NON–ST-ELEVATION ACUTE CORONARY SYNDROME Flashcards
What is non-ST-elevation acute coronary syndrome?
A continuum of unstable angina, non–Q-wave myocardial infarction, non–ST-segment elevation MI, and STEMI due to coronary plaque rupture and thrombus formation
This process is clinically recognized as acute coronary syndrome (ACS) when it causes symptoms.
What is the current definition of a myocardial infarction?
Evidence of myocardial necrosis in a clinical setting consistent with myocardial ischemia, including cardiac biomarker rise or fall
This includes symptoms of ischemia, ECG changes, pathologic Q waves, imaging evidence, or identification of an intracoronary thrombus.
Which cardiac biomarkers are utilized in the diagnosis of NSTE-ACS?
Troponin, specifically troponin T and troponin I, which are highly sensitive and specific for cardiac myocyte injury
High-sensitivity troponin (hs-cTn) assays allow earlier detection of serum troponin after an MI.
What conditions can cause elevations in troponin besides epicardial coronary artery disease?
Conditions include:
* Myocarditis
* Acute congestive heart failure
* Cardiac contusion
* Tachyarrhythmias
* Takotsubo cardiomyopathy
* Infiltrative diseases (e.g., amyloidosis)
* Systemic illnesses (e.g., chronic kidney disease)
Numerous non-coronary cardiac diseases and systemic illnesses can elevate troponin.
What are the factors that make up the TIMI risk score?
Factors include:
* Age > 65 years
* Three or more CAD risk factors
* Prior catheterization demonstrating CAD
* ST-segment deviation
* Two or more anginal events within 24 hours
* ASA use within 7 days
* Elevated cardiac markers
Each factor counts as 1 point, with total scores indicating low, intermediate, or high risk.
What are the components of the GRACE ACS risk model at the time of admission?
Components include:
* Age
* Heart rate
* Systolic blood pressure
* Creatinine
* Congestive heart failure Killip class
* Cardiac arrest at admission
* ST-segment deviation
* Elevated cardiac enzymes/markers
Risk scores categorize patients as low, intermediate, or high risk for in-hospital death.
What are the three currently used oral P2Y12 receptor inhibitors?
The three P2Y12 inhibitors are:
* Clopidogrel
* Prasugrel
* Ticagrelor
These agents block the P2Y12 receptor and are used in dual antiplatelet therapy.
What are the differences between the intravenous antiplatelet agents?
Eptifibatide and tirofiban are reversible GP IIb/IIIa inhibitors, while abciximab is an irreversible inhibitor
All three agents increase the risk of major bleeding and thrombocytopenia.
What antiplatelet agents are recommended in patients with NSTE-ACS?
Aspirin should be administered, or clopidogrel as a substitute for aspirin if contraindicated
Ticagrelor is preferred over clopidogrel based on the PLATO study.
What anticoagulant agents are recommended by the ACC/AHA guidelines?
The guidelines recommend unfractionated heparin (UFH) and enoxaparin for parenteral anticoagulant therapy
Parenteral anticoagulant therapy is recommended for all patients with NSTE-ACS.
What is the Class IIb recommendation for the use of rapidly acting P2Y12 bridge therapy in patients undergoing PCI?
The ESC NSTE-ACS guidelines provide a Class IIb recommendation for its routine use, balancing reductions in ischemic events with increased bleeding risk.
P2Y12 bridge therapy is evaluated for its efficacy and safety in the context of PCI.
Which parenteral anticoagulant agents are recommended by the ACC/AHA guidelines?
The ACC/AHA guidelines recommend:
* Unfractionated heparin (UFH)
* Enoxaparin
* Fondaparinux
* Bivalirudin
These agents are recommended for all patients with NSTE-ACS.
What is the recommended maintenance dose of aspirin for patients with NSTE-ACS?
81 mg daily
Non–enteric-coated aspirin should be administered promptly after presentation.
What are the P2Y12 inhibitors recommended for patients treated with an early invasive or ischemia-guided strategy?
The recommended P2Y12 inhibitors are:
* Clopidogrel
* Ticagrelor
These inhibitors are part of dual antiplatelet therapy (DAPT).
For how long should P2Y12 inhibitor therapy be continued in post-PCI patients treated with coronary stents?
At least 12 months
This is crucial for patients who have undergone PCI with stenting.
When is the use of GP IIb/IIIa inhibitors recommended?
In patients treated with an early invasive strategy and DAPT with intermediate-/high-risk features (e.g., positive troponin).
GP IIb/IIIa inhibitors are used selectively based on risk assessment.
What is the recommended duration for administering enoxaparin in patients with NSTE-ACS?
For the duration of hospitalization or until PCI is performed.
This strategy helps manage anticoagulation effectively.
What is the recommendation regarding the use of platelet function testing in NSTE-ACS?
Routine use of platelet function testing is not recommended.
It may be considered in selected cases where results could alter management.
Should all patients presenting with NSTE-ACS receive supplemental oxygen?
No, only patients with oxygen saturation <90%, respiratory distress, or other high-risk features of hypoxemia should receive it.
Routine supplemental oxygen can have adverse effects.
Can nitrate therapy be administered to patients taking erectile dysfunction agents?
No, concurrent use can lead to profound hypotension.
Specific waiting periods after taking ED agents are required before administering nitrates.
What is the recommendation for starting statin therapy in patients admitted with acute coronary syndromes?
Yes, statin therapy can be safely started in these patients.
High-dose lipid therapy has shown a low incidence of side effects in trials.
What other therapeutics can be considered for patients with NSTE-ACS and uncontrolled hyperlipidemia despite maximally tolerated statin therapy?
Consider the usage of:
* Ezetimibe
* PCSK-9 inhibitors (e.g., alirocumab, evolocumab)
These agents are recommended if LDL-C goals are not met.
What are the recommendations for drug discontinuation in patients undergoing CABG?
For elective CABG:
* Clopidogrel or ticagrelor: wait 5 days
* Prasugrel: wait 7 days
* Eptifibatide or tirofiban: 2-4 hours before
* Enoxaparin: 12-24 hours before
* Fondaparinux: 24 hours before
* Bivalirudin: 3 hours before
These recommendations help reduce bleeding risks during surgery.
How long should patients with NSTE-ACS be treated with dual antiplatelet therapy (DAPT)?
At least 12 months, with potential for 6 months in high bleeding risk patients or >12 months in low bleeding risk patients.
DAPT includes aspirin and a P2Y12 inhibitor.
What is the recommended duration of triple therapy for patients with NSTE-ACS and atrial fibrillation?
Only 1 week prior to discontinuation of aspirin as the default strategy for most patients.
The preferred P2Y12 inhibitor in this scenario is clopidogrel.
What is the recommended duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes (ACSs)?
> 12 mo may be reasonable
This duration is applicable to P2Y12 inhibitor therapy; aspirin is almost always continued indefinitely.
What does DAPT stand for?
Dual Antiplatelet Therapy
DAPT involves the use of two antiplatelet medications to reduce the risk of thrombotic events.
What are the implications of high bleeding risk in DAPT?
High bleeding risk denotes those who have or develop a high risk of bleeding
This includes patients on oral anticoagulant therapy or those at increased risk of severe bleeding complications.
What types of stents are mentioned in the context of DAPT?
- Bare-metal stent (BMS)
- Drug-eluting stent (DES)
These stents are used in percutaneous coronary interventions (PCI).
What is the role of aspirin in DAPT?
Aspirin is almost always continued indefinitely
Aspirin is a key component of DAPT, providing continuous antiplatelet effects.
What are the preferred anticoagulants for patients with high bleeding risk?
Novel or non–vitamin K antagonist oral anticoagulants
These are preferred over traditional vitamin K antagonists for safety in patients with high bleeding risk.
True or False: The management of combination antiplatelet and oral anticoagulant therapy is static and well-defined.
False
Management is described as a moving target in evolution, indicating ongoing changes in optimal treatment strategies.
What is the significance of the algorithm mentioned in the text?
It provides recommendations for DAPT duration in patients with ACSs
The algorithm assists healthcare providers in determining the appropriate duration of therapy.
Fill in the blank: The algorithm for DAPT applies to the duration of _______ therapy.
P2Y12 inhibitor
P2Y12 inhibitors are a class of antiplatelet agents used in conjunction with aspirin.
What does PCI stand for?
Percutaneous Coronary Intervention
PCI is a non-surgical procedure used to treat narrowing of the coronary arteries.
What is the full term for ACS?
Acute Coronary Syndromes
ACS encompasses conditions such as unstable angina and myocardial infarction.
What does STEMI stand for?
ST-segment Elevation Myocardial Infarction
STEMI is a type of heart attack characterized by a specific pattern on an ECG.
What does NSTE-ACS stand for?
Non–ST-Elevation Acute Coronary Syndrome
NSTE-ACS includes unstable angina and non-ST elevation myocardial infarction.
