Non–ST-Elevation Acute CoronarySyndromes Flashcards
What is the Class I recommendation for patients with NSTE-ACS according to the 2014 AHA/ACC guideline?
Use of either clopidogrel, ticagrelor, or prasugrel on top of aspirin
Class IIa indication for preferential use of ticagrelor or prasugrel over clopidogrel in patients undergoing PCI
What are the contraindications for prasugrel?
History of cerebrovascular accident or TIA, patients older than 75 years, or weighing <60 kg
No net clinical benefit in the latter two groups
Is adding ranolazine beneficial in NSTE-ACS patients with no anginal symptoms?
No benefit
Insulin is also the wrong choice as metformin can be uptitrated
What is the recommended maximum daily dose of metformin?
2,000 mg
Achieved maximal clinical effectiveness at this dose
Is short-acting nifedipine contraindicated in patients with NSTE-ACS?
Yes
It is contraindicated due to potential harm
What is the GRACE risk score used for?
To stratify patients into low, intermediate, and high risk of in-hospital and post-discharge 6-month mortality
Calculated using age, Killip class, systolic blood pressure, serum creatinine level, heart rate, ST-segment deviation, cardiac arrest at admission, and positive cardiac biomarkers level
What constitutes a high GRACE risk score?
GRACE risk score > 140
Indicates high risk despite absence of all components to calculate it
What is the best treatment strategy for a high-risk patient with NSTEMI?
Early invasive strategy within 12 to 24 hours
Supported by the TIMACS clinical trial
What is the difference between an immediate invasive strategy and a delayed invasive strategy?
Immediate invasive strategy is within 2 hours, while delayed is between 24 to 72 hours
Immediate reserved for patients with hemodynamic instability, heart failure, or refractory ischemia
What is the recommendation for elderly patients with acute myocardial infarction?
Invasive therapy is often underutilized despite higher risk and potential benefits
Elderly patients usually derive more benefit from evidence-based therapies
What medications are recommended for stabilized NSTE-ACS patients?
- Aspirin
- Clopidogrel
- Ticagrelor
- Prasugrel
- Beta-blockers
- ACEI
- High-intensity statin therapy
These agents are part of anti-ischemic and antithrombotic therapy
What is the recommended long-term aspirin dose according to the 2016 ACC/AHA guideline update?
81 mg daily
Higher doses do not confer added ischemic benefits and increase bleeding hazards
What role do antioxidant vitamins and folic acid play in secondary prevention after NSTE-ACS?
No role
Not beneficial in secondary prevention
What is the significance of the CURE study?
Demonstrated the benefit of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel compared to aspirin alone
Majority of subjects were medically treated NSTE-ACS patients
What is the duration of antiplatelet therapy recommended for patients with ACS?
12 months
Applies to both medically treated and PCI/stenting patients
What is the contraindication for prasugrel?
Prior TIA or stroke
Not recommended in these patients
What is the recommendation for ACE inhibitors in ACS patients?
Start and continue indefinitely in patients with LVEF < 40% and in those with hypertension, diabetes, or stable CKD
Unless contraindicated
What is the preferred antiplatelet agent in patients treated with stents?
Ticagrelor
Preferred over clopidogrel in these cases
What is the recommendation for bivalirudin in NSTE-ACS patients undergoing PCI?
Safer than heparin plus GP IIb/IIIa inhibitors
Associated with lesser bleeding and similar efficacy
What is the impact of immediate-release nifedipine on blood pressure in NSTE-ACS patients?
Can cause a precipitous drop in blood pressure
Contraindicated due to harm
What should be done if a patient develops significant overt bleeding while on DAPT?
Discontinue P2Y12 inhibitor therapy after 6 months may be reasonable
Especially in high-risk bleeding patients
What is the recommended action for patients with recurrent ischemia after appropriate use of beta-blockers?
Use oral non-dihydropyridine calcium antagonists
Verapamil and diltiazem are recommended
What is the recommended dosage of atorvastatin for patients unless intolerance or drug–drug interaction exists?
80 mg
Atorvastatin is commonly used to manage cholesterol levels.
Which anticoagulant is slightly superior to UFH among medically treated ACS patients?
Enoxaparin
Enoxaparin is a low molecular weight heparin used in the treatment of ACS.
What does the 2014 ACC/AHA NSTE-ACS guideline recommend for high-risk patients?
Early invasive therapy within 24 hours
This is recommended to improve outcomes in high-risk patients.
What is the recommended strategy for patients at low risk of NSTE-ACS?
Ischemia-guided strategy
Involves noninvasive stress testing for risk stratification.
What is the benefit of using distal embolic protection devices in vein graft PCI?
They usually reduce periprocedural MI
This is a Class I recommendation according to PCI guidelines.
What is the recommended duration for DAPT after PCI with implantation of a DES?
At least 12 months
DAPT includes aspirin and a P2Y12 receptor inhibitor.
What should be the daily dose of aspirin for NSTEMI patients treated with DES?
81 mg indefinitely
Higher doses do not provide added efficacy and increase bleeding risks.
True or False: GP IIb/IIIa inhibitors are indicated in patients undergoing PCI for vein graft disease.
False
These inhibitors are not indicated for vein graft disease.
Fill in the blank: A P2Y12 inhibitor should be administered for at least _______ months in all patients with NSTE-ACS undergoing PCI.
12
This applies regardless of whether patients received a DES or BMS.
What is contraindicated after NSTE-ACS according to Class III recommendation?
Short-acting nifedipine
It poses harm to patients post-NSTE-ACS.
What should be loaded in all patients with ACS who are not intolerant of aspirin?
Non–enteric-coated aspirin 162 to 325 mg
Followed by 81 mg once daily.
What is the preferred initial antiplatelet therapy in patients with NSTE-ACS undergoing an early invasive strategy?
DAPT with clopidogrel or ticagrelor
This includes a loading dose of 300 to 600 mg of clopidogrel.
What should be done for patients receiving DAPT and undergoing elective surgery?
Clopidogrel and ticagrelor should be withheld 5 days before the procedure
Prasugrel should be withheld 7 days before surgery.
What is the risk of stent thrombosis highest?
In the first days to weeks after implantation
This is particularly concerning during surgical procedures.
Which risk score includes variables such as age, ST-segment deviation, and cardiac arrest at admission?
GRACE risk score
It is used to assess prognosis in patients with NSTE-ACS.
What should be avoided in patients with acute cocaine intoxication who have signs of tachycardia?
Beta-blockers
They should only be used if patients are receiving coronary vasodilator therapy.
What is the recommended management for patients with ACS in the presence of acute cocaine intoxication?
Cautious lowering of blood pressure
Benzodiazepines may be used to manage hypertension and tachycardia.
What is the benefit of ticagrelor over clopidogrel in patients with NSTEMI?
It has incremental benefits and reduces ischemic complications
This includes a mortality benefit observed in the PLATO trial.
True or False: Patients with NSTEMI should receive a loading dose of prasugrel only when coronary anatomy is delineated.
True
This is according to the design of the TRITON-TIMI 38 trial.
What is the primary biomarker of choice to rule out and diagnose myocardial infarction (MI)?
Troponin levels
Refer to the third Universal Definition of Myocardial Infarction released in 2012.
What is the recommendation for using CK-MB and myoglobin in diagnosing acute coronary syndrome (ACS)?
Not useful for diagnosis
This is supported by the 2014 AHA/ACC NSTE-ACS Guideline.
What is the indication for immediate/urgent invasive strategy in patients with NSTE-ACS?
Definite NSTE-ACS with hemodynamic instability, refractory ischemia, heart failure
This represents <5% to 10% of all NSTE-ACS patients.
What is the purpose of supplemental ECG leads V7 to V9 in ACS patients?
Help diagnose lateral ischemia
These leads may reveal issues with the left circumflex artery that are not visible on a standard 12-lead ECG.
What is the TIMI risk score used for?
Assess the prognosis of patients presenting with unstable angina/NSTEMI
It is a risk stratification tool, not a diagnostic tool.
What are the seven risk indicators used in the TIMI risk score?
Age ≥65, at least three CAD risk factors, prior coronary stenosis ≥50%, ST segment deviation, at least two anginal events in 24h, aspirin use in last 7 days, elevated serum cardiac biomarkers
Each indicator contributes one point to the score.
What is the most common etiology of cardiogenic shock?
Acute MI with pump failure
Represents around 80% of cases.
What is contraindicated when a patient has taken sildenafil or vardenafil?
Use of nitroglycerin
This combination can cause severe hypotension.
What treatment is recommended for vasospastic angina (Prinzmetal angina)?
Long-acting calcium channel blockers, long-acting nitrates
Statins and cessation of tobacco use are also beneficial.
What is the role of provocative testing during invasive coronary angiography for suspected vasospastic angina?
Determine the diagnosis when noninvasive assessments fail
It is relatively safe but should be avoided in high-risk patients.
True or False: IV beta-blockers are recommended for patients with acute coronary syndrome.
False
They are associated with increased complications and risk of cardiogenic shock.
Fill in the blank: The 2014 ACC/AHA NSTE-ACS Guideline gives a Class I recommendation for the _______ vaccine in patients 65 years or older.
pneumococcal
This includes high-risk patients such as smokers and asthmatics.
What should be done for patients with NSTE-ACS and arterial oxygen saturation <90%?
Administer supplemental oxygen
Supplemental oxygen is also indicated for respiratory distress or other high-risk features of hypoxemia.
What is a common complication of ACS associated with pulmonary edema?
Heart failure
Indicates a very high short-term risk.
What is the main effect of nitroglycerin in treating ischemic symptoms?
Reduces myocardial oxygen demand
It does this by reducing preload and wall stress.
What are the risks associated with cardiogenic shock?
Isolated left or right heart failure, biventricular failure, cardiogenic shock, mechanical complications, arrhythmias
Includes ventricular tachycardia or fibrillation, atrial fibrillation, and AV nodal block.
What is the primary purpose of a noninvasive stress test in ACS patients?
Assess cardiac function
May require pharmacologic stress testing if the patient cannot exercise adequately.
