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Invasive Cardiology Board Review > Non–ST-Elevation Acute CoronarySyndromes > Flashcards

Non–ST-Elevation Acute CoronarySyndromes Flashcards

1
Q

What is the Class I recommendation for patients with NSTE-ACS according to the 2014 AHA/ACC guideline?

A

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

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2
Q

What are the contraindications for prasugrel?

A

History of cerebrovascular accident or TIA, patients older than 75 years, or weighing <60 kg

No net clinical benefit in the latter two groups

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3
Q

Is adding ranolazine beneficial in NSTE-ACS patients with no anginal symptoms?

A

No benefit

Insulin is also the wrong choice as metformin can be uptitrated

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4
Q

What is the recommended maximum daily dose of metformin?

A

2,000 mg

Achieved maximal clinical effectiveness at this dose

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5
Q

Is short-acting nifedipine contraindicated in patients with NSTE-ACS?

A

Yes

It is contraindicated due to potential harm

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6
Q

What is the GRACE risk score used for?

A

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

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7
Q

What constitutes a high GRACE risk score?

A

GRACE risk score > 140

Indicates high risk despite absence of all components to calculate it

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8
Q

What is the best treatment strategy for a high-risk patient with NSTEMI?

A

Early invasive strategy within 12 to 24 hours

Supported by the TIMACS clinical trial

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9
Q

What is the difference between an immediate invasive strategy and a delayed invasive strategy?

A

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

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10
Q

What is the recommendation for elderly patients with acute myocardial infarction?

A

Invasive therapy is often underutilized despite higher risk and potential benefits

Elderly patients usually derive more benefit from evidence-based therapies

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11
Q

What medications are recommended for stabilized NSTE-ACS patients?

A
  • Aspirin
  • Clopidogrel
  • Ticagrelor
  • Prasugrel
  • Beta-blockers
  • ACEI
  • High-intensity statin therapy

These agents are part of anti-ischemic and antithrombotic therapy

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12
Q

What is the recommended long-term aspirin dose according to the 2016 ACC/AHA guideline update?

A

81 mg daily

Higher doses do not confer added ischemic benefits and increase bleeding hazards

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13
Q

What role do antioxidant vitamins and folic acid play in secondary prevention after NSTE-ACS?

A

No role

Not beneficial in secondary prevention

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14
Q

What is the significance of the CURE study?

A

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

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15
Q

What is the duration of antiplatelet therapy recommended for patients with ACS?

A

12 months

Applies to both medically treated and PCI/stenting patients

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16
Q

What is the contraindication for prasugrel?

A

Prior TIA or stroke

Not recommended in these patients

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17
Q

What is the recommendation for ACE inhibitors in ACS patients?

A

Start and continue indefinitely in patients with LVEF < 40% and in those with hypertension, diabetes, or stable CKD

Unless contraindicated

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18
Q

What is the preferred antiplatelet agent in patients treated with stents?

A

Ticagrelor

Preferred over clopidogrel in these cases

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19
Q

What is the recommendation for bivalirudin in NSTE-ACS patients undergoing PCI?

A

Safer than heparin plus GP IIb/IIIa inhibitors

Associated with lesser bleeding and similar efficacy

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20
Q

What is the impact of immediate-release nifedipine on blood pressure in NSTE-ACS patients?

A

Can cause a precipitous drop in blood pressure

Contraindicated due to harm

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21
Q

What should be done if a patient develops significant overt bleeding while on DAPT?

A

Discontinue P2Y12 inhibitor therapy after 6 months may be reasonable

Especially in high-risk bleeding patients

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22
Q

What is the recommended action for patients with recurrent ischemia after appropriate use of beta-blockers?

A

Use oral non-dihydropyridine calcium antagonists

Verapamil and diltiazem are recommended

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23
Q

What is the recommended dosage of atorvastatin for patients unless intolerance or drug–drug interaction exists?

A

80 mg

Atorvastatin is commonly used to manage cholesterol levels.

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24
Q

Which anticoagulant is slightly superior to UFH among medically treated ACS patients?

A

Enoxaparin

Enoxaparin is a low molecular weight heparin used in the treatment of ACS.

25
Q

What does the 2014 ACC/AHA NSTE-ACS guideline recommend for high-risk patients?

A

Early invasive therapy within 24 hours

This is recommended to improve outcomes in high-risk patients.

26
Q

What is the recommended strategy for patients at low risk of NSTE-ACS?

A

Ischemia-guided strategy

Involves noninvasive stress testing for risk stratification.

27
Q

What is the benefit of using distal embolic protection devices in vein graft PCI?

A

They usually reduce periprocedural MI

This is a Class I recommendation according to PCI guidelines.

28
Q

What is the recommended duration for DAPT after PCI with implantation of a DES?

A

At least 12 months

DAPT includes aspirin and a P2Y12 receptor inhibitor.

29
Q

What should be the daily dose of aspirin for NSTEMI patients treated with DES?

A

81 mg indefinitely

Higher doses do not provide added efficacy and increase bleeding risks.

30
Q

True or False: GP IIb/IIIa inhibitors are indicated in patients undergoing PCI for vein graft disease.

A

False

These inhibitors are not indicated for vein graft disease.

31
Q

Fill in the blank: A P2Y12 inhibitor should be administered for at least _______ months in all patients with NSTE-ACS undergoing PCI.

A

12

This applies regardless of whether patients received a DES or BMS.

32
Q

What is contraindicated after NSTE-ACS according to Class III recommendation?

A

Short-acting nifedipine

It poses harm to patients post-NSTE-ACS.

33
Q

What should be loaded in all patients with ACS who are not intolerant of aspirin?

A

Non–enteric-coated aspirin 162 to 325 mg

Followed by 81 mg once daily.

34
Q

What is the preferred initial antiplatelet therapy in patients with NSTE-ACS undergoing an early invasive strategy?

A

DAPT with clopidogrel or ticagrelor

This includes a loading dose of 300 to 600 mg of clopidogrel.

35
Q

What should be done for patients receiving DAPT and undergoing elective surgery?

A

Clopidogrel and ticagrelor should be withheld 5 days before the procedure

Prasugrel should be withheld 7 days before surgery.

36
Q

What is the risk of stent thrombosis highest?

A

In the first days to weeks after implantation

This is particularly concerning during surgical procedures.

37
Q

Which risk score includes variables such as age, ST-segment deviation, and cardiac arrest at admission?

A

GRACE risk score

It is used to assess prognosis in patients with NSTE-ACS.

38
Q

What should be avoided in patients with acute cocaine intoxication who have signs of tachycardia?

A

Beta-blockers

They should only be used if patients are receiving coronary vasodilator therapy.

39
Q

What is the recommended management for patients with ACS in the presence of acute cocaine intoxication?

A

Cautious lowering of blood pressure

Benzodiazepines may be used to manage hypertension and tachycardia.

40
Q

What is the benefit of ticagrelor over clopidogrel in patients with NSTEMI?

A

It has incremental benefits and reduces ischemic complications

This includes a mortality benefit observed in the PLATO trial.

41
Q

True or False: Patients with NSTEMI should receive a loading dose of prasugrel only when coronary anatomy is delineated.

A

True

This is according to the design of the TRITON-TIMI 38 trial.

42
Q

What is the primary biomarker of choice to rule out and diagnose myocardial infarction (MI)?

A

Troponin levels

Refer to the third Universal Definition of Myocardial Infarction released in 2012.

43
Q

What is the recommendation for using CK-MB and myoglobin in diagnosing acute coronary syndrome (ACS)?

A

Not useful for diagnosis

This is supported by the 2014 AHA/ACC NSTE-ACS Guideline.

44
Q

What is the indication for immediate/urgent invasive strategy in patients with NSTE-ACS?

A

Definite NSTE-ACS with hemodynamic instability, refractory ischemia, heart failure

This represents <5% to 10% of all NSTE-ACS patients.

45
Q

What is the purpose of supplemental ECG leads V7 to V9 in ACS patients?

A

Help diagnose lateral ischemia

These leads may reveal issues with the left circumflex artery that are not visible on a standard 12-lead ECG.

46
Q

What is the TIMI risk score used for?

A

Assess the prognosis of patients presenting with unstable angina/NSTEMI

It is a risk stratification tool, not a diagnostic tool.

47
Q

What are the seven risk indicators used in the TIMI risk score?

A

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.

48
Q

What is the most common etiology of cardiogenic shock?

A

Acute MI with pump failure

Represents around 80% of cases.

49
Q

What is contraindicated when a patient has taken sildenafil or vardenafil?

A

Use of nitroglycerin

This combination can cause severe hypotension.

50
Q

What treatment is recommended for vasospastic angina (Prinzmetal angina)?

A

Long-acting calcium channel blockers, long-acting nitrates

Statins and cessation of tobacco use are also beneficial.

51
Q

What is the role of provocative testing during invasive coronary angiography for suspected vasospastic angina?

A

Determine the diagnosis when noninvasive assessments fail

It is relatively safe but should be avoided in high-risk patients.

52
Q

True or False: IV beta-blockers are recommended for patients with acute coronary syndrome.

A

False

They are associated with increased complications and risk of cardiogenic shock.

53
Q

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.

A

pneumococcal

This includes high-risk patients such as smokers and asthmatics.

54
Q

What should be done for patients with NSTE-ACS and arterial oxygen saturation <90%?

A

Administer supplemental oxygen

Supplemental oxygen is also indicated for respiratory distress or other high-risk features of hypoxemia.

55
Q

What is a common complication of ACS associated with pulmonary edema?

A

Heart failure

Indicates a very high short-term risk.

56
Q

What is the main effect of nitroglycerin in treating ischemic symptoms?

A

Reduces myocardial oxygen demand

It does this by reducing preload and wall stress.

57
Q

What are the risks associated with cardiogenic shock?

A

Isolated left or right heart failure, biventricular failure, cardiogenic shock, mechanical complications, arrhythmias

Includes ventricular tachycardia or fibrillation, atrial fibrillation, and AV nodal block.

58
Q

What is the primary purpose of a noninvasive stress test in ACS patients?

A

Assess cardiac function

May require pharmacologic stress testing if the patient cannot exercise adequately.

Invasive Cardiology Board Review (42 decks)

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