35 - ACS

Question 1

Don’t use fibrinolytic therapy in ____

Answer 1

NSTEMI

Question 2

Describe the urgent acute tx for UA/NSTEMI

Answer 2

need early, urgent coronary angiography followed by if possible, by revascularization with PCI or bypass surgery in all high risk patients

Question 3

UA/NSTEMI:

What do you use for initial attempts at symptom relief

Answer 3

nitroglycerin

Question 4

UA/NSTEMI:

What drug do you start ASAP in all patients without contraindications?

Answer 4

Beta blocker

Question 5

UA/NSTEMI:

When are CCBs indicated?

Answer 5

used to control ongoing symptoms of ischemia in patients receiving max doses of BBs and nitrates

Question 6

UA/NSTEMI:

Which type of CCBs should be used cautiously with BBs?

Answer 6

Non-DHPs (diltiazem, verapamil)

• they act more centrally and behave similar to BBs
• can cause LV dysfunction, severe bradycardia or increased AV nodal block

Question 7

UA/NSTEMI:

What CCB should you avoid bc it can cause acute drop in BP and cause a stroke?

Answer 7

IR nifedipine

Question 8

UA/NSTEMI:

Why are ACEi’s used?

Answer 8

they reduce mortality

Question 9

UA/NSTEMI:

When should you initiate an ACEi?

Answer 9

within 24 hours of presentation

Question 10

UA/NSTEMI:

What is the preferred heparin in those who don’t have significant renal dysfunction (i.e. CrCl > 30)

Answer 10

Enoxaparin

Question 11

UA/NSTEMI:

What do you use if CrCl < 30?

Answer 11

UFH is appropriate

Question 12

UA/NSTEMI:

How long is heparin used for?

Answer 12

usually used x 2-5 days

Question 13

UA/NSTEMI:

Do you use heparin following successful PCI?

Answer 13

Not usually

Question 14

UA/NSTEMI:

_____ is as effective as enoxaparin in patients with NSTEMI

Answer 14

fondaparinux (factor Xa inhibitor)

Question 15

UA/NSTEMI:

When would you consider bivalrudin (direct thrombin inhibitor)?

Answer 15

Bivalrudin use is considered a reasonable strategy in patients with ACS undergoing PCI with concomitant P2Y12 inhibition and/or GP2b/3a inhibitor use

Question 16

UA/NSTEMI:

Give ____ indefinitely as part of antiplatelet therapy

Answer 16

ASA

Question 17

UA/NSTEMI:

What are the 3 P2Y12 platelet receptor inhibitors that are classified as thienopyridines?

Answer 17

• Clopidogrel
• Prasugrel
• Ticlopidine (rarely used bc the other 2 are more safe)

Question 18

UA/NSTEMI:

What is an example of P2Y12 platelet receptor inhibitor that is classified as a cyclopentyltriazolopyrimidine?

Answer 18

Ticagrelor

Question 19

UA/NSTEMI:

_____ does not require metabolic activation

Answer 19

Ticagrelor

Question 20

UA/NSTEMI:

How long do you hold each agent before surgery? (clopidogrel, prasugrel and ticagrelor)

Answer 20

• Clopidogrel and Ticagrelor = hold 5 days

- Prasugrel = hold 7 days

Question 21

UA/NSTEMI:

List some Glycoprotein 2b/3a inhibitors (antiplatelet agents)

Answer 21

eptifibatide, tirofiban, abciximab

Question 22

UA/NSTEMI:

eptifibatide, tirofiban, abciximab - These agents can cause _______

Answer 22

thrombocytopenia

*so have to monitor platelet counts

Question 23

STEMI:

If can’t do PCI within ___ hours, do pharmacoinvasive strategy

Answer 23

2

Question 24

STEMI:

List 2 options for thrombolytic therapy

Answer 24

alteplase or tenecteplase

Question 25

STEMI: | When should thrombolytic therapy bc started?

Answer 25

best if started within 6 hours of symptom onset

Question 26

STEMI: | Give _____ to all STEMI patients receiving alteplase or tenecteplase

Answer 26

IV UFH

Question 27

STEMI: | What is an alternative to IV UFH?

Answer 27

enoxaparin (LMWH)

Question 28

STEMI: | Who should you caution enoxaparin in?

Answer 28

in those > 75 yo or those with renal insufficiency due to increased risk of bleed

Question 29

STEMI: | Heparins should be continued for a minimum of ___ hours

Answer 29

48

Question 30

STEMI: | ____ is initiated for life

Answer 30

ASA

Question 31

STEMI: | Initiate ___ once hemodynamically stable to reduce mortality and risk of recurrent MI

Answer 31

BB

Question 32

STEMI: | What is your target for BB's?

Answer 32

Titrate doses to a resting HR of 50-60 bpm

Question 33

STEMI: | What drug do we absolutely NOT recommend in STEMI patients?

Answer 33

CCBs - they increase morbidity and mortality in STEMI patients

Question 34

STEMI: | In what situation could you use a CCB?

Answer 34

ONLY if person is CI to BB. Use cautiously. Consider low-dose diltiazem and monitor HR closely

Question 35

STEMI: | Use ____ if ischemia is persistant or recurrent

Answer 35

nitrates

Question 36

STEMI: | When should you start an ACEi?

Answer 36

within 24 hours of the event unless patient is hypotensive

Question 37

STEMI: | When would you use an ARB?

Answer 37

if patient can't tolerate ACEi

Question 38

STEMI: | When would you use a MRA (ex. spironolactone or eplerenone)?

Answer 38

if patient on ACEi and BB still have symptoms of HF, LVEF < 40% or both

Question 39

STEMI: | Add ____ as DAPT with ASA

Answer 39

clopidogrel

Question 40

STEMI: | How do you treat pericarditis ?

Answer 40

increases ASA dose or adding NSAID, corticosteroid or colchicine