E3: Unstable Angina + NSTEMI Flashcards
What does OSNAAP stand for in the Acute treatment of ACS?
O: oxygen
S: Statin
N: Nitroglycerin
A: Aspirin
A: Anticoagulation
P: P2Y12 Inhibitor
In what situations would we use medical management rather than PCI in acute ACS?
- Old/ Frail
- Dialysis (contrast DI)
- No Institutional PCI capability.
Who should get OSNAAP therapy?
All Acute ACS Events.
During an ACS event, what strength statin should the patient be initiated on?
High Intensity statin.
Rosuvastatin: 20-40 mg
Atorvastatin: 40-80 mg.
Why are statins beneficial during an acute ACS event if their primary indication is for LDL lowering capabilities?
Pleotropic Effects:
Antiplatelet + Plaque stabilization.
Should all patients presenting with acute ACS receive nitroglycerin?
No, only if they are experiencing chest pain.
What is the dosing frequency for sublingual nitroglycerin in acute ACS?
- SL nitroglycerin every 5 minutes for a maximum of 3 doses.
Then the patient should be assessed for possible IV NTG use.
In what situations would we utilize IV NTG?
The patient has already maximized oral NTG. (3 doses 15 minutes)
and they have one of the following conditions:
1. Persistent Ischemia
2. HF
3. Hypertension.
What is the primary contraindication of NTG?
Recent use of a PDE5 inhibitor.
These include Sildenafil, Tadalafil, and Avanavil.
NTG can not be used for _____ hours after sildenfil or avandifil.
24 hours.
NTG can not be used for ___ hours after tadalafil.
48 hours.
Should all patients presenting with acute unstable angina/NSTEMI receive aspirin?
Yes
What is the loading dose of aspirin in acute ACS therapy?
162-365 mg.
This should be chewable aspirin only.
In an acute ACS event, IV fractionated heparin should be used until _________.
48 hours of treatment or a PCI has occurred.
In an acute ACS event, SQ enoxaparin should be used until __________.
The entire duration of the hospitalization or until PCI is performed.
In unstable angina, what is the loading dose of clopidogrel?
600 mg
In unstable angina, what is the maintenance dose of clopidogrel and for how long.
75 mg QD for 1-6 months.
In unstable angina what is the loading dose of ticagrelor?
180 mg
In unstable angina, what is the maintenance dose of ticagrelor?
90 mg BID for 1-6 months.
In unstable angina, what is the preferred P2Y12 inhibitor per OSNAAP.
Ticagrelor.
When should prasugrel be utilized for unstable angina?
After coronary visualization has occurred. (PCI)
In unstable angina, what is the loading dose of prasugrel?
60 mg
In unstable angina, what is the maintenance dose of prasugrel?
10 mg QD
This P2Y12 inhibitor should not be used for medical management due to the increased risk of intracranial bleeding. (it is reserved for patients who have undergone PCI)
Prasugrel.
Aggrastat is a __________, and the generic name is ______.
GIIB/IIIa Inhibitor
Tirofiban
Integrilin is a __________, and the generic name is ______.
GIIB/IIIa Inhibitor
Eptifibatide
Reopro is a __________, and the generic name is ______.
GIIB/IIIa Inhibitor
Abciximab
This class of drugs are indicated in unstable angina for cardiac catheterization with significant clot burden.
GIIB/IIIa Inhibitors.
Tirofiban, Eptifiban, Abciximab
This class of drugs blocks the binding site of fibrinogen, preventing clot stabilization.
GIIB/IIIa Inhibitors
Tirofiban, Eptifiban, Abciximab
What is something we should watch out for when using GIIB/IIIa inhibitors.
Increased Bleeding risk, especially with Aspirin, P2Y12 inhibitor or anticoagulant.
What acronym do we use for the long-term treatment following an unstable angina hospitalization?
SNAP-BAM
What does SNAP-BAM stand for.
- Statin
- Nitroglycerin
- Aspirin
- P2Y12 Inhibitor
- Beta Blocker
- ACEi/ARB
- Mineralocorticoid Receptor Blocker.
How long should beta-blockers be on board following an unstable angina hospitalization?
1-3 years.
What patients should be initiated on a beta-blocker on discharge following an unstable angina hospitalization?
All patients
(we would only hold for signs of acute heart failure.)
Which Beta-Blockers have proven CV mortality benefit in HFrEF?
- Bisoprolol
- Carvedilol
- Metoprolol Succinate XL
What patients should be initiated on an ACEi/ARB upon discharge following an unstable angina hospitalization?
1.All patients with an ejection fraction <40%.
AND
- All patients with diabetes, hypertension, or CKD.
Note, the HOPE trial shows data to suggest all patients should be initiated on an ACEi/ARB. However, if the patient has a normal EF and low BP. Beta-blocker therapy is preferred due to proven mortality benefit.
Upon discharge following an unstable angina hospitalization, when should mineralocorticoid receptor antagonist be used.
In all patients with an ejection fraction <40% who are already on both an ACEi/ARB and a Beta-blocker.
Eplerenone and Spironolactone are of the what drug class?
Mineralocorticoid Receptor Antagonist.
When are MRAs contraindicated?
- SCr (2.5+ in men, 2.0 in women)
- K+ (Above 5 mEq/L)
