E3: Unstable Angina + NSTEMI

Question 1

What does OSNAAP stand for in the Acute treatment of ACS?

Answer 1

O: oxygen
S: Statin
N: Nitroglycerin
A: Aspirin
A: Anticoagulation
P: P2Y12 Inhibitor

Question 2

In what situations would we use medical management rather than PCI in acute ACS?

Answer 2

1. Old/ Frail
2. Dialysis (contrast DI)
3. No Institutional PCI capability.

Question 3

Who should get OSNAAP therapy?

Answer 3

All Acute ACS Events.

Question 4

During an ACS event, what strength statin should the patient be initiated on?

Answer 4

High Intensity statin.

Rosuvastatin: 20-40 mg
Atorvastatin: 40-80 mg.

Question 5

Why are statins beneficial during an acute ACS event if their primary indication is for LDL lowering capabilities?

Answer 5

Pleotropic Effects:
Antiplatelet + Plaque stabilization.

Question 6

Should all patients presenting with acute ACS receive nitroglycerin?

Answer 6

No, only if they are experiencing chest pain.

Question 7

What is the dosing frequency for sublingual nitroglycerin in acute ACS?

Answer 7

1. SL nitroglycerin every 5 minutes for a maximum of 3 doses.

Then the patient should be assessed for possible IV NTG use.

Question 8

In what situations would we utilize IV NTG?

Answer 8

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.

Question 9

What is the primary contraindication of NTG?

Answer 9

Recent use of a PDE5 inhibitor.
These include Sildenafil, Tadalafil, and Avanavil.

Question 10

NTG can not be used for _____ hours after sildenfil or avandifil.

Answer 10

24 hours.

Question 11

NTG can not be used for ___ hours after tadalafil.

Answer 11

48 hours.

Question 12

Should all patients presenting with acute unstable angina/NSTEMI receive aspirin?

Answer 12

Yes

Question 13

What is the loading dose of aspirin in acute ACS therapy?

Answer 13

162-365 mg.
This should be chewable aspirin only.

Question 14

In an acute ACS event, IV fractionated heparin should be used until _________.

Answer 14

48 hours of treatment or a PCI has occurred.

Question 15

In an acute ACS event, SQ enoxaparin should be used until __________.

Answer 15

The entire duration of the hospitalization or until PCI is performed.

Question 16

In unstable angina, what is the loading dose of clopidogrel?

Answer 16

600 mg

Question 17

In unstable angina, what is the maintenance dose of clopidogrel and for how long.

Answer 17

75 mg QD for 1-6 months.

Question 18

In unstable angina what is the loading dose of ticagrelor?

Answer 18

180 mg

Question 19

In unstable angina, what is the maintenance dose of ticagrelor?

Answer 19

90 mg BID for 1-6 months.

Question 20

In unstable angina, what is the preferred P2Y12 inhibitor per OSNAAP.

Answer 20

Ticagrelor.

Question 21

When should prasugrel be utilized for unstable angina?

Answer 21

After coronary visualization has occurred. (PCI)

Question 22

In unstable angina, what is the loading dose of prasugrel?

Answer 22

60 mg

Question 23

In unstable angina, what is the maintenance dose of prasugrel?

Answer 23

10 mg QD

Question 24

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)

Answer 24

Prasugrel.

Question 25

Aggrastat is a __________, and the generic name is ______.

Answer 25

GIIB/IIIa Inhibitor Tirofiban

Question 26

Integrilin is a __________, and the generic name is ______.

Answer 26

GIIB/IIIa Inhibitor Eptifibatide

Question 27

Reopro is a __________, and the generic name is ______.

Answer 27

GIIB/IIIa Inhibitor Abciximab

Question 28

This class of drugs are indicated in unstable angina for cardiac catheterization with significant clot burden.

Answer 28

GIIB/IIIa Inhibitors. Tirofiban, Eptifiban, Abciximab

Question 29

This class of drugs blocks the binding site of fibrinogen, preventing clot stabilization.

Answer 29

GIIB/IIIa Inhibitors Tirofiban, Eptifiban, Abciximab

Question 30

What is something we should watch out for when using GIIB/IIIa inhibitors.

Answer 30

Increased Bleeding risk, especially with Aspirin, P2Y12 inhibitor or anticoagulant.

Question 31

What acronym do we use for the long-term treatment following an unstable angina hospitalization?

Answer 31

SNAP-BAM

Question 32

What does SNAP-BAM stand for.

Answer 32

1. Statin 2. Nitroglycerin 3. Aspirin 4. P2Y12 Inhibitor 5. Beta Blocker 6. ACEi/ARB 7. Mineralocorticoid Receptor Blocker.

Question 33

How long should beta-blockers be on board following an unstable angina hospitalization?

Answer 33

1-3 years.

Question 34

What patients should be initiated on a beta-blocker on discharge following an unstable angina hospitalization?

Answer 34

All patients (we would only hold for signs of acute heart failure.)

Question 35

Which Beta-Blockers have proven CV mortality benefit in HFrEF?

Answer 35

1. Bisoprolol 2. Carvedilol 3. Metoprolol Succinate XL

Question 36

What patients should be initiated on an ACEi/ARB upon discharge following an unstable angina hospitalization?

Answer 36

1.All patients with an ejection fraction <40%. AND 2. 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.

Question 37

Upon discharge following an unstable angina hospitalization, when should mineralocorticoid receptor antagonist be used.

Answer 37

In all patients with an ejection fraction <40% who are already on both an ACEi/ARB and a Beta-blocker.

Question 38

Eplerenone and Spironolactone are of the what drug class?

Answer 38

Mineralocorticoid Receptor Antagonist.

Question 39

When are MRAs contraindicated?

Answer 39

1. SCr (2.5+ in men, 2.0 in women) 2. K+ (Above 5 mEq/L)