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A - NAPLEX > 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

men > 45 years

women > 55 years (or early hysterectomy

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

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

Non-ST-elevation acute coronary syndrome (NSTE-ACS) is a condition that includes

  • unstable angina (UA)
  • non-ST-elevation myocardial infarction (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

percutaneous coronary intervention, a non-surgical procedure that treats blockages in the coronary arteries.

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

Fibrinolytics, also known as thrombolytics, are medications that break up blood clots or prevent new blood clots from forming. They are used as an emergency treatment to dissolve blood clots before they become fatal.

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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

A

Aspirin

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

A

5

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

A

Effient

56
Q

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

A

Prasugrel

57
Q

Ticagrelor brand name

A

Brillinta

58
Q

Which P2Y12 inhibitor comes as an injection

A

Cangrelor

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

A

7

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

A

100 mg

63
Q

Ticagrelor should be stopped ___ days prior to any surgery

A

5

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

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

A

STEMI

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)

A

90

120

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)

A

30

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

A

TNKase

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

A

PPIs

A - NAPLEX (83 decks)

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