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Notes/Facts/Brand vs Generic > Acute Coronary Syndrome > Flashcards

Acute Coronary Syndrome Flashcards

1
Q

Plavix *

A

clopidogrel
prodrug
class - P2Y12 inhibitor/antagonist
classified as thienopyridine
MOA: active metabolite irreversibly binds to the platelet ADP-P2Y12 receptor, preventing ADP-mediated activation of the GPIIb/IIIa receptor complex, thereby reducing platelet aggregation.

Dosing:
LD(Loading Dose): 300-600mg PO (600mg for PCI)

MD(Maintenance Dose): 75mg PO daily

Indication: for Acute Coronary Syndrome (UA/NSTEMI/STEMI) or as secondary prevention in patients with a history of MI, stroke or PAD

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2
Q

Effient *

A

prasugrel
prodrug
classified as thienopyridine
class - P2Y12 inhibitor/antagonist
MOA: active metabolite irreversibly binds to the platelet ADP-P2Y12 receptor, preventing ADP-mediated activation of the GPIIb/IIIa receptor complex, thereby reducing platelet aggregation.

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3
Q

Brillinta *

A

ticagrelor
class - P2Y12 inhibitor/antagonist
MOA: active metabolite (which is reversible) binds to the platelet ADP-P2Y12 receptor, preventing ADP-mediated activation of the GPIIb/IIIa receptor complex, thereby reducing platelet aggregation.

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4
Q

ReoPro **

A

abciximab
currently unavailable in US

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5
Q

Integrilin **

A

eptifibatide

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6
Q

Aggrastat

A

tirofiban

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7
Q

Zontivity

A

vorapaxar

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8
Q

Activase

A

alteplase

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9
Q

TNKase

A

tenecteplase

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10
Q

Boxed Warnings with Plavix

A

clopidogrel is a prodrug. Effectiveness depends on the conversion to an active metabolite, Mainly by CYP2C19.
Poor metabolizers of CYP2C19 exhibit higher cardiovascular events than patients with normal CYP2C19 function.

Tests to check CYP2C19 genotype can be used as an aid in determining a therapeutic strategy. Consider alternative treatments in patients identified as CYP2C19 poor metabolizers.

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11
Q

Contraindications with Plavix

A

Active serious bleeding (GI bleed, intracranial hemorrhage)

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12
Q

Warnings with Plavix

A

Bleeding risk (stop 5 days prior to elective surgery), DO NOT USE with omeprazole and esomeprazole, premature discontinuation ( increase risk of thrombosis), (TTP) thrombotic thrombocytopenic purpura

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13
Q

Boxed Warnings with Effient

A
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14
Q

Contraindications with Effient

A
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15
Q

Warnings with Effient

A
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16
Q

Pearls with Effient

A
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17
Q

ACS

A

Acute Coronary syndrome

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18
Q

Acute Coronary Syndrome(ACS) results from _______

A

plaque build up (atherosclerosis) in the coronary arteries. The plaques are made up of fatty deposits that cause the arteries to narrow, making blood flow more difficult.

The plaque can rupture, leading to clot(thrombus) formation and sudden, reduced blood flow(ischemia) to the heart. This causes an imbalance between myocardial oxygen supply and myocardial oxygen demand.

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19
Q

Risk factors for ACS

A

men > 45 , women > 55 ( or early hysterectomy), Family Hx: first degree relative with a coronary event before 55 years (men) or 65 years (women), smoking, hypertension, known coronary artery disease, dyslipidemia, diabetes, chronic stable angina, lack of exercise, excessive alcohol,

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20
Q

classic symptoms of an ACS include:

A

chest pain (often described as discomfort, pressure or squeezing), lasting > or = 10 minutes, severe dyspnea, diaphoresis, syncope/presyncope and/or palpitations

symptoms can occur at rest, or may be precipitated by minimal exertion, exercise, cold weather, extreme emotions, stress or sexual intercourse.

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21
Q

which individuals are less likely to experience the classic symptoms of and ACS?

A

females, the elderly, and patients with diabetes

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22
Q

__________ is a medical emergency. Patients with sublingual nitroglycerin should use one dose every 5 minutes for up to 3 doses to relieve chest pain. If chest pain is not improved or is worse five minutes after the first dose, they should call 911 immediately.

A

(ACS) Acute Coronary Syndrome

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23
Q

(ACS) Acute Coronary Syndrome encompasses _________ and _________

A

(NSTE-ACS) = non-ST segment elevation acute coronary syndromes
&
(STEMI) = ST-segment elevation myocardial infarction

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24
Q

(NSTE-ACS) non-ST segment elevation acute coronary syndromes describes both __________ and _________. These types of ACS are ___________ upon presentation. The types of ACS are differentiated based on ____________

A

(UA) Unstable Angina

(NSTEMI) non-ST segment elevation myocardial infarction

indistinguishable

ECG findings, the detection of cardiac enzymes and the extent of blockage in the affected artery.

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25
Q

The measurement of biochemical markers (________), released into the blood stream when myocardial cells die, helps establish the diagnosis.

A

cardiac enzymes

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26
Q

cardiac troponins _______ and _________ are the most sensitive and specific biomarkers for ACS. Levels should be obtained at presentation and 3-6 hours after symptom onset in all patients with ACS symptoms.

A

I and T (TnI and TnT)

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27
Q

(UA) Unstable angina

symptoms ________
cardiac enzymes _________
ECG changes ___________
blockage ___________

A

chest pain
negative
none or transient ischemic changes*
partial blockage

  • ST segment depression or prominent T-wave inversion
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28
Q

(NSTEMI) non-ST segment elevation myocardial infarction

symptoms ________
cardiac enzymes _________
ECG changes ___________
blockage ___________

A

chest pain
positive
none or transient ischemic changes*
partial blockade

  • ST segment depression or prominent T-wave inversion
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29
Q

(STEMI) ST-segment elevation myocardial infarction

symptoms ________
cardiac enzymes _________
ECG changes ___________
blockage ___________

A

chest pain
positive
ST segment elevation**
complete blockade

**Meeting defined criteria in > or = 2 continuous leads (leads looking at the same area of the heart

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30
Q

cardiac enzymes ________ and ________ are less sensitive markers but may still be monitored in clinical practice

A

(CK-MB) Creatine kinase - myocardial isoenzyme

myoglobin

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31
Q

(PCI)

A

Percutaneous coronary intervention

32
Q

(PCI) Percutaneous coronary intervention:

A

is a coronary revascularization procedure that involves inflating a small balloon inside a coronary artery to widen it and improve blood flow. Usually, a stent (metal mesh) is placed to keep the artery open.

33
Q

NSTE-ACS can be treated with __________ or with _________

A

medications alone (medical management)

PCI (an early invasive strategy)

34
Q

STEMI requires that the blocked arteries _______ as quickly as possible with ______ or __________

A

be opened
PCI
fibrinolysis

35
Q

If PCI is not possible within 120 minutes of first medical contact, ____________ is recommended and should be given ___________ of hospital arrival (door-to-needle time)

A

fibrinolytic therapy is recommended

within 30 minutes

36
Q

Antianginals:

Work by -

A

decrease myocardial oxygen demand *
“decreases heart’s demand for oxygen”

OR

increase supply (blood flow) to relieve ischemia

37
Q

Antiplatelets:

Work by -

A

inhibit platelet aggregation to prevent clot formation/growth*

38
Q

Anticoagulants:

Work by -

A

inhibit clotting factors to prevent clot formation/growth*

39
Q

Drug Tx options for ACS - - - NSTE-ACS

remember MONA-GAP-BA +/- PCI

A

Morphine/Oxygen/Nitrates/Aspirin

GPIIb/IIIa antagonists/Anticoagulants/P2Y12 inhibitors

Beta-blockers/Ace inhibitors

40
Q

Drug Tx options for ACS - - - STEMI + PCI or fibrinolytic (PCI preferred)

A

Morphine/Oxygen/Nitrates/Aspirin

GPIIb/IIIa antagonists/Anticoagulants/P2Y12 inhibitors

Beta-blockers/Ace inhibitors

41
Q

MONA (give these immediately PRN)
Morphine

A

Provides pain relief and helps anxiety

Not for routine use (has been shown to diminish antiplatelet effects); reserve for patients with unacceptable chest discomfort despite other treatments.

Dose 2-5mg IV repeated at 5 to 30 minute intervals PRN.
Monitor for hypotension, bradycardia, N/V, sedation and respiratory depression

42
Q

MONA
Oxygen

A

Administer to patients with arterial oxygen saturation < 90%
(SaO2 < 90%) or those with respiratory distress

43
Q

MONA
Nitrates

A

Antianginal: dilates coronary arteries and improve collateral blood flow; decreases preload and afterload (modestly); reduces chest pain

Sublingual NTG (0.4mg every 5 minutes x 3 doses) if not already administered and the patient has persistent chest pain, hypertension or heart failure.
IV NTG can be considered if symptoms persist

44
Q

MONA
Aspirin

A

Non-enteric coated, chewable aspirin (162-325mg) should be given to all patients immediately if no contraindications are present ( Do Not use extended release aspirin products)

A maintenance dose of aspirin 81-162mg daily should be continued indefinitely. If intolerant to aspirin, clopidogrel or ticagrelor may be used.

45
Q

DO NOT USE IV NTG if SBP < ___________, HR < _________ BPM or the patient is experiencing a right ventricular infarction

A

SBP < 90mmHg, HR < 50 BPM

46
Q

What is Contraindicated with (NTG) Nitroglycerin

A

PDE-5 inhibitors

47
Q

(Give these next [choice of drug/s relates to plan (PCI vc CABG vs medical management)]

GAP
GPIIb/IIIa receptor antagonists

A

Drugs include abciximab, eptifbatide and tirofiban

48
Q

GAP
Anticoagulants

A

Inhibit clotting factors and can reduce infarct size

Drugs include LMWH (enoxaparin*, dalteparin), UFH and bivalirudin (preferred for STEMI)

49
Q

GAP
P2Y12 inhibitors

A

Drugs include clopidogrel, prasugrel and ticagrelor

50
Q

(Give within 24 hours (as needed); Continue as outpatient)
BA
Beta-Blockers

A

Antianginal: decrease BP, HR and contractility; decrease ischemia, reinfarction and arrhythmias; prevent cardiac remodeling; increase long-term survival

An oral, low dose beta blocker (beta-1 selective without intrinsic sympathomimetic activity preferred) should be started within 24 hours unless contraindicated ( decompensated heart failure, cardiogenic shock, HR < 45bpm)

If the patient has concomitant HFrEF that is stable, choose bisoprolol, metoprolol succinate, or carvedilol.

An IV beta-blocker or an oral long acting nondihydropyridine calcium channel blocker (verapamil or diltiazem) are alternative options used in some situations

51
Q

BA
ACE Inhibitors

A

Inhibit angiotensin converting enzyme and block the production of angiotensin II; prevent cardiac remodeling; decrease preload and afterload

An oral ACE inhibitor should be started within the first 24 hours and continued indefinitely in all patients with left ventricular ejection fraction (LVEF) < 40%, hypertension, diabetes, or stable CKD, unless contraindicated (use an ARB if the patient is ACE inhibitor intolerant).

DO NOT Use an IV ACE inhibitor within the first 24 hours due to risk of hypotension.

52
Q

Medications to Avoid in the Acute Setting: ACS

A

NSAIDs (except aspirin), whether nonselective or COX-2-selective, should not be administered during hospitalization due to increase risk of mortality, reinfarction, hypertension, cardiac rupture, renal insufficiency and heart failure.

IR-nifedipine should NOT be used to due increase risk of mortality

53
Q

The antiplatelet drugs used in ACS inhibit __________ and _________ by different mechanisms

A

platelet aggregation
clot formation

54
Q

What are the Antiplatelet drug/classes

A

1) aspirin

2) P2Y12 inhibitor

3) GPIIb/IIIa receptor antagonist

4) Protease-activated receptor-1 antagonist

55
Q

P2Y12 inhibitor:
MOA -
drug examples -

A

bind to the platelet ADP P2Y12 receptor, preventing ADP-mediated activation of the GPIIb/IIIa receptor complex

exs. clopidogrel(Plavix), prasugrel(Effient), ticagrelor(Brillinta), cangrelor(Kengreal)

56
Q

Glycoprotein IIb/IIIa receptor antagonist (GPIIb/IIIa receptor antagonist):
MOA-
drug examples-

A

block the platelet glycoprotein IIb/IIIa receptor, which is the binding site for fibrinogen, von Willebrand factor and other ligands

examples: abciximab(ReoPro*), eptifibatide(Integrilin**), tirofiban(Aggrastat)

ReoPro Not Currently available in US

57
Q

Protease-activated receptor-1 antagonist: (PAR-1 antagonist)
MOA-
drug examples-

A

binds to the PAR-1 receptor, preventing thrombin- and thrombin receptor agonist peptide-induced platelet aggregation.

(PAR-1) = protease activated receptor = “thrombin receptor”

example: vorapaxar(Zontivity)

58
Q

Fibrinolytics
MOA-
drug examples-
Uses-

A

these medications cause fibrinolysis (clot breakdown) by binding to fibrin and converting plasminogen to plasmin.

examples: alteplase(Activase), tenecteplase (TNKase), reteplase (Retavase)

USES: fibrinolytics are USED Only for STEMI. Once a STEMI is confirmed on a 12-lead ECG, timing is critical to open a blocked artery or arteries as quickly as possible with either PCI or fibrinolytic therapy.

59
Q

When fibrinolytic therapy is used, it should be given within ___________.

In the absence of contraindications, and when PCI is not available, fibrinolytic therapy is reasonable in STEMI patients who are still symptomatic within 12-24 hours of symptom onset

A

30 minutes of hospital arrival (door-to-needle time)

60
Q

Activase*

A

alteplase

61
Q

TNKase*

A

tenecteplase

62
Q

Retavase

A

reteplase

63
Q

Integrillin**

A

eptifibatide

64
Q

ReoPro*

A

abciximab
currently unavailable in the US

65
Q

Aggrastat

A

tirofiban

66
Q

Zontivity

A

vorapaxar

67
Q

Kengreal

A

cangrelor

68
Q

Brilinta*

A

ticagrelor

69
Q

Effient*

A

prasugrel

70
Q

Plavix*

A

clopidogrel

71
Q

what classes of medications/drugs are taken for secondary prevention after ACS?

A

aspirin:
Taken indefinitely (81mg daily) unless contraindicated

P2Y12 inhibitor:
Medical therapy patients- ticagrelor (Brilinta) or clopidogrel (Plavix), with aspirin 81mg daily for at least 12 months
PCI-Treated patients (including any type of stent): clopidogrel, prasugrel or ticagrelor with aspirin 81mg daily for at least 12 months
For Continuation of DAPT beyond 12 months may be considered in patients who are tolerating DAPT and ARE NOT at high risk of bleeding following coronary stent placement

Nitroglycerin:
Taken indefinitely (SL tablets or spray PRN)

Beta blocker
3 years; continue indefinitely in patients with heart failure or if needed for management of hypertension

ACE inhibitor
indefinitely in patients with EF , 40%, hypertension, CKD or diabetes; consider for all MI patients with no contraindications

Aldosterone Antagonist
indefinitely in patients with EF < or = 40% and symptomatic heart failure or diabetes receiving target doses or an ACE inhibitor and beta blocker
Contraindications: significant renal impairment (SCr>2.5mg/dL in men, SCr > 2mg/dL in women) or hyperkalemia (K>5mEq/L)

Statin
Indefinitely; high intensity statin for most patients
patients > or = 75 years of age: consider moderate or high intensity statin

72
Q

Other considerations for Pain relief in patients with chronic musculoskeletal pain should use ________________________ before considering the use of NSAIDs.

If these options are insufficient, it is reasonable to use _______________ such as __________ (lowest CV risk)

_____________ have the highest CV risk and should be avoided

A

acetaminophen, nonacetylated salicylates, tramadol or small doses of narcotics

nonselective NSAIDs naproxen

COX-2 selective NSAIDs

73
Q

ACS + atrial fibrillation (AF): ___________ can be used in patients who require anticoagulation for AF and have had a PCI with a stent

A

dual or triple antithrombotic therapy

74
Q

If using triple therapy for ACS + atrial fibrillation (AF), then it should be used for the ________________

A

shortest time possible

75
Q

What is the preferred P2Y12 inhibitor for triple therapy and a transition to dual therapy?

A

(Plavix) clopidogrel

76
Q

___________________ should be prescribed in any patient with a history of GI bleeding while taking triple antithrombotic therapy

A

proton pump inhibitors

77
Q

Lifestyle Counseling should include:

A

smoking cessation, managing chronic conditions (hypertension and diabetes), avoiding excessive alcohol intake, encouraging physical exercise and a healthy diet

Notes/Facts/Brand vs Generic (23 decks)

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