Tintinalli: Acute Coronary Syndromes & Unstable Angina

Question 1

Canadian Cardiovascular Society Class I Angina

Answer 1

Angina only with strenuous, rapid, or prolonged exertion. Ordinary physical activity does not cause angina.

Question 2

Canadian Cardiovascular Society Class II Angina

Answer 2

Slight limitation of ordinary activity. Angina occurs with rapid stair climbing, walking uphill, walking after meals, in cold, in wind, or under emotional stress.

Question 3

Canadian Cardiovascular Society Class III Angina

Answer 3

Marked limitations of ordinary physical activity. Angina occurs on walking 1-2 level blocks or climbing 1 flight of stairs at usual pace.

Question 4

Canadian Cardiovascular Society Class IV Angina

Answer 4

Inability to carry on physical activity without discomfort. Anginal symptoms may be present at rest.

Question 5

Rest angina presentation

Answer 5

Angina occurring at rest, usually prolonged > 20 min occurring within 1 week of presentation

Question 6

New-onset angina presentation

Answer 6

Angina of at least CCSC III severity within 2 months of presentation

Question 7

Increasing angina presentation

Answer 7

Previously diagnosed angina that is distinctly more frequent, longer in duration, or lower in threshold (increased by at least 1 CCSC class to at least CCSC III severity)

Question 8

PCI time goal for reperfusion:

Answer 8

90 minutes from door to balloon inflation

Question 9

What is considered the optimal treatment for unstable angina caused by cardiac ischemia?

Answer 9

Percutaneous coronary intervention, or PCI.Get dat ass to the cath lab!

Question 10

For whom is fibrinolytic therapy indicated?

Answer 10

Patients with STEMI if time to treatment is < 6-12 hours from symptom onset, & ECG has at least 1mm ST-segment elevation in 2 or more contiguous leads.

Question 11

What are some contraindications to fibrinolysis? Are they absolute or relative?

Answer 11

Relative!

#Age > 65 years
#Low body weight < 70kg
#Hypertension upon presentation

Question 12

Contraindications to fibrinolytic therapy are all related to what one complication?

Answer 12

Hemorrhage! Intracranial bleeding is the most catastrophic complication.

Question 13

If a STEMI patient gets fibrinolysis, what type of therapy should follow?

Answer 13

Full-dose anticoagulants for at least 48 hours.

Question 14

What are the guidelines for reperfusion in non-STEMI?

Answer 14

The AHA/ACC recommend early invasive therapy for patients with 
#recurrent angina/ischemia with or without CHF symptoms
#elevated troponins
#new or presumed-new ST-segment depression
#high-risk findings on stress tests
#depressed LV function
#hemodynamic instability
#sustained v-tach
#a PCI within the last 6 months
#prior CABG.

Question 15

What is our favorite little magic pill for patients with any kind of ischemia (STEMI, NSTEMI, or unstable angina)?

Answer 15

Aspirin! Give ≥162mg, preferably 325mg, ASAP to all patients with these diagnoses.

Question 16

Aspirin: enteric-coated or not?

Answer 16

Do NOT give enteric-coated for STEMI, NSTEMI, or unstable angina. It delays absorption & they kinda need it NOW.

Question 17

If a patient needs a CABG, how long should you hold the clopidogrel?

Answer 17

5 days, because of increased bleeding risk

Question 18

If a patient with an acute coronary syndrome is seen initially at a non-PCI capable hospital, what is the goal “door in/door out” (DIDO) time (time between arrival & transfer to a PCI-capable facility)?

Answer 18

≤ 30 minutes

Question 19

If a patient with an acute coronary syndrome is seen initially at a non-PCI capable hospital, what is the goal from first medical contact to device time, including transfer?

Answer 19

≤ 120 minutes

Question 20

A loading dose of what drug is recommended before PCI? How much of it?

Answer 20

Clopidogrel, 600 mg

Question 21

True or false: PPIs have an effect on clopidogrel metabolism?

Answer 21

True

Question 22

True or false: the effect of PPIs on clopidogrel metabolism directly translate into worse outcomes?

Answer 22

False!

Question 23

When should we consider fibrinolytic therapy?

Answer 23

When a patient has a STEMI with onset of symptoms within the previous 12 hours AND we know we can’t get them to a cath lab within 120 minutes.

Question 24

What adjunctive therapy is recommended for patients with ACS who are going to get fibrinolytic therapy?

Answer 24

Antiplatelet therapy with ASPIRIN (162-325mg) and CLOPIDOGREL (300mg for ≤ 72 yrs old, 75mg for > 75 yrs old)

Question 25

After we’ve administered fibrinolytic therapy at our non-PCI-capable band-aid station hospital out in the sticks, should we still transfer our STEMI folks anyway?

Answer 25

YES. Especially if they:

#Have cardiogenic shock or acute HF
#Have evidence of failed reperfusion or reocclusion

It’s STILL reasonable if they have none of the above.

Question 26

So, we’ve given our little STEMI patient fibrinolytics & transferred them to the PCI-capable hospital. How long should the new hospital wait after our fibrinolytics until they perform an angiography?

Answer 26

2-3 hours

Question 27

If a patient is in cardiogenic shock, should we go ahead & perform PCI, or do we need to wait until they are more stable?

Answer 27

Go to the cath lab
Do not pass “go”
Do not collect $200