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Therapeutics > Therapy of Acute Coronary Syndromes > Flashcards

Therapy of Acute Coronary Syndromes Flashcards

1
Q

A clot is composed of:

A

1) Fibrin
2) Platelets

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2
Q

What are the Acute Coronary syndromes?

A

1) Unstable angina (UA)
2) Myocardial Infarction

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3
Q

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

A

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

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4
Q

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

A

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

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5
Q

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

A

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

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6
Q

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

A

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.

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7
Q

Which drugs are P2Y12 (ADP receptor) inhibitors?

A

1) Clopidogrel
2) Prasugrel
3) Ticagrelor

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8
Q

What is Bivalirudin?

A

Direct thrombin inhibitor

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9
Q

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

A

A glycoprotein IIb/IIIa inhibitor

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10
Q

Which drugs are glycoprotein IIb/IIIa inhibitors?

A

1) Abciximab
2) Eptifibatide
3) Tirofiban

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11
Q

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

A

Slows; Decreased

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12
Q

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

A

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)

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13
Q

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

A

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

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14
Q

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

A

Clopidogrel

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15
Q

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

A

P2Y12 inhibitor

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16
Q

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

A

Modifiable risk factors

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17
Q

Ventricular Remodeling is characterized by:

A

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

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18
Q

Which drugs can slow down or reverse ventricular remodeling?

A

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

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19
Q

Post-MI, patients may also need:

A

1) Bed rest for 12 hours in hemodynamically stable patients

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

3) Pain relief

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20
Q

Antiplatelet Therapy in PCI and STEMI and NSTEACS:

A

1) Aspirin
2) P2Y12 inhibitor antiplatelet

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21
Q

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

A

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

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22
Q

Administration of a fibrinolytic agent is indicated in which patients?

A

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.

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23
Q

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

A

30 minutes

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24
Q

Which drugs are fibrin-specific agents?

A

1) Alteplase
2) Reteplase
3) Tenecteplase

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25
Q

Which fibrinolytics are preferred and why?

A

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

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26
Q

Adverse effects of fibrinolytics?

A

1) Intracranial hemorrhage (ICH)
2) Major bleeding

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27
Q

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

A

Fibrin-specific agents

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28
Q

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

A

Streptokinase

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29
Q

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?

A

Anticoagulant for up to 8 days

30
Q

What are some Absolute Contraindications to Fibrinolytic Therapy?

A

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

31
Q

Which anticoagulants should be given to patients undergoing primary PCI?

A

Either UFH or Bivalirudin

32
Q

When is anticoagulation discontinued?

A

Immediately following the PCI procedures

33
Q

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

A

Bivalirudin

34
Q

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

A

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

35
Q

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

A

Prolongs

36
Q

What do beta-blockers do?

A

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

37
Q

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

A

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

38
Q

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

A

An early risk of cardiogenic shock

39
Q

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

A

Pulmonary congestion or systolic BP less than 120 mm Hg

40
Q

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

A

Oral

41
Q

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

A

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

42
Q

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

A

Signs of hypotension and
HF

43
Q

The most serious adverse effects early in ACS are:

A

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

44
Q

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

A

Before

45
Q

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

A

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

46
Q

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

A

5 minutes; 3

47
Q

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

A

24 hours

48
Q

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

A

Preload

49
Q

What is the mortality benefit of nitrates?

A

NONE

50
Q

The most significant adverse effects of nitrates are:

A

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

51
Q

Nitrate administration is contraindicated in patients who:

A

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

52
Q

Which drugs are phosphodiesterase-5 inhibitors?

A

1) Sildenafil
2) Vardenafil

53
Q

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

A

Have certain contraindications to β-blockers

54
Q

Which Calcium Channel Blockers lower heart rate?

A

1) Diltiazem
2) Verapamil

55
Q

When do we use Amlodipine or Felodipine?

A

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

56
Q

Why should Nifedipine be avoided in ACS?

A

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

57
Q

Which calcium channel blocker should not be given in ACS?

A

Nifedipine

58
Q

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

A

NO; because it is associated
with increased mortality.

59
Q

All NSTE-ACS patients should receive:

A

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

60
Q

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?

A

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

61
Q

β-blockers should be used in patients with a:

A

Previous MI

62
Q

ACE Inhibitors should be initiated in all patients
following:

A

MI

63
Q

Adverse effects of ACEi?

A

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

64
Q

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

A

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

65
Q

Which drugs are aldosterone antagonists?

A

1) Spironolactone
2) Eplerenone

66
Q

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.

A

Aldosterone antagonists

67
Q

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

A

Spironolactone

68
Q

Treatment for smoking cessation?

A

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

69
Q

What is Bupropion?

A

An antidepressant that decreases cravings and withdrawal symptoms of nicotine

70
Q

What is Varenicline?

A

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

Therapeutics (23 decks)

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