Chapter 30: Acute Coronary Syndromes Flashcards by Rohit Sampat

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

plaque

coronary arteries

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

thrombus

ischemia

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Risk factors that lead to plaque buildup that causes an ACS

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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Classic signs and symptoms of ACS

chest pain (pressure and squeezing) lasting > 10 min

severe dyspnea

diaphoresis

syncope/presyncope

and/or palpitations

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Pain from ACS can radiate to

arms

back

neck

jaw

epigastric region

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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

one dose every 5 min up to 3 doses

5 min

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NSTE-ACS describes which 2 medical conditions

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

UA - negative

NSTEMI - Positive

STEMI - Positive

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

UA - partial
NSTEMI - partial
STEMI - complete

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

A 12-lead ECG

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

percutaneous coronary intervention (PCI)

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What are the most sensitive and specific biomarkers for ACS

Cardiac troponins I & T (TnI and TnT)

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

At presentation

3-6 hours after symptom onset

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What is PCI

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

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

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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Acute treatment of ACS is aimed at

Immediate relief of ischemia & preventing MI expansion and death

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Drug treatment for ACS

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

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Which antianginals are used in ACS

Morphine, BB, nitrates

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MOA of antianginals in ACS

Decrease myocardial O2 demand

increase myocardial O2 supply (blood flow) to relieve ischemia

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MOA of antiplatelets in ACS

Inhibit platelet aggregation to prevent clot formation/growth

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MOA of anticoagulants in ACS

inhibit clotting factors to prevent clot formation/growth

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

MONA-GAP-BA +/- PCI

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STEMI is treated with

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

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

Immediately as needed

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MOA of morphine in ACS

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

MOA of nitrates in ACS

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

Which dose and formulation of NTG should be administered in ACS

SL 0.4 mg

Which drug class is CI with nitrates

PDE5-i

Which dose and formulation of aspirin should be administered in ACS

Non-EC, chewable ASA | 162-325 mg

Do not use which formulation of ASA in ACS

extended release

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

81-162 mg daily

Which drugs are GPIIb/IIIa receptor antagonists

abciximab eptifibatide tirofiban

Which anticoagulant is preferred for STEMI

bivalirudin

Which anticoagulants are used in ACS

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

Which P2Y12 inhibitors are used in ACS

clopidogrel prasugrel ticagrelor

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

BB and ACEi

Why are BB used in ACS

they increase long-term survival

Which type of BB is preferred in ACS

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

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

acebutolol penbutolol pindolol

Which two drugs are continued indefinitely post ACS

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

Which medications should be avoided in ACS

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

MOA of aspirin

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

MOA of P2Y12 inhibitors

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

GPIIb/IIIa receptor antagonists MOA

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

Vorapaxar MOA

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

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

Clopidogrel prasugrel

Clopidogrel and prasugrel are classified as

thienopyridines

P2Y12 inhibitors are commonly used with ___ after ACS

Aspirin

Clopidogrel maintenance dose

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

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

an active metabolite | 2C19

Clopidogrel CI

active serious bleeding

Clopidogrel should be stopped ___ days prior to elective surgery

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

omeprazole esomeprazole

All P2Y12 inhibitors can cause

Thrombotic thrombocytopenic purpura (TTP)

Prasugrel brand name

Effient

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

Prasugrel

Ticagrelor brand name

Brillinta

Which P2Y12 inhibitor comes as an injection

Cangrelor

Ticagrelor maintenance dose

90 mg PO BID for 1 year then 60 mg BID

Prasugrel CI

Active serious bleeding history of TIA or stroke

Prasugrel should be stopped ___ days prior to elective surgery

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

100 mg

Ticagrelor should be stopped ___ days prior to any surgery

Besides bleeding, what is another side effect of ticagrelor

Dyspnea | think of a tiger chasing you and you're out of breath

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

NSAIDs SSRI, SNRI warfarin

Abciximab brand name

ReoPro

Eptifibatide brand name

Integrilin

Side effect of GPIIb/IIIa receptor antagonists

Bleeding, thrombocytopenia

MOA of fibrinolytics

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

Fibrinolytics are only used for

STEMI

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)

90 | 120

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

Which drugs are fibrinolytics

Alteplase (tPA) and tenecteplase

Alteplase brand name

``` Activase Cathflo Activase (single-use 2 mg vial) ```

tenecteplase brand name

TNKase

Fibrinolytic CI

Active internal bleeding history of recent stroke severe uncontrolled HTN

Alteplase CI and dosing differ for which condition

ischemic stroke

Drugs used for secondary prevention after ACS & duration

- 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

Aldosterone antagonist CI

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

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

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

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

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

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

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

Which NSAID can be used for pain relief after ACS

Naproxen (lowest CV risk)

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

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

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

PPIs