Therapy of Acute Coronary Syndromes Flashcards
A clot is composed of:
1) Fibrin
2) Platelets
What are the Acute Coronary syndromes?
1) Unstable angina (UA)
2) Myocardial Infarction
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 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.
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
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.
Which drugs are P2Y12 (ADP receptor) inhibitors?
1) Clopidogrel
2) Prasugrel
3) Ticagrelor
What is Bivalirudin?
Direct thrombin inhibitor
What may be considered if UFH is selected as the anticoagulant for patients undergoing primary PCI?
A glycoprotein IIb/IIIa inhibitor
Which drugs are glycoprotein IIb/IIIa inhibitors?
1) Abciximab
2) Eptifibatide
3) Tirofiban
Morphine __(hastens/slows) the absorption of oral antiplatelet agents due to __(increased/decreased) gastric motility.
Slows; Decreased
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)
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
____ should be continued for at least 14 days, and ideally 1 year, in patients with STEMI treated with fibrinolytics.
Clopidogrel
A ____ should be continued for at least 12 months for patients undergoing PCI and for patients treated medically (without PCI or thrombolytics).
P2Y12 inhibitor
For all patients with ACS, treatment and control
of _____ are essential.
Modifiable risk factors
Ventricular Remodeling is characterized by:
1) Left ventricular (LV) dilation
2) Reduced pumping function of the LV
= Leading to HF
Which drugs can slow down or reverse ventricular remodeling?
1) ACE-inhibitors
2) ARBs
3) β-blockers
4) Aldosterone antagonists
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
Antiplatelet Therapy in PCI and STEMI and NSTEACS:
1) Aspirin
2) P2Y12 inhibitor antiplatelet
Earlier discontinuation of the P2Y12 inhibitor can be reasonable in which patients?
1) High bleeding risk
2) With “overt bleeding”.
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.
A door-to-needle time of less than ___ from the time of hospital presentation until start of fibrinolytic therapy is recommended.
30 minutes
Which drugs are fibrin-specific agents?
1) Alteplase
2) Reteplase
3) Tenecteplase
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:
MI
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
