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PHRM 845 > Exam 1: ACS (Rogers) > Flashcards

Exam 1: ACS (Rogers) Flashcards

1
Q

Signs and Symptoms of ACS

A
  • nausea or vomiting
  • diaphoresis (sweating)
  • shortness of breath
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2
Q

Atypical Symptoms

A
  • epigastric pain
  • indigestion
  • stabbing or pleuritic pain
  • increasing dyspnea in the absence of chest pain
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3
Q

Diagnosing ACS

A

all patients with acute chest pain should have an ECG and troponin measured within 10 minutes of arrival at an emergency facility

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4
Q

STEMI on ECG

A
  • persistent ST elevation
  • Q wave not present on initial ECG, but develops over hours to days
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5
Q

NSTEMI/UA on ECG

A
  • may have normal ECG
  • ST depression, transient ST elevation, or new T-wave inversion
  • Q wave changes unlikely
  • no ST elevation
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6
Q

high sensitivity troponin unit

A

ng/L (preferred)

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7
Q

conventional troponin unit

A

ng/mL

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8
Q

high sensitivity troponin normal value

A

< 14 ng/L

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9
Q

conventional troponin normal value

A

< 0.05 ng/mL

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10
Q

need to check troponin trends

A

3 levels over 12 hours

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11
Q

Unstable Angina Signs

A
  • chest pain may occur at rest, while sleeping, or with little physical exertion
  • is more severe and lasts longer than stable angina (>30 min)
  • comes as a suprise
  • less ischemia
  • does not lead to detectable quantities of troponin
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12
Q

NSTEMI

A
  • troponin is elevated
  • not a full occlusion of the vessel
  • chest pain
  • no ST elevation
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13
Q

STEMI

A
  • chest pain
  • troponin is elevated
  • persistent ST elevation on ECG
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14
Q

Ventricular Remodeling

A

changes in the size, shape and function of the left ventricle after an ACS

leads to heart failure

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15
Q

If initial ECG is not diagnostic but the patient remains symptomatic and there is a high clinical suspicion for ACS

A

serial ECGs should be performed every 15-30 minutes for the first hour

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16
Q

serial troponin levels

A

levels should be obtained at presentation and 3-6 hours after symptom onset

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17
Q

MONA: M

A

Morphine
4-8 mg IV, followed by 2-8 mg IV q5-15 min

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18
Q

Side Effects: Morphine

A
  • sedation
  • respiratory depression
  • nausea/vomiting
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19
Q

MONA: O

A

oxygen
maintain oxygen saturation > 90%

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20
Q

MONA: N

A

Nitroglycerin
0.3-0.4 mg q5min x 3 for ischemic pain

IV for persistent ischemia: start at 10 mcg/min and titrate by 5 mcg/min q5min (max 200mcg/min)

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21
Q

Side Effects: NTG

A
  • headache
  • hypotension
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22
Q

MONA: A

A

Aspirin
162-325 mg chewable x 1 dose

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23
Q

coronary angiography

A

catheter is inserted into the radial and femoral artery and fed up the heart to show blocked artery

stent will be placed if needed

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24
Q

percutaneous coronary intervention (PCI)

A

small balloon is used to reopen a blocked artery to increase blood flow

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25
Q

fibrinolytic mechanism of action

A

promotes the conversion from plasminogen to plasmin to increase rate of fibrin degradation

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26
Q

tenecteplase (TNK-tPA) dosing

A

weight based

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27
Q

reteplase (rPA) dosing

A

10 units x 2 doses (30 minutes apart)

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28
Q

alteplase (tPA)

A

15 mg bolus, then weight based dosing

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29
Q

Steptokinase (SK)

A
  • first fibrinolytic
  • less expensive
  • less specific for fibrin
  • not often used in the US
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30
Q

absolute contraindications for Fibrinolytics

A
  • history of intracranial hemorrhage
  • ischemic stroke within the past 3 months
  • aortic bleeding or dissection
  • significant closed-head or facial trauma within the past 3 months
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31
Q

Reperfusion in STEMI

A

should be administered to all eligible STEMI patients whose symptoms began in the past 12 hours

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32
Q

Is PCI or use of fibrinolytic preferred

A

PCI: lower rates of death, recurrent ischemia or infarction, intracranial hemorrhage

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33
Q

door to needle time: stemi

A

within 30 minutes of hospital arrival

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34
Q

door-to-balloon time: stemi

A

within 90 minutes of hospital arrival

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35
Q

fibrinolytic use in therapy

A

recommended for stemi patients at non-PCI capable hospital or when ≥120 minutes away from PCI-capable hospital

not recommended for NSTEMI/UA

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36
Q

Early Invasive: NSTEMI

A

coronary angiography +/- revascularization

preferred for patients with high-risk featurs

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37
Q

Ischemia Guided: NSTEMI

A

treatment with evidence-based medications

no heart cath unless patient has recurrent ischemic symptoms or becomes hemodynamically unstable

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38
Q

P2Y12 inhibitors in ACS

A

DAPT recommended for 12 months in STEMI/NSTEMI/UA

DAPT is always ASA+P2Y12

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39
Q

Cangrelor in ACS

A

IV option used during PCI when patient does not receive loading dose

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40
Q

Cangrelor Dosing

A

30 mcg/kg followed by 4 mcg/kg/min x 2hours

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41
Q

When to use 300 mg Plavix loading dose

A

fibrinolytic + ≤75 yoa

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42
Q

when to not use a loading dose of plavix

A

fibrinolytic + > 75 yoa

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43
Q

Prasugrel not recommended in

A

ischemia guided strategy (ticagrelor/clopidogrel) preferred

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44
Q

Contraindication: Prasugrel

A

history of TIA/stroke

not recommended in patients ≥ 75, <60kg, or high bleeding risk

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45
Q

P2Y12 in NSTEMI/UA: Ischemia Guided Therapy

A

clopidogrel and ticagrelor preferred

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46
Q

P2Y12 in NSTEMI/UA: PCI

A

any could be used, preference for ticagrelor or prasugrel

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47
Q

P2Y12 in STEMI: Fibrinolytic

A

clopidogrel preferred

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48
Q

P2Y12 in STEMI: PCI

A

ticagrelor or prasugrel preferred

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49
Q

Patient Counseling: Aspirin

A
  • bleeding
  • take with food
  • take lifelong
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50
Q

Patient: P2Y12 inhibitors

A
  • bleeding
  • take with aspirin for 1 year
  • Take ticagrelor 12 hours apart and let Dr. know of SOB
51
Q

GP IIb/IIIa Inhibitors place in therapy

A

potent IV anti-platelets given in addition to ASA and P2Y12 inhibitor

given at the time of PCI

52
Q

Considering GP IIb/IIIa inhibitors in NSTEMI

A

highrisk features such as positive troponin

inadequate P2Y12 inhibitor loading

bail out

53
Q

Considering GP IIb/IIIa inhibitors in STEMI

A

large thrombus burden

inadequate P2Y12 inhibitor loading

bail out

54
Q

Abciximab (Reopro) bolus dose

A

0.25 mg/kg IV

55
Q

Abciximab (Reopro) maintenance dose

A

0.125 mcg/kg/min
continue up to 12 hours

56
Q

Eptifibatide (Integrilin) bolus dose

A

180 mcg/kg IV x 2 (10 minute apart)

57
Q

Eptifibatide (Integrilin) : maintenance dose

A

2 mcg/kg/min
continue up to 18 hours

58
Q

Eptifibatide (Integrilin) : Renal adjustment

A

CrCl<50 mL/min
1 mcg/kg/min

59
Q

Tirofiban (Aggrastat): bolus dose

A

25 mcg/kg IV

60
Q

Tirofiban (Aggrastat): maintenance dose

A

0.15 mcg/kg/min
continue up to 18 hours

61
Q

Tirofiban (Aggrastat): renal dosing

A

CrCl < 60 mL/min
0.075 mcg/kg/min

62
Q

Anticoagulation place in ACS

A

recommended in addition to anti-platelet therapy to improve vessel patency and prevent reocclusion

63
Q

Unfractionated Heparin (UFH) MOA

A

Anti-Xa and anti-IIa activity

64
Q

Risk of UFH Therapy

A

HIT: drop in platelet count and increased thrombosis

65
Q

Enoxaparin MOA

A

Anti Xa and anti IIa activity (higher ratio than UFH)

accumulates in renal impairment (avoid)

66
Q

Bivalirudin MOA

A

direct thrombin inhibitor

67
Q

Bivalirudin in ACS

A

may not be effective for MACE and stent thrombosis

may have lower bleeding risk

not used together with GPIIb/IIIa inhibitors except for bail out

68
Q

Fondaparinux MOA

A

Factor Xa inhibitor

69
Q

Fondaparinux in ACS

A

do not use alone for PCI (high risk of thrombosis)

if already giving fondaprinux and patient needs a PCI, need to give unfractionated heparin or bivalirudin

70
Q

Fondaparinux Renal Impairment

A

contraindicated for CrCl < 30 mL/min

71
Q

UFH Bolus Dose

A

60 units/kg iv (max 4000 units)

50-100 units/kg during PCI

72
Q

UFA maintenance dose

A

12 units/kg/hr infusion titrated to aPPT target

no maintenance dose during PCI

73
Q

Enoxaparin bolus dose

A

30 mg IV

74
Q

Enoxaparin maintenance dose

A

1 mg/kg sc q12h (first dose 15 min after bolus)

≥75 years reduce to 0.75 mg sc q12h

75
Q

Enoxaparin Renal Adjustment

A

CrCl < 30 mL/min
1 mg/kg q24

76
Q

Bivalirudin Bolus Dose

A

0.75 mg/kg IV

77
Q

Bivalirudin maintenance dose

A

1.75 mg/kg/hr infusion

78
Q

Bivalirudin renal dosing

A

CrCl < 30 mL/min
1 mg/kg/hr

dialysis
0.25 mg/kg/hr

79
Q

Fondaparinux bolus dose

A

2.5 mg IV

80
Q

fondaparinux maintenance dose

A

2.5 mg sc q24h

81
Q

UFA: NSTEMI Ischemia Guided Strategy

A

Yes: 48 hours

82
Q

UFA: NSTEMI Early Invasive Strategy

A

Yes (until PCI)

83
Q

UFA: STEMI Fibrinoltyic

A

yes: 48 hours

84
Q

UFA: STEMI PCI

A

yes: until pci

85
Q

Bivalirduin: UA/NSTEMI Ischemia Guided Strategy

A

NO

86
Q

Bivalirduin: UA/NSTEMI early invasive

A

Yes (until PCI)

87
Q

Bivalirudin: STEMI fibrinolytic

A

NO
consider using for HIT

88
Q

Bivalirudin: STEMI PIC

A

yes until PCI (preferred for high bleeding risk)

89
Q

Enoxaparin: UA/NSTEMI ischemia guided

A

yes (LOS up to 8 days)

90
Q

Enoxaparin: UA/NSTEMI early invasive

A

yes until pci

91
Q

Enoxaparin: STEMI fibrinoltyic

A

Yes (LOS up to 8 days)

92
Q

Enoxaparin: STEMI PCI

A

no

93
Q

Fondaparinux: UA/NSTEMI ischemia guided

A

Yes (LOS up to 8 days)

94
Q

Fondaparinux: UA/NSTEMI PCI

A

not ideal, do not use alone for pci

95
Q

Fondaparinux: STEMI fibrinolytic

A

yes (LOS up to 8 days)

96
Q

Fondaparinux: STEMI pci

A

no

97
Q

Beta Blockers place in ACS

A

initiate within the first 24 hours of ACS

98
Q

reasons not to start a beta blocker

A
  • bradycardia
  • HF or other low-output state
  • risk for cardiogenic shock
  • PR interval > 0.24s
  • second or third degree heart block
  • active asthma or reactive airway disease
99
Q

Metoprolol target dose

A

tartrate: 100 mg BID
succinate: 200 mg daily

100
Q

carvedilol starting dose

A

6.25 mg bid

101
Q

carvedilol target dose

A

25 mg bid

102
Q

propranolol starting dose

A

40 mg BID/TId

103
Q

propranolol maintenance dose

A

80 mg qid

104
Q

atenolol starting dose

A

25-50 mg daily

105
Q

atenolol target dose

A

100 mg daily

106
Q

beta blockers without beta 2 activity

A

atenolol, metoprolol, bisoprolol, nebivolol

107
Q

Calcium Channel Blockers place in ACS

A

administer nonDHP to patients with recurrent ischemia and contraindications to beta blockers

108
Q

do not use CCBs in patients with

A

-LV dysfunction
- increased risk for cardiogenic shock
- PR interval > 0.24s
- second or third degree AV block without a cardiac pacemaker

109
Q

Statins in ACS

A
  • initiate or continue high intensity statin
  • obtain lipid profile
110
Q

High intensity statins

A

atorvastatin 40-80 mg
rosuvastatin 20-40 mg

111
Q

ACE inhibitor/ARB place in ACS

A

recommended in all patients

use cautiously in the first 24 horus of AMI, initiate after 24 hours

112
Q

captopril starting dose

A

6.25-12.5 mg tid

113
Q

captopril target dose

A

25-50 mg tid

114
Q

lisinopril starting dose

A

2.5-5mg daily

115
Q

lisinopril target dose

A

≥10 mg daily

116
Q

ramipril starting dose

A

2.5 mg bid

117
Q

ramipril target dose

A

5 mg bid

118
Q

valsartan starting dose

A

20 mg bid

119
Q

valsartan target dose

A

160 mg bid

120
Q

when not to use ACE inhibitor

A
  • hypotension/shock
  • bilateral renal artery stenosis
  • acute renal failure
    -drug allergy/angioedma
121
Q

monitoring ACEis

A
  • serum creatinine
  • potassium (increases)
  • decreased blood pressure
  • angioedema
122
Q

maintenance dual antiplatelet

A

ASA 81 mg
P2Y12 inhibitor x 12 months

123
Q

Triple Antithrombotic Therapy

A
  • some patients require oral anticoagulation in addition to DAPT
  • AFib
  • STEMI and asymptomatic LV mural thrombi
  • STEMI and anterior apical kinesis or dyskineases

PHRM 845 (14 decks)

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