Management of Acute Coronary Syndromes

Question 1

general pathobiology of ACS

Answer 1

Ruptured atherosclerosis pack ruptures and releases tissue factors. Stimulates thrombus formation. Can completely occlude the vessel. Cuauses symptoms consistent with chest discomfort and anginal equivalent.

Question 2

3 main types of ACS

Answer 2

1. unstable angina
2. STEMI; would also have LBBB on the ECG
3. NSTEMI

Question 3

what types of ACS are considered Type 1 MI;s?

Answer 3

STEMI and NSTEMI

Question 4

what is the defining factors of a TYPE 1 MI

Answer 4

1. elevation of troponin or cardiac biomarkers?

plus one or more of:

Symptoms of ischemia

⬩ New or presumed new significant ST-segment or T-wave changes or new LBBB on ECG
⬩ Development of pathological q-waves on ECG

⬩ Imaging showing new myocardium loss or regional wall motion changes
⬩ Intracoronary thrombus identified on angiography or autopsy

Question 5

an NSTEMI meets definitions of myocardial infeaction and does not have ST elevation. What else might it have on ECG instrad?

Answer 5

might have other changes tho like T inversion or ST depression.

Question 6

why is unstable angina not classified as type I MI?

Answer 6

because it does not always meet the cardiac biomarker rise criteria for MI.

• it may or may not have elevation in troponin. It wont have ST elevation of ECG.

Question 7

T/F Unstable angina could be complete occlusion of the coronary vessels

Answer 7

false. UA and NSTEMI have subtotal occlusion of coronary vessel. STEMi is complete occlusion.

Question 8

immediate medical management (big 3) for ACS

Answer 8

1. first antiplatelet (ASA)
2. second antiplatelet (P2Y1y inhibitor like cloperdigrel or ticagrelor
3. anticoagulation

Question 9

mechanism of first apa therapy (ASA) and dosage

Answer 9

blocks cyclooxygenase and thus decreases prostaglandin and thromboxane synthesis. pervents platelets from aggregating. irreversibly blocks these enzymes for the lifetime of the platelet.

Question 10

mechanism of second APA therapy (P2Y1Y inhibitor)

Answer 10

blocks adenosine diphosphate to the paltelet receptor P2Y1Y which inhibits platelet aggregation. Clopidogrel binds irreversible. Yicagrelor is reversible but more rapid onset. Giving this in addition to ASA does reduce CV death and Mi likelihood compared to just ASA alone. Ticagrelor is considered first line over slopidogrel, but has a higher bleeding risk.

Question 11

T/F addition of second APA therapy reduces cardiovascular death, MI, and stroke compared to ASA alone

Answer 11

true. Ticagrelor preferred agent compared to clopidogrel
(PLATO trial) in most ACS but considered to have higher
bleeding risk
⬩ Clopidogrel recommended if patient to receive
thrombolytic (see “Thrombolysis” in later slides)

Question 12

T/F ASA increases bleeding risk

Answer 12

false. BUT the use of P2Y1y inhibitors in addition to ASA does increase the bleeding risk. this is important to consider if your patient will have surgery or are at risk of increased bleeding.

Question 13

note:

Question 14

duration of first and second APA therapy

Answer 14

Question 15

choices of anticoagulation therapy

Answer 15

1. UF hep
2. LMWH
3. fondaparinux

Question 16

what the duration of anticoagulation therapy.

Answer 16

▸ Often continued until reperfusion/revascularization
procedure and then discontinued
▸ If patient not receiving revascularization procedure, usual
duration is 48 hours minimum but can be extended in
different situations

Question 17

out of the 3 types of ACS, which one requires immediate reperfusion/revascularization surgical intervention

Answer 17

STEMI.

Question 18

3 types of surgical intervention for STEMi and 2 types for NSTEMI and UA?

Answer 18

STEMI: PCI, CABG, or thrombolysis if there is a delay to the PCI.

NSTEMI/UA: PCI or CABG

Question 19

there are 3 types of surgical intervention (PCI< CABG or thromboylysis) for STEMI ACS, but what is the more favorable?

Answer 19

⬩ Emergent revascularization procedure to re-open an
occluded epicardial vessel
⬩ Percutaneous coronary intervention (PCI) preferred

Question 20

for PCI, it’s preferred because it’s minimally invasice and rapid delivery. we aim to have finished the procedure within 90 minutes of first medical contact. It requires ___ ___ therapy to protect delivered stends

Answer 20

requires dual antiplatelet therapy to protect delivered stents.

Question 21

if there is anticipated delay to PCI when a pt is having a STEMI, consider doing ____ using ____, a fibrin-specific plasminogen activator.

Answer 21

if there is anticipated delay to PCI when a pt is having a STEMI, consider doing THROMBOLOSYS using TNK, a fibrin-specific plasminogen activator.

• patients will be planned for PCI wihtin 24 hours but often require emergency PCI if thrombolytic is unsuccessful. ▸ Significant risk of hemorrhage with thrombolysis (e.g.
  intracranial hemorrhage)

Question 22

biggest risk in thrombolysis. what are absolute contraindications to thrombolysis?

Answer 22

• signifacnt risk of hemorrhage with thrombolysis.
• contraindications include prior intracranial hemorrhage, AV malformation, ischemic stroke within 6 months, aoritc dissection etc.. basically anything that involves bleeding.

Question 23

for NSTEMIs and UAs, patients usually get cardiac catherterization and angiogram with PCI wihtin 24-48 hours of presentation. However, if the patient has signidicant ______, they should consider a CABG

Answer 23

if the patient has significant multivessel disease or other high-risk coronayr lesions,

Question 24

after a patient receives the 3 immediate medical management (ASA, clop/trig, and anticoagulant), as well as the PCI/CABG/thrombolytic procedure, they require chronic medical management to reduce ACS incidents in the future. What medical therapies and cardiac rehabilitation efforts should be done?

Answer 24

medical therapies:

beta blockers ,ace inhibitors, ARBS, statins.

cardiac rehabilitation:

medical optimization, holistic appraoch (smoking cessation, exercise, diet)

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