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cardio mt2 > MT2_10_Acute Coronary Syndrome > Flashcards

MT2_10_Acute Coronary Syndrome Flashcards

1
Q

What are the main causes of ACS?

A
  • atherosclerotic rupture
  • narrowing after PCS
  • vasopasms
  • coronary artery dissection
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2
Q

What happens with a plaque ruptures?

A
  • collagen: activates platelet aggregation

- tissue factor: coagulation cascade for thrombus formation (activates factor 10) over platelets

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3
Q

EKG: T Wave Inversion

A
  • ischemia

- UA/NSTEMI

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4
Q

ST Depression

A
  • subendocardial ischemia

- UA/STEMI

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5
Q

ST Elevation

A
  • ACUTE infarct
  • revertive damage/injury
  • STEMI
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6
Q

Q Waves

A
  • transmural infarct, prior MI

- dead myocardial tissue, not reversible

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7
Q

When does analgesics come into play when it comes to therapy? What is the DOC? Why? monitor?

What if the patient is hemodynamically unstable?

A
  • if NTG does not work
  • morphine: releases histamine, vasodilation, anxiolytic
  • monitor decrease in BP, HR, RR, caution in RV infarction
  • fentanyl (due to less histamine release)
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8
Q

How much O2 to give to a patient?

A

2-4 L/min

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9
Q

MOA of Nitro?

  • Dose?
  • Monitor?
  • AE
  • CI
A

muscle relaxant and vasodilator, decrease in preload and after load

  • 0.4mg tab q5min 3x
  • AE/monitor: headache, hypo, tacky
  • CI: use with PDE5inhibitor, RV infarction, SBP less than 90
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10
Q

For aspirin, monitor for___and CI in____

A
  • bleeding, CBC

- aspirin allergy (use clopidogrel)

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11
Q

For a bare metal stent, when is it indicated?

A
  • pts with compliance issues
  • high bleed risk
  • larger arteries
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12
Q

For a drug eluting stent, what is it for?

A
  • to prevent tissue growth, and narrower vessels (DM patients)
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13
Q

Comparing BMS and DES

  • risk of restenosis (tissue grows over stent)
  • stent thrombosis (formation of blood clot)
  • antiplatelet therapy
  • long-term mortality benefit
A
  • higher for BMS
  • higher DES
  • longer for DES
  • same mortality benefit
  • DES has reduction in target lesion revasc.
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14
Q

What is the indication for fibrinolytic therapy? In a STEMI patient? The do we not use it?

A
  • delay in primary PCI within 2 hours of onset, onset of symptoms was less than 12 hours ago
  • if the symptoms happened 12-24 hours ago and there is evidence of ongoing ischemia (ECG) and there is a large area myocardium at risk
  • do not use if ST depression
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15
Q

What is the MOA of fibrinolytic?

A
  • catalyze plasminogen to plasmin which breaks down fibrin
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16
Q

Absolute CI of fibrinolytic?

A
  • prior brain bleed, current bleeds, brain lesions, brain tumors
  • stroke within 3 months, except acs within 4.5 hours
  • aortic dissection
  • uncontrolled HTN
  • head/facial trauma within 3 months
  • intracranial or spinal surgery

-steptokinase use 6 months prior

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17
Q

For TPA, what is the dose?

A
  • 15mg bolus
  • .75mg/kg 30 min (max 50)
  • .5 mg/kg in one hour
18
Q

If the fibrinolytic doesn’t work, when should you consider a PCI?

A
  • if there is no relief of chest pain
  • no resolution of ST elevation greater than 70%
  • lack of reperfusion arrhythmias
19
Q

What to monitor for when giving a fibrinolytic? (4)

A
  • blleding
  • CBC
  • INR
  • aPTT (with heparin)
20
Q

Class I indication for fibrinolytic therapy is a STEMI pt presents within __ hours of symptom onset and time of delay to PCI greater than __min

A
  • 12

- 120

21
Q

After STEMI or fibrinolytic, what to you do? With what agents?q

A
  • prevent clot expansion

- (anti platelet) aspirin, P2y12 inhibitor, (GP2B3A inhibitor), and an anticoagulant

22
Q

When is ASA indicated, monitor for…? Dose

A
  • ALL ACS patients
  • monitor for bleeding and CBC
  • 165-325 loading, then 81 QD
23
Q

For dual anti platelet therapy, what are the indications?

A
  • in all ACS patients for 12 months

- PCI w stent to prevent thrombosis

24
Q

Indication of clopidogrel

Dosing

Hold

BBW

What if patient is on a PPI?

A
  • ALL patients with ACS, alternative to aspirin
  • LD: 300mg, 600 for stent, no LD if greater than 75, less than 75 300
  • all MD is 75mg

Hold 5 days prior surgery

  • BBW: variant 2C19 alleles, reduce conversion to active metabolite
  • weigh risk vs benefits, pantoprazole> omeprazole, which inhibits 2C19 the most
25
Q

For prasugrel, what is the indication?
- why is it “better” than clopidogrel

  • Dose
  • Hold
  • CI

BBW

A
  • ACS w PCI ONLY
  • faster inhibition of platelets bc only one single CYP conversion
  • LD 60mg, 10mg PO QD 1Y (less than 60, 5mg)
  • hold 7 days
  • CI: hx of stroke or TIA
  • BBW: greater than 75 years old
26
Q

Compared to Plavix, how does ticagrelor work?

  • Dose
  • Hold
  • CI
  • BBW
A
  • similar, but it is reversible so you can recover platelets if need be, NOT a prodrug
  • 180 mg, 90mg BID 1year, 60mg BID after
  • hold 5 days before
  • CI: hepatic impairment, brain bleeds
  • use w aspirin less than 100
27
Q

For cangrelor, what is the main indication?

A
  • adjunct to PCI, in patients not treated with other P2y12 inhibitors of GP2B3A inhibitors
  • reversible! inhibition happens within 2 minutes, platelet function returns in one hour
28
Q

Indication for Vorapaxar?
Dose
CI

A
  • hx of MI or PAD
  • 2.08 mg PO daily w aspirin and/or clopidogrel
  • CI: stroke, TIA, intracranial bleeding
  • DO NOT USE in ACS or prior to PCI
29
Q

How long should patients on a DAPT?

A
  • drug eluting stent: at least 3-6months - 12 years
  • bare metal stent: at least 1 month, for one year
  • non invasive ticagrelor or clopidogrel up to 12 months

all with aspirin

30
Q

When risk stratifying ACS NSTEMI, what has to be present? (just one is needed)

A
  • prolonged chest pain
  • hemodynamic instability
  • dynamic ST changes on EKG
  • Heart failure symptoms
  • new/worsening regurgitation mitral
31
Q

What are the GP2B3A inhibitors, and what is their indication? Why do we use these agents?

  • Can it be used in PCI?
  • What if pt is getting CABG
  • MUST BE
  • Monitor
  • CI
A
  • Abciximab, Eptifibatide, Tirofiban
  • binds to the GP receptors on activated platelets to prevent fibrinogen cross linking, therefore no platelets
  • only use if patients are at high risk, unable to get a PCI right away
  • yes
  • can get these drugs, if scheduled within 5-7 days
  • given with another anti platelet
  • monitor: bleeding
  • CI: active bleeding within 30 days, hx of stroke in 30 days, severe HTN (>200/110), major surgery within 6 weeks
32
Q

For Abciximab (Reopro), what is the indication, and is adjustment needed?

A
  • PCI ONLY
  • ab binds to receptor, causing hinderance
  • no renal adjustment is needed
33
Q

For Eptifibatide, what is the indication?adjust?

A
  • ACS w.wo PCI
  • synthetic peptide that blocks the inhibitor
  • adjust if clearance is less than 50, to 1mcg/kg/min
34
Q

For tirofiban, indication?really adjust?

A
  • ACS w/wo PCI

- renal adjust, clearance is less than 60, 0.075 mcg/kg/min

35
Q

For anticoagulation therapy, what can be used?

A

Heparin: UFH, LMWH
DTI: bivalirudin, argatroban
Factor 10a inhibitor: fonda

36
Q

When is UFH indicated?Dosing?Monitoring?

A

all patients with ACS

  • LD: 60U, MD12U /kg
  • titrate to 1.5-2x baseline aPTT
  • monitor bleeding, CBC, ACT,/aPTT
37
Q

For LMWH, when is it indicated?

A
  • all patents with ACS, more affinity to 10a
  • enox: less than 75, 30mg IV bolus, then 1mg.kg SQ Q12
  • BBW: spinal/epidermal hematomas
  • monitor: bleeding, CBC, CrCl, anti-10a sometimes
38
Q

When are DTI indicated?
Monitor?
What are the drugs?

A
  • alternative to UFH, LMWH in patents with HIT and antithrombin III deficiency
  • monitor bleed, CBC, ACT/aPTT

bivalirudin, agatriban, fonda

39
Q

What is the dose for bivalirudin?

A

0.75 mg/kg/hr, then 1.75 until end of infusion

if CrCL is less than 30, 1mg/kg/hr

40
Q

Dosing for agatriban?

When to avoid?

A

350 mcg/kg bolus 3-5 min

AST/ALT greater than 3x normal
falsely elevated INR
if needed for post PCI, 2-10 mcg/kg/min, closely monitor aPTT

cardio mt2 (12 decks)

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