Percutaneous Coronary Intervention for Acute Coronary Syndromes Flashcards
What is the medical therapy recommended for STEMI patients?
Aspirin, beta-blockers, statins, and ACE inhibitors
Medical therapy is crucial for managing patients with STEMI.
What did the Occluded Arteries Trial (OAT) conclude about PCI in asymptomatic patients?
No benefit with PCI regarding death, reinfarction, or reduction in heart failure at 4-year follow-up
The trial involved over 2,000 patients with total occlusion of the infarct-related artery.
What is the recommended dose of enoxaparin for patients undergoing PCI?
0.3 mg/kg IV once
This is typically administered at the time of PCI for adequate anticoagulation.
What is a significant risk associated with fondaparinux during PCI?
Significant increase in catheter-related thrombosis
Fondaparinux is an indirect inhibitor of factor Xa with no effect on thrombin.
When is early angiography indicated in patients?
In patients with refractory angina or hemodynamic instability
The term ‘early’ generally means within 24 hours.
What is the recommended action for patients who received thrombolytic therapy 2 hours ago?
Admit to the coronary care unit for evaluation
Angiography should be considered within 3- to 24-hours after thrombolysis.
What are high-risk features that support an ‘early invasive’ strategy?
[“Recurrent angina/ischemia at rest”, “Elevated TnT or TnI”, “New ST-segment depression”, “Recurrent angina with symptoms”, “High-risk findings on stress testing”, “Depressed systolic function”, “Hemodynamic instability”, “Sustained ventricular tachycardia”, “Prior CABG”]
What is the Class III recommendation regarding PCI of a non-infarct-related artery?
Due to concerns over additional contrast use and higher complication rates
Recent trials have shown safety and efficacy for PCI of a non-infarct-related artery.
What are GP IIb/IIIa inhibitors primarily used for in ACS patients?
In patients considered for early invasive approach not adequately preloaded with a P2Y12 inhibitor
They provide rapid antiplatelet activity but are associated with increased bleeding risk.
What is the recommended treatment for a patient in cardiogenic shock with inferior STEMI?
Thrombolyze and transfer immediately
This approach is known as ‘drip and ship’ to a PCI-capable facility.
What procedure should be performed for a patient with a large thrombus burden?
Angioplasty and stent placement
This is to prevent distal embolization and poor cardiovascular outcomes.
What is the ideal strategy for antiplatelet therapy in patients undergoing PCI?
IV cangrelor loading followed by an infusion for 4 hours, transitioned to ticagrelor
Cangrelor provides immediate antiplatelet effects, suitable for patients inadequately loaded with P2Y12 inhibitors.
True or False: Patients undergoing PCI should receive a loading dose of P2Y12 inhibitors.
True
This is critical for achieving rapid platelet inhibition.
What is the outcome of the TAPAS trial regarding aspiration thrombectomy?
Significant improvement in myocardial blush grade with aspiration thrombectomy plus PCI
However, subsequent trials showed no benefit with routine thrombus aspiration.
What is a key benefit of clopidogrel in PCI?
Reduction in stent thrombosis
Cited from Bhatt DL, et al. N Engl J Med 2013;368(14):1303–1313.
When is cangrelor ideally suited for use?
For patients who couldn’t be adequately loaded with P2Y12 inhibitors before PCI and in whom GP inhibitors are not used.
What is a risk of administering clopidogrel hours after PCI?
Increased risk of stent thrombosis.
Why is it less desirable to use GP IIb/IIIa inhibitors with bivalirudin?
It negates the bleeding risk reduction provided by bivalirudin.
What is the recommendation for PCI of completely occluded vein grafts?
Class III recommendation against it due to low success rates and high risk for complications.
What intervention reduces MACE in vein graft procedures?
Distal embolic protection with a filter.
What is the bleeding risk range for patients on triple therapy?
10% to 14%.
What did the WOEST trial find regarding single antiplatelet treatment?
Fewer bleeding complications and no increase in thrombotic events compared to DAPT.
What does the PIONEER AF-PCI trial compare?
Rivaroxaban plus clopidogrel, very low-dose rivaroxaban plus DAPT, or warfarin plus DAPT.
What is a Class I recommendation for NSTEMI patients regarding P2Y12 inhibitors?
Give a loading dose of P2Y12 inhibitor.
What is the difference between thienopyridines and ticagrelor?
Thienopyridines are prodrugs; ticagrelor does not require activation.
Why is ticagrelor preferred over clopidogrel for a clopidogrel nonresponder?
Due to prior stent thrombosis indicating clopidogrel failure.
What are the independent predictors of major bleeding in ACS?
- Advanced age
- Female gender
- History of bleeding
- Renal insufficiency
What is a major predictor of contrast-induced nephropathy (CIN)?
Volume of contrast.
What strategies are beneficial in reducing CIN?
- Infusion of normal saline
- Minimizing contrast use
When is routine stress testing indicated after PCI?
Only for patients with high-risk features.
What is the recommended dosing of bivalirudin for a patient with eGFR <30 mL/min?
1 mg/kg/h infusion.
What did the ISAR-REACT 3 trial compare?
Bivalirudin versus UFH in patients undergoing PCI.
What is a common misconception regarding platelet function testing?
It can tailor antiplatelet therapy effectively.
What is the role of clopidogrel in patients undergoing PCI?
Patients were pretreated with clopidogrel 600 mg more than 2 hours before PCI
Clopidogrel is an antiplatelet medication used to prevent blood clots in patients undergoing percutaneous coronary intervention (PCI).
What is the bleeding risk comparison between bivalirudin and heparin?
Bivalirudin is as effective as UFH or LMW heparin plus a GP IIb/IIIa inhibitor and associated with a lower bleeding risk
The effectiveness and safety of bivalirudin versus heparin were evaluated in patients with acute coronary syndrome (ACS).
What is the ideal treatment strategy for a patient with cardiogenic shock?
Emergent angiography and revascularization as indicated
This strategy is essential for managing patients presenting with cardiogenic shock.
When should hemodynamic support devices be used in cardiogenic shock?
When patients are refractory to pharmacologic measures
Hemodynamic support devices assist patients who are not responding adequately to medications.
What is the function of the intra-aortic balloon pump?
Improves diastolic coronary blood flow but does not provide meaningful cardiac output in pump failure
It is commonly used in cardiogenic shock situations.
What is the Impella device used for?
Provides a forward flow of up to 2.5 L (Impella 2.5) or 3.5 L (Impella CP)
The Impella is a percutaneous left ventricular assist device used in cardiogenic shock.
Have hemodynamic support devices shown improved outcomes in cardiogenic shock?
No, none have shown improved outcomes in randomized clinical trials
Observational data may show improved hemodynamics, but randomized trials do not support outcome improvements.
What is the only strategy consistently shown to improve outcomes in cardiogenic shock?
Early revascularization
Early intervention is crucial for improving prognosis in patients with cardiogenic shock.
What is the benefit of supervised cardiac rehabilitation programs?
Significant reduction in all-cause mortality and cardiovascular mortality
These programs improve exercise tolerance, cardiac symptoms, and overall psychosocial well-being.
In which patients should cardiac rehabilitation be particularly considered?
Intermediate- to high-risk patients
Cardiac rehabilitation is beneficial for patients with a higher risk of cardiovascular events.
What improvements are associated with cardiac rehabilitation?
Improvements in exercise tolerance, cardiac symptoms, lipid levels, smoking cessation rates, stress levels, medical regimen compliance, and psychosocial well-being
These benefits contribute to the recommendation of cardiac rehabilitation in clinical guidelines.
What is indicated by a thin fibrotic cap and large atheromatous burden?
Most likely would provoke an ACS in the event of rupture
This finding suggests a higher risk for acute coronary syndrome due to plaque instability.
What does normal vessel anatomy with very mild atherosclerotic changes indicate?
Normal vessel anatomy with very mild atherosclerotic changes
This finding is typically not associated with significant clinical risk.
What does the presence of a side branch in coronary angiography indicate?
Presence of a side branch
Side branches are anatomical features that may influence blood flow and treatment options.
What is indicated by unstable angina in the context of coronary artery disease?
Shows plaque rupture/dissection
Unstable angina is a clinical manifestation of acute coronary syndrome and indicates significant plaque instability.
What is associated with a significant atheromatous burden and decreased mean lumen area?
Most likely would be associated with stable angina
Stable angina typically arises from chronic ischemia due to atheromatous changes in coronary arteries.
