Lecture 4 - Acute Coronary Symptoms 2

Question 1

PCI indications

Answer 1

Patients with STEMI

“door-to-PCI time”<90 min in PCI capable or. <120min for those transferred from non capable to capable hospital.

Question 2

PCI outcomes are dependent on….

Answer 2

operator skill
time to Cath lab
tertiary vs community hospital
Cath lab access

Question 3

Benefits of PCI

Answer 3

Lower bleed risks than fibrinolytic

Method of choice where possible

Question 4

TIMI grade Perfusion

Answer 4

0 = worst, no perfusion
3 = best, most perfusion

Question 5

Pre-op meds for PCI

Answer 5

1. Aspirin
2. Loading Dose Clopidogrel
3. Maybe IV GPIIb/IIIa inhibitor, no bivalirudin*

D/C anticoagulants after PCI

Question 6

How long should you hold metformin for?

Answer 6

prior to procedure and for 48hrs after until renal function normalizes (monitor Scr)

Question 7

Warnings with Radioactive contrast Dye

Answer 7

pretreat with antihistamines or steroids

potential for renal failure, prevent with hydration

*normal salive IV or sodium bicarb IV

Question 8

Fibrinolytics are used for….

Answer 8

STEMI only

Question 9

When to use Fibrunolytics

Answer 9

1. Early presentation, < 3 hrs of symptoms
2. Invasive strategy is not an option
3. Delay to invasive strategy

Question 10

Alteplase Dosing

Answer 10

Bolus followed by infusions over 90 min, weight based dosing

Question 11

Reteplase Dosing

Answer 11

Two bolus doses, 30 min apart

Question 12

Tenecteplase Dosing

Answer 12

single bolus dose, weight based dosing

Question 13

Absolute CI Fibrinolytic

Answer 13

1. active internal bleeding
2. previous intracranial hemorrhage at any time, stroke within 3 months
3. Known intracranial neoplasm
4. Known structural vascular lesion
5. Suspected aortic dissection
6. Significant closed head/facial trauma within 3 months
7. intracranial or intraspinal surgery within pervious 6 month

Question 14

Relative CI Fibrinolytics

Answer 14

1. unctonroll HTN (> 180/110)
2. History of prior ischemic stroke
3. current use of anticoagulants
4. Known bleeding diathesis
5. Traumatic or prolonged CPR or major surgery
6. non compressible vascular puncture
7. Recent internal bleeding
8. Previous streptokinase use, if giving streptokinase
9. Pregnancy
10. Active peptic ulcer
11. History of poorly controlled HTN

Question 15

Clopidogrel Loading dose

Answer 15

600 mg

Question 16

Prasugrel loading dose

Answer 16

60 mg

Question 17

Ticagrelor loading dose

Answer 17

180 mg

Question 18

When to discontinue prasugrel before CABG?

Answer 18

7 days before

Question 19

When to discontinue clopidogrel & ticagrelor before CABG?

Answer 19

5 days before

Question 20

When to discontinue enoxaparin before CABG?

Answer 20

12 - normal renal function

24hr - reduced renal function

Question 21

When to discontinue fondaparinux before CABG?

Answer 21

24hrs

Question 22

When to discontinue bivalrudin before CABG?

Answer 22

3 hrs

Question 23

When to discontinue GPIIb/IIIa before CABG?

Answer 23

2-4 hrs

Question 24

What is shown to reverse or slow down ventricular remodeling?

Answer 24

ACEi
ARBs
B-blockers
Mineralocorticoid receptor antagonists

Question 25

How long should dual anti platelet therapy last?

Answer 25

~ 12 months