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Pharmacotherapy 4271 > IHD Part III (ACS) > Flashcards

IHD Part III (ACS) Flashcards

1
Q

what are the three subtypes of ACS

A
  • unstable angina
  • STEMI
  • NSTEMI
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2
Q

this subtype of ACS is a fully occlusive clot that may result in significant myocardial damage and release of biochemical markers

A

STEMI

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3
Q

this subtype of ACS is usually a transient partially occlusive clot that does not result in myocardial cellular damage or release of biochemical markers

A

unstable angina

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4
Q

this subtype of ACS is similar to unstable angina as it is a transient partially occlusive clot; however myocardial cellular damage occurs and there is an increase in biochemical markers

A

NSTEMI

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5
Q

how is ACS diagnosed

A
  • patient sx’s
  • ECG findings
  • Lab results
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6
Q

true or false: ischemic chest pain present in ACS is relieved by SL NTG

A

false!!!

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7
Q

these are biochemical markers that are released into the blood on myocardial cell death. they are sensitive and specific for myocardial necrosis

A

troponin and CK MB

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8
Q

what are some complications of ACS (more so STEMI then NSTEMI)

A
  • arrhymias/sudden cardiac death
  • HF
  • angina
  • HTN
  • cariogenic shock
  • embolic stroke
  • re-infarction
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9
Q

what is the main goal of ACUTE management of STEMI

A

reperfusion: opening the infarct related artery

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10
Q

KE presents with chest pain (not relieved by SL NTG), N/V, diaphoresis. PMHx is significant for stable CAD. current BP is 92/56 mmHg and HR is 10bpm. which of these medications should be given to KE immediately?
a) ASA EC 325mg orally x 1 dose
b) ASA 81mg two tabs chewed x 1 dose
c) NTG IV drip at 20mcg/min
d) metoprolol 5mg IV x 1 dose

A

B - Aspirin 81mg two tabs chewed x 1 dose

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11
Q

this repercussion strategy is preferred as it reduces death, MI, stroke, and major bleeding compared to the other strategy

A

PCI - PCI vs thrombolysis will entirely depend on the institution + resources

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12
Q

these agents are plasminogen activators: they convert plasminogen to plasmin which results in clot lysis. e.g. Alteplase, Reteplase and Tenecteplase

average time to repercussion (restore blood flow) is 45-60 mins

A

thrombolytics

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13
Q

who should NOT receive thrombolytics?

A

Absolute Contraindications:
- any prior hemorrhagic stroke
- ischemic stroke within 3 months (except in past 4.5 hours)
- intracranial neoplasm or arteriovenous malformation
- active internal bleeding
- aortic dissection
- considerable facial trauma or closed head trauma in the past 3 months
- intracranial or intraspinal surgery within 2 months
- severe, uncontrolled HTN (unresponsive to emergency therapy)

Relative Contraindications:
- BP > 180/110 mmHg on presentation or history of chronic poorly controlled hTN
- history of ischemic stroke greater than 3 months before
- recent major surgery (less than 3 weeks before)
- traumatic or prolonger CPR (> 10 mins)
- recent internal bleeding (within 2-4 weeks)
- active peptic ulcer
- noncomressible vascular punctures
- pregnancy
- known intracranial pathology (dementia)
- OAC

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14
Q

what is the main adverse effect of thrombolytics

A

bleeding - including hemorrhagic stroke!!!

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15
Q

who is at an increased risk of intracranial hemorrhage with fibrinolysis?

A
  • older age
  • females
  • low body weight ( <70 kg female and < 80 kg for male)
  • prior stroke
  • HTN ( BP > 160 - 170/95 mmHg, at any time)
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16
Q

what needs to be monitored when a patient is on thrombolytic therapy

A
  • bleeding
  • mental status changes for signs of intracranial hemorrhage
  • baseline aPTT, INR, CBC (for Hgb and platelets)
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17
Q

this type of antiplatelet therapy is an irreversible inhibitor of COS therefore inhibits platelet aggregation. For STEMI, loading dose here is 162 - 325 mg (chewed) x 1 dose and maintenance dose is 81 mg/day

A

ASA

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18
Q

what are some adverse effects of ASA

A

GI: N/V, heartburn, epigastric pain, ulceration
bleeding
hypersensitivity rash (Rare)

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19
Q

what should be monitored if a patient is on ASA

A

anaphylaxis, rash
GI tolerability
bleeding (CBC periodically or if signs and symptoms of bleeding to check Hgb)

20
Q

these antiplatelet P2Y12 inhibitor tx’s are preferred in patients undergoing primary PCI

A

Prasugrel & Ticagrelor

21
Q

this antiplatelet P2Y12 inhibitor tx is preferred if the patient is on fibrinolytic

A

clopidogrel

22
Q

this P2Y12 inhibitor is a platelet ADP-recpetor antagonist therefore inhibits platelet aggregation.
loading dose: 300mg x 1 dose (fibrinolytic) or 600mg x 1dose (PCI)
maintenance dose = 75mg/day

A

clopidogrel

23
Q

what are some adverse effects of clopidogrel

A

GI: n/v, abdominal pain, dyspepsia
bleeding
headache, dizziness
rash (rare)

24
Q

what should be monitored in a patient taking clopidogrel

A

GI tolerability
bleeding
rash

25
Q

this P2Y12 inhibitor is a platelet ADP-recpetor antagonist therefore inhibits platelet aggregation. prodrug that needs to be activated. onset is faster than clopidogrel. higher risk of bleeding. special auth by NLPDP

A

Prasugrel

26
Q

this P2Y12 inhibitor is a platelet ADP-recpetor antagonist therefore inhibits platelet aggregation.
loading dose = 180mg x 1 dose
maintenance dose = 90mg BID (60mg BID for therapy > 1 year).
NLPDP coverage - special auth
*contraindications - hx of intracranial hemorrhage, severe hepatic impairment and concomitant use with strong CYP3A4 inhibitors

A

Ticagrelor (Brillinta)

27
Q

what are some adverse effects of Ticagrelor

A

dyspnea
ventricular pauses
headache, dizziness
rash
N/V/D

28
Q

what should be monitored for a patient on Ticagrelor

A

bleeding - baseline and periodic CBC

29
Q

this anticoagulant therapy potentiates the action of antithrombin III and thereby inactivates thrombin. can be given IV (onset mins) or SC (onset 1-2 hr).

A

UFH

30
Q

this anticoagulant inhibits factor Xa & enoxaprin is the primary agent used. dose used for ACS is weight based subcut injections.

A

LMWH

31
Q

this anticoagulant is an indirect synthetic inhibitor of factor Xa. dose is 2.5 mg SC daily, but if STEMI first dose should be given IV

A

Fondaparinux

32
Q

this anticoagulant is a direct thrombin inhibitor that is given IV. it approved for use during PCI for STEM/UA?NSTEMI, including patients with heparin induced thrombocytopenia (HIT)

A

bivalirudin

33
Q

true or false: fibrinolytics are used in STEMI/UA/NSTEMI

A

false - only STEMI

34
Q

this acute management strategy of NSTE ACS refers to medical management that is often used in patients found to be low risk. potential strategy for intermediate risk groups who go onto elective PCI later

A

ischemia guided

35
Q

this acute management strategy of NSTE ACS refers to coronary angiography +/- PCI. used in patients with high risk indicators. TMI risk score of 5-7; score of 3-4 have also shown benefit

A

early invasive

36
Q

this is a 7 point risk score that assigns 1 point for the following risk factors
- age > 65
- more than 3 coronary risk factors (smoking, DM, HTN, family history, dyslipidemia)
- prior history of CAD (> 50% stenosis on angiography)
- aspirin use within 7 days
- at least 2 anginal events within last 24 hours
- ST-segment deviation
- elevation of cardiac biomarkers (troponin or CK MB)

A

TIMI risk score

37
Q

a 55 yo female with a hx of HTN presents to ED for one episode of back pain accompanied by nausea and vomiting. home meds include: indapamine 2.5 mg daily and amlodipine 5 mg daily. the ECG demonstrates some ST-segment depression. labs are WNL and her estimated CrCl is 67 mL/min. troponin is undetectable. she weighs 80 kg, and is a non smoker. no family hx of CAD. based on her TIMI risk score, which is the most appropriate treatment strategy for this patient?
a) early invasive approach
b) fibrinolytic therapy
c) iscehmia guided approach
d) primary PCI

A

C - ischemia guided approach b/c TIMI score is 1 therefore low risk

38
Q

what are some examples of dual antiplatelet therapy (DAPT)

A

ASA and one of P2Y12 inhibitors (clopidogrel, ticagrelor or prasugrel)

39
Q

Dual anti platelet therapy (DAPT) and duration of therapy for standard treatment of ACS

A

ASA 81mg daily + Ticagrelor 90mg BID or Prasurgrel 10mg daily

40
Q

Dual Antiplatelet Therpay (DAPT) and duration of therapy of extended ACS therapy

A

Dose reduction of ASA 81mg daily+ Ticagrelor 60mg BID
Or continuation of ASA 81 mg daily + Clopidogre, 75mg daily

41
Q

Dual Antiplatelt Therapy (DAPT) and duration of therapy for de-escalation therapy of ACS

A

Single antiplatelt therapy with a P2Y12 inhibitor or ASA 81mg or ASA 81mg daily or Clopidogrel 75 mg daily for minimum 1-3 months

42
Q

Dual Antiplatelet therapy (DAPT) and duration of therapy for elective PCI

A

Extend (min 3 years), standard [6 months] and de-escalate (min 1-3 months): all ASA 81 mg daily + Clopidogrel 75mg daily

43
Q

This is done in patients with stable ischemic heart disease (SIHD) but symptoms cannot be controlled

A

Elective PCI

44
Q

True or false: ASA is continued prior to CABG

A

True

45
Q

How long before surgery should a patient with ACS discontinue their Clopidogrel

A

2-7 days

46
Q

How long before surgery should a patient with ACS discontinue their Ticagrelor

A

2-3 days

Pharmacotherapy 4271 (29 decks)

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