Therapeutics - ACS (Acute Coronary Syndrome) Part 1 Flashcards
acute coronary syndrome is also called
unstable angina
coronary artery disease (CAD) presents with ____
angina
why does CAD present with angina
due to atherosclerosis of the coronary vessels
what are the 3 categories of CAD
chronic stable
coronary artery vasospasm
ACS
3 subtypes of ACS
NSTEMI
unstable angina
STEMI
differentiate the EKG changes and biomarkers for:
-unstable angina
-NSTEMI
-STEMI
unstable angina - nonspecific EKG changes, no positive biomarkers (no myocardial injury)
NSTEMI - nonspecific EKG changes BUT there are positive biomarkers which indicates myocardial injury
STEMI - ST segment elevation on EKG AND positive biomarkers which indicates myocardial NECROSIS
differentiate between the symptoms of unstable angina vs NSTEMI vs STEMI
unstable angina and NSTEMI have the same clinical symptoms of angina
STEMI has these symptoms too, but women, elderly, and diabetics have an ATYPICAL REACTION – they dont get the classic gripping chest pain - get atypical symptoms like fatigue, back pain
true or false
in NSTEMI, there is no injury to the heart
FALSE- there is
have positive biomarkers
true or false
STEMI will lead to myocardial necrosis because there is TOTAL occlusion of the coronary artery
true
3 complications of ACS
cardiogenic shock
heart failure
left ventricle thrombus (very dangerous)
what are the 2 key things that we look for to determine the type of ACS?
be specific
EKG changes and cardiac biomarkers
cardiac biomarkers - we look to see if troponins and CK-MB (creatinine kinase) are elevated
in ECG, we look to see if ST is elevated specifically
invasive vs noninvasive diagnostic measures of ACS
invasive- cardiac catheterization
non-invasive - cardiac stress test
when a patient presents with ACS, what is important to obtain within 10 mins of presentation
ECG!!!!
determines STEMI or NSTEMI
risk stratification
true or false
even if a heart attack has resolved, troponins will still be elevated
true
cardiac biomarkers are secreted in response to….
injury or necrosis of muscle tissue
*target times for reperfusion when dealing with a STEMI patient
-give fibrinolytics within 12 hours of symptom onset (if more than 12 hours - DO NOT GIVE)
-do PCI within 120 minutes of symptom onset (door to needle time 30 mins ie - once pt gets to hospital, should get to cath lab within 30 mins)
-length of stay 4-5 days
TOTAL TIME FOR REPERFUSION NO MORE THAN 120 MINS!!! this is highest chance of survival
true or false
if it has been determined through EKG and cardiac biomarkers that the pt has STEMI, no further assessment is needed
TRUE - patient must directly go for reperfusion
true or false
fibrinolytics have NO ROLE in NSTEMI patients
TRUE
bc for NSTEMI we’re not dealing with a thrombus, but rather a platelet plug
true or false
the GRACE and TIMI scores are used for STEMI patients
FALSE
used for NSTEMI
for STEMI we do not stratify the risk - just directly reperfuse the patient
explain what we would do based on TIMI score:
high (5-7)
moderate (3-4)
low risk (0-2)
high risk (5-7) - invasive strategy. either PCI or CABG
moderate (3-4) - if they have high risk features, will be invasive (PCI/CABG)
if they do not have high risk features - will be conservative (ie - cardiac stress test)
low risk - will do stress test (noninvasive)
true or false
the longer we wait to reperfuse, the larger the area of injury/necrosis
true
what is an “ischemia-guided” strategy
AKA conservative strategy. NSTEMI pt has low risk TIMI score
4 words that show the approach to ACS treatment
modify (CV risk factors)
slow (progression athero.)
stabilize (plaques)
improve (balance between O2 demand and supply)
there is clinical suspicion of ACS
what 2 things are done STAT
LOADING DOSE OF aspirin (162-325mg CHEWED) and EKG within 10 mins of symptoms
patient presents with chest pain (clinical suspicion of ACS)
They are immediately given CHEWED 162-325mg of aspirin and an EKG is done
EKG shows elevated ST segment and troponins are (+)
what is done immediately
MUST REPERFUSE
-fibrinolytic (if within 12 hrs symptoms)
-PCI within 120mins symptoms (door to needle 30 mins)
true or false
cardiac biomarkers taken time to be released, so a patient’s EKG may show STEMI but biomarkers are (-)
true
check biomarkers 2-4 hours later
patient presents with clinical suspicion of ACS (chest pain) and is given 162mg-325mg of chewed aspirin, and an EKG is conducted
ST comes back depressed, and biomarkers are positive
what is done next
have to stratify risk! using GRACE/TIMI
have mod - high risk - early invasive approach - either PCI or CABG. however, unlike for STEMI, this does NOT need to be done within 120 minutes of symptom presentation
if low risk - “ischemia guided appraoch” - do noninvasive stress test. if stress test (-) - not cardiac origin. if stress test positive, do PCI/CABG typically within 24 hrs
patient presents with clinical suspicion of ACS (chest pain)
they are given 162mg-325mg of chewed aspirin STAT and an EKG is conducted
EKG comes back with ST depression and biomarkers are negative
what is done
this is considered unstable angina
like for NSTEMI, risk stratification is done.
same treatment algorithm– if low risk, “ischemia-guided approach” - do stress test
if stress test negative, the issue was not cardiac related
if stress test positive, PCI or CABG (doesnt have to be within 120 mins)
if mod-high risk, PCI or CABG typically within 24 hrs
acronym to remember the treatment overview for ACS
Explain what each letter in the acronym means
THROMBINS2
T - thienopyridines and other P2Y12 antagonists
H - heparins (UFH and LMWH) and bivalrudin (direct thrombin inhibitor)
R - RAAS antagonsits (ACEI OR ARB)
O - oxygen (only if O2 sat less than 90% or hypoxemia)
M - morphine
B - beta blockers
I - interventions (PCI)
N - nitroglycerin
S - high intensity statins and/or ezetimibe and/or PCSK9 inhibitor
S - loading dose aspirin
when are the P2Y12 antagonists like thienopyridines given?
at what doses?
loading dose upon medical contact
true or false
RAAS like ACE inhibitors or ARBS must be given immediately
false - within 24-48 hours of index event
true or false
anyone presenting with ACS symptoms like chest pain gets morphine
FALSE - only if patient is still in a lot of pain depsite giving the max dose of nitroglycerin
how soon are beta blockers typically given for ACS patient
typically within 24 hours of index event
true or false
only SL nitroglycerin can be given to ACS patients for pain
FALSE - can give IV if needed, but it heavily depends on the patients BP
if BP less than 90/less than 50, cannot titrate the nitroglycerin anymore and patient may need morphine
also, if HR increases over 10 beats/min - cant tolerate anymore (reflex tachycardia)
acronym for initial anti ischemic therapy
“MONA +BB”
Morphine (if no response/intolerant to high dose NTG)
Oxygen (if sat less than 90% or in resp distress or high risk)
Nitroglycerin (spray or sublingual - max 3 doses - then move to IV titration)
Aspirin - loading dose then maintenance
BB within 24 hours – can give CCB if beta blocker is contraindicated
why is oxygen only given to patients whos O2 saturation is less than 90%?
bc too much O2 can actually increase the infarct size
for antiplatelet management, EVERY PATIENT gets aspirin and a P2Y12 antagonist
explain how the treatment regimen differs:
-NSTEMI, ischemia-guided
-NSTEMI, invasive
-STEMI, PPCI
-STEMI + fibrinolytic
NSTEMI, ischemia-guided - ONLY clopidogrel or ticagrelor
NSTEMI, invasive - clopidogrel or prasugrel or ticagrelor
STEMI, PPCI - clopidogrel or prasugrel or ticagrelor
STEMI + fibrinolytic - ONLY CLOPIDOGREL!!!!
prasugrel is ONLY indicated if….
patient is getting a PCI
patient has STEMI + fibrinolytic
what is the only P2Y12 antagonist that can be used?
what dose?
clopidogrel - loading dose of 300mg
LD 600mg if event was OVER 24 hours ago
when is the only time that GPIIb/IIIa inhibitors are used as part of antiplatelet therapt
really only if patient has a thrombus and going for PCI mainly only NSTEMI - not really used a lot
true or false
when aspirin is being given STAT for ACS, it CANNOT BE ENTERIC COATED
true
EC ASPIRIN HAS NO ROLE INITIALLY!!!! must be chewed 162mg-325mg loading dose – need aspirin to the blood ASAP
*maintenance dose of aspirin after ACS
81-325mg (81mg preferred - less bleeding risk and same benefit)
what is DAPT
dual antiplatelet therapy
75mg-100mg aspirin given with an oral P2Y12 antagonist
true or false
in DAPT, aspirin CANNOT BE enteric coated
false - once you get to maintenance dosing it’s fine if it’s enteric coated
loading dose and maintenance dose of clopidogrel
LD - 300mg if on lytics or high risk bleeding - 600mg
maintenance dose - 75mg
clopidogrel DDI concern
polymorphisms in CYP2C19 AND - DDI with PPIs like omeprazole. PPI’s are CYP2C19 inhibitors - efficacy concern
pantoprazole is preferred!
true or false
if a patient is going for surgery, it is unnecessary to hold the plavix
false - hold 5 days before surgery
true or false
prasugrel is more potent than clopidogrel
TRUE - higher risk of bleeding
*concern with prasugrel
HIGH RISK OF BLEEDING!!!! CONTRAINDICATED IF PT HAS HISTORY OF TIA/STROKE
how long to hold prasugrel before surgery
7 days - longer than plavix - higher bleed risk
*loading dose and maintenance dose of prasugrel
LD - always 60mg
maintance dose usually 10mg
HOWEVER - need to switch to 5mg if patient is over 75 or under 60kg
loading dose and maintenance dose of ticagrelor
LD - 180mg
MD- 90mg BID
can ticagrelor be crushed
yes
major side effect of ticagrelor
dyspnea (SOB - lot of pts experience)
between prasugrel, clopidogrel, and ticagrelor, which is the only one taken BID
ticagrelor
advantage of ticagrelor over clopidogrel and prasugrel
only one that can be crushed - good for patients with g tube or who cant swallow
what must be the aspirin maintenance dose if patient is taking ticagrelot
less than 100mg
how long does ticagrelor have to be held before surgery
3 days
doesnt hold platelet for entire life
what is the only IV P2Y12 antagonist
is it ever used?
cangrelor
not used too often – only in 3 scenarios:
- who cant take oral agents
- PCI and P2Y12 inhibitor naive. cangrelor may be used to reduce periprocedural ischemia
- potential bridge in high risk CABG procedures
true or false
cangrelor cannot be coadministered with prasugrel
TRUE
cangrelor CANNOT be given with oral P2Y12 antagonists
true or false
cangrelor has a short half life
true - very short. around 5 mins
true or false
GpIIb/IIIa inhibitors are oral anticoagulants
FALSE - IV antiplatelets
give example of when GPIIb/IIIa inhibitors are used
in PCI patients with large thrombus for NSETMI patients
ofc used with aspirin
ie - LV thrombus complication!
2 common AE of GpIIb/IIIa antagonists
bleeding, thrombocytopenia
which 2 GpIIb/IIIa antagonists need to be dose adjusted for renal issues
eptifibatide
tirofiban
disadvantage of abciximab (GpIIb/IIIa inhibitor)
it can only be reversed with platelet transfusions
