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Cardio Exam 2 > Pharmacotherapy of ACS > Flashcards

Pharmacotherapy of ACS Flashcards

1
Q

Signs/Symptoms

A

Chest, arm, jaw/neck, or epigastric discomfort with exertion or at rest

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2
Q

Atypical Signs/Symptoms

A

SOB, jaw and back pain, nausea, dizziness, “cold sweat”, n/v, anorexia, hypotension, crackles

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3
Q

Women Signs/Symptoms

A

SOB, jaw/back pain, nausea

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4
Q

Diabetics Signs/Symptoms

A

May be reduced due to autonomic neuropathy (HR/BP may not increase)

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5
Q

Elderly Signs/Symptoms

A

Altered mental status

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6
Q

Which of the following agents used in the management of ACS may decrease MORTALITY?

A

Aspirin

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7
Q

Early Hospital/ ER based Pharmacotherapy MONA

A

Morphine
Oxygen
Nitrate
Aspirin

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8
Q

Aspirin

A

High dose 325

Will decrease mortality

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9
Q

Oxygen

A

Maintain O2 saturation of 90% or greater

- Oxidative damage to ischemic tissues

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10
Q

Chest pain

A

SL NTG
Morphine
IV NTG

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11
Q

Morphine dose

A

2-5 mg IV q5minutes PRN chest pain not relieved by SL NTG

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12
Q

Morphine causes

A

analgesia
vasodilation
decreased sympathetic tone (slows tachycardic HR)

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13
Q

Morphine hold

A

Histamine release –> itching

Sedation, hypOTN

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14
Q

IV NTG hold for

A

HypOTN, tachycardia, bradycardia, arrhythmia

Do not immediately discontinue, must titrate down

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15
Q

Early BB use:

A

NOT if they seem to have acute heart failure (PE, low BP)

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16
Q

Low-Medium Risk NSTEMI

A

No troponin increase

EKG changes: None, nonspecific, ST depression, T-wave inversion

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17
Q

High Risk NSTEMI

A

Yes troponin increase

EKG changes: None, nonspecific, ST depression, T-wave inversion

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18
Q

STEMI

A

Yes Troponin increase

EKG: ST elevation

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19
Q

ROMI Cardiac Enzyme Panel

A

Every 3-6 hours 2-3 times

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20
Q

STEMI Management

A

Percutaneous coronary intervention (angioplasty/stenting) or fibrinolysis

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21
Q

Goal of STEMI management

A

Restore complete blood flow to occluded artery within 90 minutes of arriving at hospital

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22
Q

Symptoms less than 12 hours

A

Significant improvement with treatment

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23
Q

Symptoms 12-24 hours

A

Might improve with treatment

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24
Q

Symptoms greater than 24 hours

A

Unlikely to prove beneficial and tissue cannot be salvaged

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25
PCI Goal
Within 90 minutes of medical contact
26
Fibrinolysis Goal
Within 30 minutes of arrival at hospital | - Not as successful as PCI
27
NSTEMI -->
Risk stratification ot identify high risk patients vs medium or low risk
28
NSTEMI Goal
ID an appropriate management of high and moderate risk patient to minimize loss of myocardium
29
Risk Stratification is based on
GRACE score greater than 140 Elevated troponin (tissue death) ST depression
30
High Risk Patients
Go to Cath lab within 24 hours
31
Medium Risk Patients
Go to cath lab in 1-3 days
32
Low Risk Patients
``` Further diagnostics (exercise stress test) Don't think they are having a heart attack but lets make sure ```
33
Medical management + Patients
Some patients don't want to go to cath lab so they just start standard anti-thrombotics and secondary preventative measures
34
MONA-PA
``` Morphine Oxygen Nitrate Aspirin P2Y12 Inhibitor Anti-coagulant - So one of the first 4 + PA ```
35
Cath Lab Required Therapy
Potent anti-thrombotic bc you are going in angainst week vessel walls and poking/breaking up a clot (make it angry)
36
Fibrinolysis complications
If there is any place in your body that you were going to bleed, it will hemorrhage so you keep pt on anti-thrombotic but back off on other therapies
37
Antiplatelet Agents
Aspirin P2Y12 inhibitors 2b3ai's
38
Anticoagulant agents
Heparin Direct Thrombin inhibitors Factor Xa inhibitors
39
Fibrinolytic agents
Ateplase Reteplase Tenecteplase
40
Those undergoing fibrinolysis (STEMI) are at
high risk of bleeding so use less potent agents
41
Clopidogrel Adverse Reactions
TTP
42
When is clopidogrel used?
Med mgmt NSTEMI PCI STEMI PCI SETMI Fibrinolysis
43
Dosing of Clopidogrel
300 mg PO x 1 (loading) or 600 mg PO x 1 if PCI | 75 mg PO daily (maint)
44
When would you not give a loading dose?
>75 years old
45
CABG + Clopidogrel
hold for 5 days for CABG
46
Prasugrel CI
History of stroke/TIA
47
Prasugrel uses
NSTEMI PCI and STEMI PCI ONLY
48
Prasegrel Dosing
60 mg POx1 (loading) 10 mg PO daily (maint) DO NOT administer until planning on stent placement
49
Prasugrel + CABG
Hold for 7 days for CABG
50
Ticagrelor AE
``` Dyspnea Ventricular pauses (don't give in bradycardia pts) ```
51
Ticagrelor one up =
Reversible!!!
52
Ticagrelor use
Med mgmt NSTEMI PCI STEMI PCI
53
Ticagrelor dosing
180 mg PO X1 (loading) | 90 mg PO BID (maint)
54
Ticagrelor + CABG
Hold for 3-5 days for CABG
55
Abciximab (Reopro) Dosing and renal adjustment
For up to 12 hours | None
56
Abciximab AE
Thrombocytopenia
57
CI for 2b3ai
Active bleed, prior stroke (2 years), thrombocytopenia, recent surgery or trauma (6 mths), severy HTN, intracranial tumor or aneurysm
58
Tirofiban (Aggrastat) Dosing and Renal adjustment
For up to 18-24 hours | Decreased infusion 50% for CrCl <60
59
Eptifibatide (Intergillin) Dosing and Renal adjustment
For up to 18-24 hours | Decreased infusion 50% for CrCl < 50
60
Abciximab vsTirofiban and Eptifibatide
A: doesn't need activated platelets | T&E: activated platelets required
61
Gp2b3ai are not used with:
Bivalirudin (angiomax)
62
Heparin and Enoxaparin CI
Active bleed, bleed risk, HIT, stroke
63
Heparin Enoxaparin AE
Bleeding and HIT
64
Heparin dosing
60 u/kg IV bolus 12 u/kg/hr IV maint This is for med mgmt, PCI and fibronlysis
65
Enoxaparin dosing
Med mgmt and NSTEMI PCI: 1 mg/kg SC q12h with IV bolus if going for PCI
66
Enoxaparin Renal adjustment
For CrCl less than 30, give q24h | Avoid if CrCl less than 15
67
Fondaparinux (Arixtra) class and CI
Factor Xa inhibitor | Active bleed or bleed risk
68
Fondaparinux dosing
Med, NSTEMI PCI, STEMI PCI: 2.5 mg SQ daily, add UFH IV if going PCI Fibronlysis: 2.5 mg IV x1 then 2.5 mg SQ daily
69
Fondaparinux renal adjustment
Caution in CrCl less than 50 | Avoid if less than 30
70
Bivalirudin (angiomax) class and CI
``` Direct thrombin (factor 2) inhibitor Active bleed and risk of bleed ```
71
Bivalirudin dosing
Avoid in Med mgmt and fibronylsis bc of cost | Used in PCI but no dose
72
Bivalirudin renal adjustment
CrCl less than 30, decrease dose | Dialysis, even lower
73
Bivalirudin doesn't require
Gp2b3ais
74
HIT
Activation of platelets leads to increased risk of blood clot in the legs and lungs despite thrombocytopenia
75
Fibrinolytics Drugs
Alteplase (Activase) Reteplase (Retavase) Tenecteplase (TNKase)
76
Dosing Alteplase
1 bolus + continuous infusion
77
Dosing Reteplase
2 bolus
78
Dosing Tenecteplase
1 bolus
79
Fibrinolytics should be combined with
ASA high dose in ER Clopidogrel 300 mg LD Anticoagulants (heparin, enoxaparin, fondaparinux)
80
Secondary Prevention of ACS HTN/Prevent HF
BB within 24 hrs for pts with cardiogeneic shock/AHF ACEi/ARBs (Within 24 hrs but not IV) Aldosterone antagonists (LVEF less than 40% + DM OR LVEF less than 40% + HF symptoms)
81
Aldosterone antagonists
Within first week after MI | Hold for CrCl less than 30 or potassium > 5
82
Secondary Prevention of ACS Dyslipidemia
High dose statins initiated before discharge (plaque stabilizing via pleiotropic effects)
83
Secondary Prevention of ACS Lifestyle
Obesity Diet Alcohol Exercise (rehab)
84
Dual Antiplatelet Therapy (DAPT)
Stent: 1 year | Fibrinolysis or med mgmt: 12 months
85
No PCI/stenting
Aspirin | P2Y12 Inhibitor for at least 1 month up to 12 months
86
Stenting
Aspirin | P2Y12 inhibitor for at least 12 months
87
Prevention of GI bleed with DAPT
Addition of acid-suppression
88
Use a PPI if patient is at increased risk of GI bleed if:
History of GI bleed or chronic anticoagulant | Advanced age, steroids, or NSAID use
89
Triple anti-thrombotic therapy for ACS and Afib
ASA + P2Y12 inhibitor + anticoagulate | - Target warfarin is 2-2.5 INR, ASA no greater than 81 mg

Cardio Exam 2 (10 decks)

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