ACS Part 5

Question 1

Long term goals of ACS therapy

Answer 1

-Control CAD risk factors
-Prevent MACE
-Improve quality of life

Question 2

When should beta blockers be initiated?

Answer 2

Within the first 24 hours of ACS

Question 3

Reasons not to start beta blocker

Answer 3

-Bradycardia
-HF or low-output state
-Risk of cardiogenic shock
-PR interval greater than 0.24
-Second or third degree heart block
-Active asthma or reactive airway disease

Question 4

Which beta blockers should be used in patients with HFrEF?

Answer 4

-Metoprolol succinate
-Carvedilol
-Bisoprolol

Question 5

When should IV BB be considered?

Answer 5

When hypertensive or ongoing ischmia

Question 6

Starting dose of metoprolol

Answer 6

25-50 mg q6-12h (tartrate)

Question 7

Target dose of metoprolol

Answer 7

-100 mg bid (tartrate)
-200 mg daily (succinate)

Question 8

Starting dose of carvedilol

Answer 8

6.25 mg bid

Question 9

Target dose of carvedilol

Answer 9

25 mg bid

Question 10

Starting dose of propranolol

Answer 10

40 mg bid-tid

Question 11

Target dose of propranolol

Answer 11

80 mg qid

Question 12

Starting dose of atenolol

Answer 12

25-50 mg daily

Question 13

Target dose of atenolol

Answer 13

100 mg daily

Question 14

IV metoprolol dosing

Answer 14

5 mg IV every 5 min for 3 doses

Question 15

Which beta blocker should you use on a patient suffering from cocaine-induced chest pain?

Answer 15

Non-selective beta blocker such as carvedilol

Question 16

Is it safe to continue maintenance beta blockers in a patient suffering from a heart failure exacerbation?

Answer 16

Yes, worse outcomes have been shown when they are discontinued

Question 17

Beta blocker patient counseling

Answer 17

-This med lowers bp and cause dizziness especially when standing
-This med should be continued even when your blood pressure is under control
-This medication can mask the signs of hypoglycemia if you have diabetes

Question 18

Hold parameters for beta blocekrs

Answer 18

-HR less than 50
-BP less than 90/60

Question 19

When should non-DHP CCBs be used?

Answer 19

Patients who are contraindicated to beta blockers

Question 20

When should you not use non-DHP CCBs?

Answer 20

-LV dysfunction
-Increased risk for cardiogenic shock
-Pr interval greater than 0.24
-Second or third degree atrioventricular block without a cardiac pacemaker

Question 21

When should you give a statin?

Answer 21

Everyone should be on a high intensity statin

Question 22

Most common side effect for statins

Answer 22

Muscle pain

Question 23

Statin counseling

Answer 23

-Must be taken lifelong
-Continue to take even if your cholesterol is normal
-Let your doctor know if you experience unexpected muscle pain

Question 24

When should an ACE be given?

Answer 24

Recommended in all patients but especially those with HFrEF, DM, or CKD

Question 25

When not to use ACE inhibitors

Answer 25

-Hypotension or shock
-Bilateral renal artery stenosis or history of worsening renal function with ACEi or ARB exposure
-Acute renal failure
-Drug allergy/angioedema

Question 26

What to monitor when on ACEi

Answer 26

-Scr
-Potassium
-Blood pressure
-Angioedema

Question 27

ACEi counseling

Answer 27

-This medication helps you live longer not just control bp
-May cause hypotension and side effects such as dizziness especially when standing. If dizziness or lightheadedness persists let your doctor know
-May cause a dry cough
-Angioedema then STOP taking and seek medical attention

Question 28

Which patients may require an additional oral anticoagulation along with the dual antiplatelet therapy (triple antithrombotic therapy)?

Answer 28

-Patients with arterial fibrillation
-STEMI and asymptomatic LV mural thrombi
-STEMI and anterior apical akinesis or dyskinesis (abnormal wall movement)

Question 29

How do you give triple antithrombotic therapy after ACS?

Answer 29

-Duration should be minimized
-Assess benefit vs bleeding risk
-In patients with AF: discontinue aspirin after 1-4 weeks after PCI and continue P2Y12 inhibitor and anticoagulant
-NOAC preferred over warfarin to reduce bleed risk

Question 30

Dose for SL nitroglycerin

Answer 30

0.3-0.4 mg every 5 min 3 times then call 911

Question 31

Nitroglycerin patient counseling

Answer 31

-Keep bottle of tabs or spray with you at all times
-Tabs must be stored in an air tight, amber vial
-Good for 3-6 months once opened
-Sublingual spray must be primed before spraying

Question 32

How to prevent recurrent MI?

Answer 32

-Stop smoking
-Adherence to meds
-Control BP
-Healthy diet and exercise