < 40%, HTN, CKD or diabetes
  • Aldosterone antagonist if EF = 40% and either sx HF or DM receiving target doses of an ACEi and BB
  • High-intensity Statin indefinitely
79
Q

Aldosterone antagonist CI

A

significant renal impairment (SCr > 2.5 mg/dl in men, SCr > 2 mg/dl in women) or hyperkalemia (K > 5 mEq/L)

80
Q

Which P2Y12 inhibitors can a patient who was treated with PCI receive (including any type of stent) for secondary prevention after ACS

A

Clopidogrel, prasugrel or ticagrelor with ASA 81 mg for at least 12 months

81
Q

Continuation of dual antiplatelet therapy beyond 12 months can be considered in pts who received a PCI or stent in which pts

A

Pts who are tolerating DAPT and are not at high risk of bleeding following coronary stent placement

82
Q

Which P2Y12 inhibitors can a patient who received fibrinolytics receive for secondary prevention after ACS

A

Ticagrelor or clopidogrel with ASA 81 mg for at least 12 months

83
Q

Which NSAID can be used for pain relief after ACS

A

Naproxen (lowest CV risk)

84
Q

Which NSAIDs should be avoided after ACS since they have high CV risk

A

COX-2 selective NSAIDs (Bextra, Celebrex, and Vioxx)

85
Q

Which drug class should be prescribed in any patient with a history of GI bleeding while taking triple antithrombotic therapy

NAPLEX 2023 (88 decks)

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