Therapy of Acute Coronary Syndrome Flashcards by Sarah Assaf

A clot is composed of:

1) Fibrin
2) Platelets

How well did you know this?

Not at all

Perfectly

What are the Acute Coronary syndromes?

1) Unstable angina (UA)
2) Myocardial Infarction

How well did you know this?

Not at all

Perfectly

What are the short-term desired outcomes in a patient with ACS?

1) Early reperfusion therapy
2) Prevention of death and other MI complications
3) Prevention of coronary artery re-occlusion
4) Relief of ischemic chest discomfort
5) Resolution of ST-segment and T-wave changes on the ECG

How well did you know this?

Not at all

Perfectly

How and when is early reperfusion done in ST-segment elevation myocardial infarction (STEMI)?

Percutaneous coronary intervention (PCI) of the infarct artery in patients presenting within 12 hours of symptom onset.

How well did you know this?

Not at all

Perfectly

What are the long-term desired outcomes in a patient with ACS?

1) Control of CV risk factors
2) Prevention of re-infarction, stroke, and HF
3) Improving the quality-of-life

How well did you know this?

Not at all

Perfectly

All patients with STEMI and without contraindications should receive within the first day of hospitalization:

1) Intranasal oxygen (if oxygen saturation is low).

2) Sublingual (SL) nitroglycerin (NTG)

3) Aspirin

4) A P2Y12 (ADP receptor) inhibitor

5) Anticoagulation with bivalirudin, unfractionated heparin (UFH), Enoxaparin, or Fondaparinux.

6) A high-intensity statin should be administered prior to PCI (in patients >75 years old)

7) Oral β-blockers should be initiated (IV β-blockers and IV NTG should be administered cautiously)

8) An ACE inhibitor in STEMI who have either an anterior wall MI or LVEF ≤ 0.40 with no contraindications.

9) Morphine for refractory angina as an analgesic and a venodilator that lowers preload.

How well did you know this?

Not at all

Perfectly

Which drugs are P2Y12 (ADP receptor) inhibitors?

1) Clopidogrel
2) Prasugrel
3) Ticagrelor

How well did you know this?

Not at all

Perfectly

What is Bivalirudin?

Direct thrombin inhibitor

How well did you know this?

Not at all

Perfectly

What may be considered if UFH is selected as the anticoagulant for patients undergoing primary PCI?

A glycoprotein IIb/IIIa inhibitor

How well did you know this?

Not at all

Perfectly

Which drugs are glycoprotein IIb/IIIa inhibitors?

1) Abciximab
2) Eptifibatide
3) Tirofiban

How well did you know this?

Not at all

Perfectly

Morphine __(hastens/slows) the absorption of oral antiplatelet agents due to __(increased/decreased) gastric motility.

Slows; Decreased

How well did you know this?

Not at all

Perfectly

In the absence of contraindications, all patients with NSTE-ACS should be treated in the ED with:

1) Intranasal oxygen (if oxygen saturation is low)

2) SL NTG

3) Aspirin

4) An anticoagulant (UFH, enoxaparin, fondaparinux, or bivalirudin)

5) High-risk patients should proceed to early angiography, and may receive a GPI

6) A P2Y12 inhibitor in all
patients

7) A high-intensity statin prior to PCI

8) Oral β-blockers should be initiated (IV β-blockers and IV NTG should be administered cautiously)

How well did you know this?

Not at all

Perfectly

All patients following MI, in the absence of contraindications, should receive indefinite treatment with:

1) Aspirin
2) β-blocker
3) Moderate-to-high intensity statin
4) ACEi

How well did you know this?

Not at all

Perfectly

____ should be continued for at least 14 days, and ideally 1 year, in patients with STEMI treated with fibrinolytics.

Clopidogrel

How well did you know this?

Not at all

Perfectly

A ____ should be continued for at least 12 months for patients undergoing PCI and for patients treated medically (without PCI or thrombolytics).

P2Y12 inhibitor

How well did you know this?

Not at all

Perfectly

For all patients with ACS, treatment and control
of _____ are essential.

Modifiable risk factors

How well did you know this?

Not at all

Perfectly

Ventricular Remodeling is characterized by:

1) Left ventricular (LV) dilation
2) Reduced pumping function of the LV
= Leading to HF

How well did you know this?

Not at all

Perfectly

Which drugs can slow down or reverse ventricular remodeling?

1) ACE-inhibitors
2) ARBs
3) β-blockers
4) Aldosterone antagonists

How well did you know this?

Not at all

Perfectly

Post-MI, patients may also need:

1) Bed rest for 12 hours in hemodynamically stable patients

2) Avoidance of the Valsalva maneuver (prescribe stool softeners routinely)

3) Pain relief

How well did you know this?

Not at all

Perfectly

Antiplatelet Therapy in PCI and STEMI and NSTEACS:

1) Aspirin
2) P2Y12 inhibitor antiplatelet

How well did you know this?

Not at all

Perfectly

Earlier discontinuation of the P2Y12 inhibitor can be reasonable in which patients?

1) High bleeding risk
2) With “overt bleeding”.

How well did you know this?

Not at all

Perfectly

Administration of a fibrinolytic agent is indicated in which patients?

1) With STEMI who present within 12 hours of the onset of chest discomfort to a hospital NOT capable of primary PCI.

2) Who have no absolute contraindications to fibrinolytic therapy.

3) Who are NOT able to be transferred to undergo primary PCI within 2 hours of medical contact.

How well did you know this?

Not at all

Perfectly

A door-to-needle time of less than ___ from the time of hospital presentation until start of fibrinolytic therapy is recommended.

30 minutes

How well did you know this?

Not at all

Perfectly

Which drugs are fibrin-specific agents?

1) Alteplase
2) Reteplase
3) Tenecteplase

How well did you know this?

Not at all

Perfectly

Which fibrinolytics are preferred and why?

Fibrin-specific agents, because they open a greater percentage of arteries.

Adverse effects of fibrinolytics?

1) Intracranial hemorrhage (ICH) 2) Major bleeding

The risk of Intracranial hemorrhage (ICH) is higher with: Streptokinase or fibrin-specific agents?

Fibrin-specific agents

The risk of systemic bleeding (other than ICH) is higher with: Streptokinase or fibrin-specific agents?

Streptokinase

How do you treat patients who who have a contraindication to fibrinolytics and PCI, or who do NOT have access to a facility that can perform PCI?

Anticoagulant for up to 8 days

What are some Absolute Contraindications to Fibrinolytic Therapy?

1) Active internal bleeding 2) Previous ICH at any time; ischemic stroke within 3 months (except acute ischemic stroke within ~4 hours) 3) Known intracranial neoplasm 4) Known structural cerebral vascular lesion (AVM) 5) Suspected aortic dissection 6) Significant closed head or facial trauma within 3 months 7) Intracranial or intraspinal surgery within 2 months 8) Severe uncontrolled hypertension (unresponsive to emergency therapy) 9) For streptokinase, prior treatment within the previous 6 months

Which anticoagulants should be given to patients undergoing primary PCI?

Either UFH or Bivalirudin

When is anticoagulation discontinued?

Immediately following the PCI procedures

Which anticoagulant would be preferred for patients with a history of heparin-induced thrombocytopenia (HIT) undergoing PCI?

Bivalirudin

Which anticoagulants can be used for fibrinolysis and those who don't undergo reperfusion therapy?

1) UFH (48 hrs) 2) Enoxaparin (8 days) 3) Fondaparinux (8 days)

Reducing the heart rate ___(prolongs/shortens) diastole.

Prolongs

What do beta-blockers do?

1) Reduce heart rate (HR), myocardial contractility, and blood pressure (BP) 2) Decrease myocardial oxygen demand 2) Improve ventricular filling 3) Improve coronary artery perfusion

Beta-blockers reduce the risks and occurrences of what hours and days after an MI?

1) Recurrent ischemia 2) Infarct size 3) Re-infarction 4) Ventricular arrhythmias

Initiating IV followed by oral β-blockers early in the course of STEMI was associated with:

An early risk of cardiogenic shock

Cardiogenic shock caused by b-blockers is mostly found in patients presenting with:

Pulmonary congestion or systolic BP less than 120 mm Hg

___(IV/Oral) beta blockers are preferred in the management of ACS.

Oral

Initiation of β-blockers should be limited to patients who:

1) Present with HTN 2) Have ongoing signs of MI 3) Do NOT demonstrate any signs or symptoms of acute HF

What should we look for following β-blocker initiation and prior to any dose titration?

Signs of hypotension and HF

The most serious adverse effects early in ACS are:

1) Hypotension 2) Acute HF 3) Bradycardia 4) Heart block

β-blockers should be initiated __(before/after) hospital discharge in most patients following treatment of acute HF.

Before

A high-intensity statin should be administered to which patients?

All patients without contraindications prior to PCI to reduce the frequency of peri procedural MI following PCI.

One SL NTG tablet should be administered every ___ for up to _ doses in order to relieve myocardial ischemia.

5 minutes; 3

IV NTG should be continued for approximately ___ after ischemia is relieved.

24 hours

Venodilation lowers __(afterload/preload) and myocardial oxygen demand.

Preload

What is the mortality benefit of nitrates?

NONE

The most significant adverse effects of nitrates are:

1) Tachycardia 2) Flushing 3) Throbbing headache 4) Hypotension

Nitrate administration is contraindicated in patients who:

Have received oral phosphodiesterase-5 inhibitors within the last 24 hours, and Tadalafil within the last 48 hours.

Which drugs are phosphodiesterase-5 inhibitors?

1) Sildenafil 2) Vardenafil

Calcium channel blockers are used for relief of ischemic symptoms only in patients who:

Have certain contraindications to β-blockers

Which Calcium Channel Blockers lower heart rate?

1) Diltiazem 2) Verapamil

When do we use Amlodipine or Felodipine?

When the patient has: 1) LV systolic dysfunction 2) Bradycardia 3) Heart block

Why should Nifedipine be avoided in ACS?

1) Reflex sympathetic stimulation 2) Tachycardia 3) Worsened MI

Which calcium channel blocker should not be given in ACS?

Nifedipine

Is fibrinolytic therapy indicated in patients with NSTE-ACS? Why or why not?

NO; because it is associated with increased mortality.

All NSTE-ACS patients should receive:

1) Anticoagulants 2) Low-dose aspirin (± Clopidogrel) 3) Short-acting SL NTG or NTG spray

For NSTE-ACS patients managed with conservative strategy but who experience recurrent ischemia, HF, or arrhythmias after initial medical therapy necessitating a change in strategy to angiography and revascularization, what must be done?

Add Glycoprotein IIb/IIIa Receptor Inhibitors (GPI) to aspirin and clopidogrel prior to the angiogram

β-blockers should be used in patients with a:

Previous MI

ACE Inhibitors should be initiated in all patients following:

Adverse effects of ACEi?

1) Hypotension 2) Cough 3) Acute renal failure 4) Hyperkalemia 5) Angioedema

Aldosterone plays an important role in HF and in MI because it promotes:

1) Vascular and myocardial fibrosis 2) Endothelial dysfunction 3) HTN 4) LV hypertrophy 5) Sodium retention 6) Potassium and magnesium loss 7) Arrhythmias

Which drugs are aldosterone antagonists?

1) Spironolactone 2) Eplerenone

To reduce mortality, _____ should be considered within the first 7 days following MI in all patients who are already receiving an ACE inhibitor (or ARB) and a β-blocker and have an LVEF ≤ 0.40 and either HF symptoms or DM.

Aldosterone antagonists

___ decreases all-cause mortality in patients with stable severe HF.

Spironolactone

Treatment for smoking cessation?

1) Behavioral therapy + 2) Nicotine replacement ± a) Bupropion b) Varenicline

What is Bupropion?

An antidepressant that decreases cravings and withdrawal symptoms of nicotine

What is Varenicline?

A partial agonist of the nicotinic acetylcholine receptor, used to treat smoking addiction