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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
Q

PCI Goal

A

Within 90 minutes of medical contact

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26
Q

Fibrinolysis Goal

A

Within 30 minutes of arrival at hospital

- Not as successful as PCI

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27
Q

NSTEMI –>

A

Risk stratification ot identify high risk patients vs medium or low risk

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28
Q

NSTEMI Goal

A

ID an appropriate management of high and moderate risk patient to minimize loss of myocardium

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29
Q

Risk Stratification is based on

A

GRACE score greater than 140
Elevated troponin (tissue death)
ST depression

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30
Q

High Risk Patients

A

Go to Cath lab within 24 hours

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31
Q

Medium Risk Patients

A

Go to cath lab in 1-3 days

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32
Q

Low Risk Patients

A 
Further diagnostics (exercise stress test)
Don't think they are having a heart attack but lets make sure
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33
Q

Medical management + Patients

A

Some patients don’t want to go to cath lab so they just start standard anti-thrombotics and secondary preventative measures

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34
Q

MONA-PA

A 
Morphine
Oxygen
Nitrate
Aspirin
P2Y12 Inhibitor
Anti-coagulant
- So one of the first 4 + PA
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35
Q

Cath Lab Required Therapy

A

Potent anti-thrombotic bc you are going in angainst week vessel walls and poking/breaking up a clot (make it angry)

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36
Q

Fibrinolysis complications

A

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
Q

Antiplatelet Agents

A

Aspirin
P2Y12 inhibitors
2b3ai’s

38
Q

Anticoagulant agents

A

Heparin
Direct Thrombin inhibitors
Factor Xa inhibitors

39
Q

Fibrinolytic agents

A

Ateplase
Reteplase
Tenecteplase

40
Q

Those undergoing fibrinolysis (STEMI) are at

A

high risk of bleeding so use less potent agents

41
Q

Clopidogrel Adverse Reactions

42
Q

When is clopidogrel used?

A

Med mgmt
NSTEMI PCI
STEMI PCI
SETMI Fibrinolysis

43
Q

Dosing of Clopidogrel

A

300 mg PO x 1 (loading) or 600 mg PO x 1 if PCI

75 mg PO daily (maint)

44
Q

When would you not give a loading dose?

A

> 75 years old

45
Q

CABG + Clopidogrel

A

hold for 5 days for CABG

46
Q

Prasugrel CI

A

History of stroke/TIA

47
Q

Prasugrel uses

A

NSTEMI PCI and STEMI PCI ONLY

48
Q

Prasegrel Dosing

A

60 mg POx1 (loading)
10 mg PO daily (maint)
DO NOT administer until planning on stent placement

49
Q

Prasugrel + CABG

A

Hold for 7 days for CABG

50
Q

Ticagrelor AE

A 
Dyspnea
Ventricular pauses (don't give in bradycardia pts)
51
Q

Ticagrelor one up =

A

Reversible!!!

52
Q

Ticagrelor use

A

Med mgmt
NSTEMI PCI
STEMI PCI

53
Q

Ticagrelor dosing

A

180 mg PO X1 (loading)

90 mg PO BID (maint)

54
Q

Ticagrelor + CABG

A

Hold for 3-5 days for CABG

55
Q

Abciximab (Reopro) Dosing and renal adjustment

A

For up to 12 hours

None

56
Q

Abciximab AE

A

Thrombocytopenia

57
Q

CI for 2b3ai

A

Active bleed, prior stroke (2 years), thrombocytopenia, recent surgery or trauma (6 mths), severy HTN, intracranial tumor or aneurysm

58
Q

Tirofiban (Aggrastat) Dosing and Renal adjustment

A

For up to 18-24 hours

Decreased infusion 50% for CrCl <60

59
Q

Eptifibatide (Intergillin) Dosing and Renal adjustment

A

For up to 18-24 hours

Decreased infusion 50% for CrCl < 50

60
Q

Abciximab vsTirofiban and Eptifibatide

A

A: doesn’t need activated platelets

T&E: activated platelets required

61
Q

Gp2b3ai are not used with:

A

Bivalirudin (angiomax)

62
Q

Heparin and Enoxaparin CI

A

Active bleed, bleed risk, HIT, stroke

63
Q

Heparin Enoxaparin AE

A

Bleeding and HIT

64
Q

Heparin dosing

A

60 u/kg IV bolus
12 u/kg/hr IV maint
This is for med mgmt, PCI and fibronlysis

65
Q

Enoxaparin dosing

A

Med mgmt and NSTEMI PCI: 1 mg/kg SC q12h with IV bolus if going for PCI

66
Q

Enoxaparin Renal adjustment

A

For CrCl less than 30, give q24h

Avoid if CrCl less than 15

67
Q

Fondaparinux (Arixtra) class and CI

A

Factor Xa inhibitor

Active bleed or bleed risk

68
Q

Fondaparinux dosing

A

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
Q

Fondaparinux renal adjustment

A

Caution in CrCl less than 50

Avoid if less than 30

70
Q

Bivalirudin (angiomax) class and CI

A 
Direct thrombin (factor 2) inhibitor
Active bleed and risk of bleed
71
Q

Bivalirudin dosing

A

Avoid in Med mgmt and fibronylsis bc of cost

Used in PCI but no dose

72
Q

Bivalirudin renal adjustment

A

CrCl less than 30, decrease dose

Dialysis, even lower

73
Q

Bivalirudin doesn’t require

74
Q

HIT

A

Activation of platelets leads to increased risk of blood clot in the legs and lungs despite thrombocytopenia

75
Q

Fibrinolytics Drugs

A

Alteplase (Activase)
Reteplase (Retavase)
Tenecteplase (TNKase)

76
Q

Dosing Alteplase

A

1 bolus + continuous infusion

77
Q

Dosing Reteplase

78
Q

Dosing Tenecteplase

79
Q

Fibrinolytics should be combined with

A

ASA high dose in ER
Clopidogrel 300 mg LD
Anticoagulants (heparin, enoxaparin, fondaparinux)

80
Q

Secondary Prevention of ACS HTN/Prevent HF

A

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
Q

Aldosterone antagonists

A

Within first week after MI

Hold for CrCl less than 30 or potassium > 5

82
Q

Secondary Prevention of ACS Dyslipidemia

A

High dose statins initiated before discharge (plaque stabilizing via pleiotropic effects)

83
Q

Secondary Prevention of ACS Lifestyle

A

Obesity
Diet
Alcohol
Exercise (rehab)

84
Q

Dual Antiplatelet Therapy (DAPT)

A

Stent: 1 year

Fibrinolysis or med mgmt: 12 months

85
Q

No PCI/stenting

A

Aspirin

P2Y12 Inhibitor for at least 1 month up to 12 months

86
Q

Stenting

A

Aspirin

P2Y12 inhibitor for at least 12 months

87
Q

Prevention of GI bleed with DAPT

A

Addition of acid-suppression

88
Q

Use a PPI if patient is at increased risk of GI bleed if:

A

History of GI bleed or chronic anticoagulant

Advanced age, steroids, or NSAID use

89
Q

Triple anti-thrombotic therapy for ACS and Afib

A

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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