Heart Disease and ACS

Question 1

What is the treatment summary for Chronic Stable Angina?

Answer 1

A - Antiplatelet & Antianginal medications
B - Blood Pressure & Beta Blockers
C - Cholesterol & Cigarettes
D - Diet & Diabetes
E - Exercise & Education

Question 2

What is the drug treatment for Chronic Stable Angina?

Answer 2

1) Beta blocker +- CCB +- Nitrates +- Ranolazine, AND
2) ASA (if contraindicated, use Clopidogrel), AND
3) Nitroglycerin SL PRN

-Beta blockers are first line. If they continue to experience symptoms, add CCB or Nitrate or Ranolazine

*These patients are candidates for high-intensity statins

Question 3

How does Aspirin work?

Answer 3

Aspirin is used first-line in Angina.

It blocks the COX enzyme, which inhibits Thromboxane A2 production. This is a potent vasoconstrictor and platelet aggregator.

Contraindications: Salicylate Allergy

Question 4

How does Clopidogrel work?

Answer 4

Clopidogrel is a pro-drug which is converted by CYP2C19.

Question 5

Do we use DAPT therapy for Chronic Stable Angina patient?

Answer 5

Nope..no DAPT unless the patient has a stent.

Question 6

When should we use Ranolazine for Chronic Stable Angina?

Answer 6

If the patient has low HR or BP, you can use Ranolazine, since it has a unique mechanism which doesn’t lower BP or HR.

Question 7

Contraindications of Nitrates

Answer 7

1) Concurrent use of PDE-5 Inhibitors (Sildenafil, tadalafil) or Riociguat

Question 8

Uses of Short-Acting Nitrates

Answer 8

For Immediate Relief

-3 doses given at 5 minute interval
-The SL tablet (Nitroglycerin) is good for 6 months. Keep in original amber bottle.

Question 9

Uses of Long-Acting Nitrates

Answer 9

To prevent Chest-pain

-Not to be used for acute chest pain
-Nitrate free interval is required to prevent tolerance

Question 10

What is ACS?

Answer 10

Acute Coronary Syndrome

This results from plaque buildup in the coronary arteries.

ACS covers:
-Unstable Angina
-NSTEMI (Non-ST Segment Elevation MI)
-STEMI (ST Segment Elevation MI)

Question 11

Signs and Symptoms of ACS

Answer 11

-Chest Pain
-Dyspnea
-Syncope or Lightheadedness
-Diaphoresis (Sweating)

Question 12

What Cardiac enzymes are specific for ACS?

Answer 12

Troponin I & Troponin T

Question 13

How can you tell if the patient is experiencing an NSTEMI, UA or STEMI based on Lab Results?

Answer 13

1) ST is elevated on an ECG (This is due to the complete block of the arteries)
2) There isn’t any cardiac enzyme for UA

Question 14

Drug Treatment of ACS

Answer 14

MONA-GAP-BA
M - Morphine
O - Oxygen
N - Nitrates (SL)
A - Aspirin (non-EC coated preferred)
*These are started right away, PRN

G - gp2b/3a Antagonists (Abciximab, Eptifibatide, Tirofiban)
A - Anticoagulants (LMWH, UFH, Bivalirudin)
P - P2Y12 Inhibitor (Clopidogrel, Prasugrel, Ticagrelor)

B - Beta Blocker
A - ACE Inhibitor
*Think about initiating this within 24 hours

Question 15

What is the drug treatment for a NSTE-ACS?

Answer 15

MONA-GAP-BA +/- PCI

Question 16

What is the drug treatment for a STEMI?

Answer 16

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

Question 17

What medications to avoid in the acute setting?

Answer 17

1) NSAIDs
2) IR Nifedipine

Question 18

How does Aspirin work?

Answer 18

It irreversibly inhibits COX-1 and COX-2, which decreases the production of thromboxane A2, to inhibit platelet aggregation.

Question 19

How does P2Y12 work?

Answer 19

Clopidogrel, ticagrelor, prasugrel

These bind to the platelet ADP P2Y12 receptor, to inhibit platelet aggregation.

Avoid prasugrel use in Stroke Patients.

Question 20

How does gp2b/3a receptor antagonists work?

Answer 20

Abciximab, Eptifibatide, Tirofiban

These blocks the platelet aggregation glycoprotein 2b/3a receptor, to inhibit platelet aggregation.

Question 21

Important information about P2Y12 Inhibitors

Answer 21

Clopidogrel: It is a prodrug. Avoid omeprazole and esomeprazole use with it.

Prasugrel: Do not use in patients with a history of Stroke/TIA

Question 22

How do Fibrinolytics work?

Answer 22

These cause clot breakdown by binding to fibrin and converting plasminogen to plasmin.

Only used for STEMI (Since this is a complete blockage)

Alteplase (Activase)
Tenecteplase(TNKase)
Reteplase (Retavase)

Question 23

PCI vs. Fibrinolytics

Answer 23

PCI is always preferred, but in a situation where a Cath Lab is not available within 120 minutes, a fibrinolytic is used.

Question 24

Secondary prevention after an ACS

Answer 24

1) Aspirin indefinitely
2) P2Y12 Inhibitor (DAPT)
-Medical Management: Clopidogrel or Ticagrelor + ASA for atleast 12 months
-PCI-treated: Any P2Y12 + ASA for atleast 12 months
3) NTG Spray PRN indefinitely
4) BB daily for atleast 3 years
5) ACE Inhibitor
6) Aldosterone Antagonist
7) Statin