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CVB by Minnie (Madeleine) > SM 129a - Acute Coronary Syndromes > Flashcards

SM 129a - Acute Coronary Syndromes Flashcards

1
Q

If a patient presents with unstable angina or NSTEMI, what factors would place them in the higher risk category?

How are they treated?

A
  • Elevated troponin levels
  • Changes in ST segment of ECG
  • Recurrent angina or ischemia
  • Evidence of chronic heart failure (ejection fraction <40%)
  • Hemodynamic instability
  • Sustained VT
  • Prior revascularization (PCI within 6 months or CABG)

Treat acutely with an invasive strategy (PTCA) + GP IIB/IIIa inhibitor (abciximab, eptifibatide, tirofiban)

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2
Q

What are the 5 basic principles for treatment of acute coronary syndrome?

A
  1. Restore blood flow as soon as possible
  2. Stop intravascular clot formation
  3. Relieve pain
  4. Reduce ischemia
  5. Control spasm
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3
Q

If a patient presents with unstable angina or NSTEMI, what factors would place them in the lower risk category?

How are they treated?

A
  • No ECG changes
  • No enzyme markers elevated
  • TIMI risk score 0-2

Treat acutely with a conservative strategy (pharmacologic only)

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4
Q

What defines acute coronary syndrome?

A

Anything more serious than stable angina

  • Unstable angina
  • Myocardial infarction
    • NSTEMI
    • STEMI
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5
Q

Which coronary artery disease is pictured?

A

Stable angina

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6
Q

What fibrinolytic agents might be used to restore blood flow in patients with STEMI?

A

-eplase or -tokinase drugs

Anistreplase

Alteplase

Reteplase

Tenecteplase (TNK-tPa) (most commonly used: single bolus)

Streptokinase

*Note: only use fibrinolytics in STEMI when recatheterization is NOT available

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7
Q

What kind of drugs end in -dipine?

A

Ca2+ channel blockers (anti-ischemic agents)

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8
Q

What strategies are used to stop intravascular clot formation in patients with acute coronary syndrome?

A

Antithrombin + antiplatelet therapy

  • Antithrombin
    • Unfractionated heparin
    • LMWH (preferred)
  • Antiplatelet
    • Aspirin (give immediately)
    • Thienopyridine ADP receptor antagonists
      • Clopidogrel, ticlopidine
    • GP IIb/IIIa inhibitors
      • Abciximab, Eptifibatide
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9
Q

What is the most worrisome diagnosis if ST elevation is seen on an ECG?

A

STEMI

(ST elevation myocardial infarction)

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10
Q

What is the underlying pathology of acute coronary syndrome?

A

Acute rupture or erosion of a coronary atherosclerotic plaque

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11
Q

What drugs are given to decrease spasm in patients with STEMI?

A

Nitrates and/or Ca2+ channel blockers

  • Nitrates
  • Ca2+ channel blockers
    • Amlodipine, other -dipines
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12
Q

What is the most commonly used fibrinolytic agent for patients with STEMI?

Why?

A

Tenecteplase

  • Weight-specific dosing
  • Given as a single bolus
  • High fibrin specificity
  • Not antigentic
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13
Q

What are the pros and cons of fibrinolytic therapy in treating patients with STEMI?

A
  • Pros
    • Universally available
    • Easy to use
    • Fast-acting
  • Cons
    • Increased chances of (intracerebral) hemorrhage, stroke
    • Reocclusion possible
    • Contraindications
      • High BP, previous stroke
    • Not always effective
      • Only 54-60% of patients achieve grade 3 flow
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14
Q

True statements about NSTEMI include all of the following except:

  1. Reinfarction occurs more frequently than following STEMI
  2. Fibrinolytic therapy is frequently used as a reperfusion strategy
  3. There is less of an urgency to perform PTCA within 90 minutes of presentation
  4. Discharge medications are identical to patients with STEMI
  5. The incidence of mortality at one year is similar to patients with STEMI
A

Fibrinolytic therapy is frequently used as a reperfusion strategy

The truth: fibrinolytic therapy is NOT used in patients with NSTEMI

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15
Q

What strategies are used to restore blood flow in patients with STEMI? With NSTEMI?

A
  • STEMI
    • Goal: Restore blood flow <12 hours after onset (this is an emergency)
    • Mechanical dilation (PTCA)
    • Fibrinolytic agents if PTCA cannot be performed immediately
    • Give aspirin immediately
  • NSTEMI
    • Goal: Restore blood flow 1-3 days after admission (less of an emergency)
    • Mechanical dilation
    • Do not use fibrinolytic agents in these patients
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16
Q

What causes STEMI?

A

Total obstruction of flow without adequate residual flow

Also known as transmural MI, Q-wave MI

17
Q

Which patient populations are mostly likely to present with atypical or absent symptoms of acute coronary syndrome?

A
  • Diabetics (especially with neuropathy)
  • Women
  • Elderly patients
18
Q

What are the general guidelines for medical therapy to treat STEMI?

A
  • Restore blood flow
    • PTCA
    • Fibrinolytic drugs (Tenecteplase)
  • Stop intravascular clot formation
    • Antithrombotic
      • Heparin or LMWH
    • Antiplatelet
      • Aspirin
      • If PTCA:
        • Clopidogrel, Prasugrel, or Ticagrelor (ADP receptor blockers)
        • Abciximab or Eptifibatide (GP IIB/IIIa inhibitors)
  • Relieve pain
    • Analgesics
  • Reduce ischemia
    • Beta blockers
  • Control spasm
    • Nitrates
    • Ca2+ channel blockers (if no systolic LV dysfunction)
19
Q

What kind of drugs are spironolactone and eplerenone?

Who are they given to?

A

Aldosterone receptor antagonists (blockers)

Given to patients following MI to derease mortality, especially if there is systolic LV dysfunction

20
Q

What are the goals of long-term treatment for acute coronary syndrome?

How are they usually accomplished?

A
  • Prevent recurrence
    • Aspirin +/- ADP receptor antagonist (clopidogrel)
    • Statin
    • ACE inhibitor or angiotensin receptor antagonist
    • Beta blockers
    • Lifestyle modification
  • Prevent left ventricle remodeling
    • ACE inhibitor or angiotensin receptor antagonist if evidence of heart failure (ejection fraction 40% or less)
  • Prevent fibrosis
    • Aldosterone receptor antagonist (spironolactone, eplerenone)
21
Q

Which drug is most often prescribed to reduce ischemia in patients with STEMI?

A

Beta blockers

22
Q

What causes NSTEMI?

A

Partial obstruction without adequate residual flow

Also known ans subendocardial MI, Non Q-wave MI

23
Q

A patient with STEMI is on their way to the catheter lab for a revascularization procedure. What drugs should they be recieving on the way?

How would this change in a setting where the catheter lab is not available?

A

MONA-AB

  • Morphine
  • Oxygen
  • Nitrate
  • Antiplatelet (Aspirin +/- clopidogrel or other ADP receptor antagonist +/- abciximab or other Gp IIb/IIIa inhibitor)
  • Antithrombin (LMWH)
  • Beta blocker (Metoprolol)

If no catheter lab, use fibrinolytic (tenecteplase aka TNK-tPa) to destory the clot

CVB by Minnie (Madeleine) (43 decks)

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