43. Acute Coronary Syndromes (ACS) Flashcards Preview

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Flashcards in 43. Acute Coronary Syndromes (ACS) Deck (40):
1

Angelo has coronary artery disease and has had a stent placement. He has come to the pharmacy to get his clopidogrel refilled. Angelo has active peptic ulcer disease and states he has stool that looks dark and tarry. He wife notes that the toilet bowl needs more regular scrubbing. Choose the correct statement concerning clopidogrel:

A. He should take one 300 mg tablet daily.
B. He should take one 75 mg tablet daily.
C. The patient needs 2C9 pharmacogenetic testing to continue receiving clopidogrel.
D. The patient should be seen right away and instructed to contact his doctor before using any more clopidogrel or aspirin.
E. The pharmacist should contact the prescriber; he requires the addition of an H2 receptor antagonist.

D. Clopidogrel has a risk of bleeding. This patient may have a current bleed. Due to the bleeding risk, clopidogrel should not be used concurrently with anticoagulants or with NSAIDs (except if used with aspirin).

P2Y12 Inhibitors: binds to the adenosine diphosphate (ADP) P2Y12 receptor on platelet surface which prevents ADP-mediated activation of the GPIIb/IIIa receptor complex resulting in a reduction of platelet aggregation. prasugrel and ticagrelor is indicated for reduction of thrombotic events in patients with ACS.

clopidogrel (Plavix): irreversible binding, prodrug (2C19). Boxed warning: effectiveness depends on the activation to an active thiol metabolite mainly by 2C19. Poor metabolizes exhibit higher cardiovascular events than patients with normal 2C19 function. CI: active bleed (PUD, ICH). Warning: avoid 2C19 inhibitors (omeprazole, esomeprazole), thrombotic thrombocytopenic purpura (TTP) has been reported (fever, weakness, extreme skin paleness, purple skin patches, yellowing of the skin/eyes, neurological changes. SE: bleeding, bruising, rash, pruritus. Discontinue 5 days prior to major surgery.

2

Maureen was diagnosed with an acute STEMI. The physician is determining if she is a candidate for fibrinolysis. Which of the following is an absolute contraindication to fibrinolysis?

A. An intracranial hemorrhage within the past 60 days
B. A BP of 165/98
C. Hypersensitivity to soy products
D. Ischemic stroke within the past 4 years
E. Concurrent use of aspirin

A. Absolute contraindications to fibrinolysis include any prior intracranial hemorrhage, suspected aortic dissection, active bleeding, intracranial or intraspinal surgery or trauma in last 3 months, previous ischemic stroke within 3 months and others.

Fibrinolytics: they cause fibrinolysis by binding to fibrin in a thrombus (clot) and converting entrapped plasminogen to plasmin. CI: Absolute (active bleeding, or bleeding diathesis, any prior intracranial hemorrhage, recent intracranial or intraspinal surgery or trauma in last 3 months, intracranial neoplasm, arteriovenous malformation, or aneurysm, aortic dissection, severe uncontrolled hypertension unresponsive to emergency therapy, ischemic stroke within past 3 months except acute ischemic stroke within 4.5 hours), Relative (pregnancy, active peptic ulcer, current use of anticoagulants). SE: bleeding, hypotension, intracranial hemorrhage, fever

alteplase (Activase, t-PA)

tenecteplase (TNKase)

reteplase (Retevase, r-PA)

3

All of the following are antiplatelet agents used in the treatment of ACS except:

A. Clopidogrel
B. Dalteparin
C. Tirofiban
D. Ticagrelor
E. Aspirin

B. Dalteparin is an anticoagulant.

clopidogrel (Plavix), ticagrelor (Brilinta): P2Y12 inhibitos

tirofiban (Aggrastat): GP IIb/IIIa inhibitor

4

Which of the following are likely signs/symptoms of a heart attack? (Select ALL that apply.)

A. Uncomfortable pressure, squeezing, or pain in the chest that lasts more than a few minutes, or goes away and comes back
B. Shortness of breath
C. Trouble speaking and weakness predominantly on one side of the body
D. Decreased troponin levels
E. Increased CK-MB level

A, B, E. Confusion and trouble speaking are more likely symptoms of a stroke. Most myocardial infarctions involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain. The pain can be in one or both arms, the back, neck, jaw or stomach. Shortness of breath is common. Patients will have increased troponin and CK-MB levels.

S/sx: chest pain (encompasses discomfort, pressure, squeezing) lasting >10 minutes, severe dyspnea, diaphoresis, syncope/presyncope, palpitations. pain may radiate to arms, back, neck, jaw, epigastric area. precipitating factors include exercise, cold weather, extreme emotions, stress, sexual intercourse.

5

The hospital where Maureen is admitted does not have the capability to perform percutaneous coronary intervention (PCI) and fibrinolysis may be done as an alternative. What is the mechanism of action of alteplase?

A. Binds to fibrin and converts plasmin to plasminogen
B. Binds to antithrombin and converts thrombin to fibrin
C. Binds to thrombin and converts fibrinogen to fibrin
D. Binds to thrombin and converts fibrin to fibrinogen
E. Binds to fibrin and converts plasminogen to plasmin

E. Fibrinolytics work by binding to fibrin and converting entrapped plasminogen to plasmin. Plasmin then degrades the fibrin mesh into soluble end products leading to clot dissolution.

Fibrinolytics: they cause fibrinolysis by binding to fibrin in a thrombus (clot) and converting entrapped plasminogen to plasmin. CI: Absolute (active bleeding, or bleeding diathesis, any prior intracranial hemorrhage, recent intracranial or intraspinal surgery or trauma in last 3 months, intracranial neoplasm, arteriovenous malformation, or aneurysm, aortic dissection, severe uncontrolled hypertension unresponsive to emergency therapy, ischemic stroke within past 3 months except acute ischemic stroke within 4.5 hours), Relative (pregnancy, active peptic ulcer, current use of anticoagulants). SE: bleeding, hypotension, intracranial hemorrhage, fever

alteplase (Activase, t-PA)

tenecteplase (TNKase)

reteplase (Retevase, r-PA)

6

A patient at the hospital is receiving morphine for chest pain. What are the advantages/reasons for using morphine in a patient with chest pain? 

A. Provides analgesia, increases blood pressure and reduces preload
B. Reduces preload, provides analgesia and reduces myocardial oxygen demand
C. Reduces myocardial oxygen demand, reduces anxiety and reduces clot expansion
D. Reduces chest pain, increases myocardial oxygen supply and increases blood pressure
E. Provides analgesia, reduces preload and increases ejection fraction

B. With the use of morphine, be careful with the blood pressure-hypotension can result. Morphine can cause respiratory depression if overdosed.

Treatment:

MONA

morphine: reduce pain to help reduce anxiety, has vasodilation properties

oxygen: O2 via nasal cannula (only if patient is desaturating O2 <90%)

nitrates: SL tabs/spray, 1 dose and if pain persist call 911, then take 2 more doses every 5-10 minutes (max 3 doses)

aspirin: 162-325mg, must chew the aspirin dose for quick onset

7

Which of the following laboratory tests is the most sensitive marker for detecting myocardial damage in the blood of a patient with an acute coronary syndrome?

A. CKMB
B. BNP
C. Troponins
D. Myoglobin
E. Echocardiogram

C. Troponins are the most sensitive and specific laboratory test for detecting myocardial damage due to ischemia in patients with ACS.

Unstable Angina: chest pain (NSTE-ACS, non-ST segment elevation acute coronary syndrome)

NSTEMI: chest pain, increased troponins (NSTE-ACS, non-ST segment elevation acute coronary syndrome)

STEMI: chest pain, increase troponins, ECG changes (ST segment elevation)

8

Which of the following side effects is common with Brilinta?

A. Tachyarrhythmias
B. Decreased serum creatitine
C. Hepatic impairment
D. Dyspnea
E. Puffy eyes

D.

ticagrelor (Brilinta): reversible binding, not a prodrug. Boxed warning: can cause significant or fatal bleeding. maintenance doses of aspirin above 100mg reduce the effectiveness of ticagrelor and should be avoided (after any initial aspirin dose, maintenance aspirin dose should not exceed 100mg daily). CI: active bleeding, history of ICH, severe hepatic impairment. SE: bleeding, dyspnea, increase SCr, bradyarrhythmias. Do not start in patients likely to undergo CABG surgery. Discontinue 5 days prior to any major surgery.

9

Duane is a 77 year old male (6'3", 315 pounds) who presents to the emergency department with a NSTEMI.  He was given aspirin 325 mg in the field and was started on a nitroglycerin drip that is currently running at 200 mcg/min.  His oxygen saturation is 94% and he has received morphine sulfate 2 mg IV x 2 and metoprolol 5 mg IV in the past 30 minutes.  The patient still has ongoing ischemia and is going for PCI.  The physician wants to start ReoPro on this patient.  Which of the following statements are correct regarding ReoPro?

A. The aPTT must be monitored while the patient is receiving ReoPro.
B. The INR must be monitored while the patient is receiving ReoPro.
C. ReoPro must be filtered during administration.
D. ReoPro must be shaken upon reconstitution.
E. All patients receiving ReoPro should be transitioned to the oral formulation as soon as possible due to cost.

C. ReoPro is a protein and should be not shaken during reconstitution. The medication requires filtering during administration and platelets must be monitored. ReoPro is not available orally.

Glycoprotein IIb/IIIa Receptor Antagonists: blocks platelet glycoprotein IIb/IIIa receptor, which is the binding site for fibrinogen, von Willebrand factor, and other ligands to block platelet aggregation and prevent thrombosis. Eptifibatide and tirofiban have reversible blockade and abciximab has irreversible blockade. all agents are IV. CI: thrombocytopenia (platelets <100,000), history of bleeding diathesis, recent (within 6 weeks) GI or GU bleeding of clinical significance (abciximab), active internal bleeding, recent (within 4-6 weeks) major surgery or trauma (4 weeks for tirofiban/eptifibatide and 6 weeks for abciximab), increase prothrombin time, history of stroke within 2 years (abciximab), history of stroke within 30 days or any history of hemorrhagic stroke (eptifibatide/tirofiban), severe uncontrolled hypertension, hypersensitivity to murine proteins (abciximab), dependency on renal dialysis (eptifibatide). SE: bleeding, thrombocytopenia (esp. abciximab), hypotension. Do not shake vials upon reconstitution.

abciximab (ReoPro): irreversible blockade. requires filter for administration

eptifibatide (Integrilin): reversible blockade

tirofiban (Aggrastat) reversible blockade

10

A patient at the hospital is receiving nitroglycerin for chest pain. What are the advantages/reasons for using nitroglycerin in a patient with chest pain? (Select ALL that apply.)

A. Increases blood pressure
B. Reduces systemic vascular resistance and preload
C. Dilates coronary vessels and increases blood flow
D. Relieves chest pain
E. Helps with fibrinolysis

B, C, D. With the use of nitroglycerin, monitor for bradycardia and/or tachycardia, hypotension and for drug interactions with the PDE5 inhibitors used for erectile dysfunction.

11

Ronald is being discharged from the hospital after he suffered a myocardial infarction.  He has a past medical history significant for hypertension.  Upon discharge, he will continue taking his Zestril therapy which was started yesterday in addition to his hydrochlorothiazide for hypertension.  How long is it recommended that Ronald take his Zestril therapy?

A. 6 months
B. 1 year
C. 2 years
D. 3 years
E. Indefinitely

E.

Secondary Prevention in s/p MI

Aspirin: 81-325mg daily indefinitely (if taking ticagrelor, ASA dose <100mg/day)

P2Y12 inhibitor: clopidogrel, prasugrel, ticagrelor for up to 1 year

Beta blockers: daily for 3 years

ACE-I: daily indefinitely

Aldosterone antagonists: indefinitely if they have LVEF <40% without significant renal impairment

Statin: high intensity if ≤75 years of age, moderate intensity if >75 years of age

Nitroglycerin: PRN only

Control risk factors: smoking cessation, physical activity, diet and weight management

12

Duane is a 77 year old male (6'3", 315 pounds) who presents to the emergency department with a NSTEMI.  He was given aspirin 325 mg in the field and was started on a nitroglycerin drip at 100 mcg/min.  His oxygen saturation is 94% and he has received morphine sulfate 2 mg IV x 2 and metoprolol 5 mg IV in the past 30 minutes.  His blood pressure is 164/101, HR is 95 BPM, and his respiratory rate is 22 BPM.  Which of the following medications should not be given to the patient due to increased mortality?

A. Procardia
B. Demadex
C. Atacand
D. Cardizem
E. Vasotec

A.

IR nifedipine (Procardia) should not be used due to increased risk of mortality

13

Which of the following patients should be placed on statin therapy post MI?

A. Patients < 75 years old
B. Patients ≤ 75 years old
C. Patients > 75 years old
D. Patients ≥ 75 years old
E. All patients who are S/P MI

E. Statin therapy should be initiated in all patients who have had a heart attack.

Secondary Prevention in s/p MI

Aspirin: 81-325mg daily indefinitely (if taking ticagrelor, ASA dose <100mg/day)

P2Y12 inhibitor: clopidogrel, prasugrel, ticagrelor for up to 1 year

Beta blockers: daily for 3 years

ACE-I: daily indefinitely

Aldosterone antagonists: indefinitely if they have LVEF <40% without significant renal impairment

Statin: high intensity if ≤75 years of age, moderate intensity if >75 years of age

Nitroglycerin: PRN only

Control risk factors: smoking cessation, physical activity, diet and weight management

14

Which of the following medications should be avoided in a patient presenting with ACS?

A. Metoprolol
B. Lisinopril
C. Celecoxib
D. Aspirin
E. Enoxaparin

C. NSAIDs should be avoided in patients with ACS.

15

Which of the following statements are true regarding clopidogrel? (Select ALL that apply.)

A. It increases bleeding risk
B. It is metabolized to its active form by CYP 2C19
C. It should be discontinued about 12 hours prior to major surgery
D. It binds irreversibly to the platelet
E. The typical maintenance dose is 300 mg daily

A, B, D. Clopidogrel is a prodrug that is converted to its active form by CYP 2C19. It binds irreversibly to platelet receptors and is commonly dosed 75 mg daily for maintenance. It should be discontinued 5 days prior to major surgery.

clopidogrel (Plavix): irreversible binding, prodrug (2C19). Boxed warning: effectiveness depends on the activation to an active thiol metabolite mainly by 2C19. Poor metabolizes exhibit higher cardiovascular events than patients with normal 2C19 function. CI: active bleed (PUD, ICH). Warning: avoid 2C19 inhibitors (omeprazole, esomeprazole), thrombotic thrombocytopenic purpura (TTP) has been reported (fever, weakness, extreme skin paleness, purple skin patches, yellowing of the skin/eyes, neurological changes. SE: bleeding, bruising, rash, pruritus. Discontinue 5 days prior to major surgery.

prasugrel (Effient): irreversible binding, prodrug, only one in class with CI to history of TIA/stroke. Boxed warning: can cause significant or fatal bleeding, not recommended in patient ≥75 years due to increased risk of intracranial bleeding, do not start in patient undergoing urgent CABG surgery, discontinue 7 days prior to any major surgery. CI: active bleeding, patients with history of TIA or stroke. Warning: thrombotic thrombocytopenia purpura (TTP). SE: bleeding (more than clopidogrel)

ticagrelor (Brilinta): reversible binding, not a prodrug. Boxed warning: can cause significant or fatal bleeding. maintenance doses of aspirin above 100mg reduce the effectiveness of ticagrelor and should be avoided (after any initial aspirin dose, maintenance aspirin dose should not exceed 100mg daily). CI: active bleeding, history of ICH, severe hepatic impairment. SE: bleeding, dyspnea, increase SCr, bradyarrhythmias. Do not start in patients likely to undergo CABG surgery. Discontinue 5 days prior to any major surgery.

16

A patient at the hospital is receiving a beta blocker for chest pain. Which of the following are true regarding the use of beta blockers in this setting? 

A. In STEMI, beta-blockers should not be used.
B. They can be administered PO or IV.
C. They should be combined with a long-acting non-dihydropyridine calcium antagonist.
D. They increase myocardial oxygen demand.
E. Beta-blockers with ISA activity are preferred.

B. Beta blockers reduce myocardial oxygen demand and should be given to all patients without contraindications who present with UA/NSTEMI within 24 hours. In STEMI, the should be given promptly. They can be administered PO or IV.

MONA

morphine: reduce pain to help reduce anxiety, has vasodilation properties

oxygen: O2 via nasal cannula (only if patient is desaturating O2 <90%)

nitrates: SL tabs/spray, 1 dose and if pain persist call 911, then take 2 more doses every 5-10 minutes (max 3 doses)

aspirin: 162-325mg, must chew the aspirin dose for quick onset

GAP-BA

glycoprotein (GP) IIb/IIIa inhibitors: blocks fibrinogen, prevent platelet aggregation

anticoagulants: UFH/LMWH

p2Y12 inhibitor:

beta blocker: helps with remodeling

ACE-I: oral to decrease BP, help with remodeling

17

Which of the following orders should not be placed in a patient receiving ticagrelor?

A. Enoxaparin 1 mg/kg every 12 hours
B. Warfarin 2 mg daily
C. Metoprolol XL 50 mg daily
D. Morphine 1 mg IV every 2-4 hours PRN pain
E. Aspirin 325 mg daily

E. Aspirin doses greater than 100 mg reduce the effectiveness of ticagrelor and should be avoided.

ticagrelor (Brilinta): reversible binding, not a prodrug. Boxed warning: can cause significant or fatal bleeding. maintenance doses of aspirin above 100mg reduce the effectiveness of ticagrelor and should be avoided (after any initial aspirin dose, maintenance aspirin dose should not exceed 100mg daily). CI: active bleeding, history of ICH, severe hepatic impairment. SE: bleeding, dyspnea, increase SCr, bradyarrhythmias. Do not start in patients likely to undergo CABG surgery. Discontinue 5 days prior to any major surgery.

18

What is the brand name of vorapaxar?

A. Zontivity
B. Zonegran
C. Kalydeco
D. Kadcyla
E. Savaysa

A.

vorapaxar (Zontivity): PO, reversible antagonist of protease-activated receptor-1 (PAR-1) expressed on platelets, but its long half life makes it effectively irreversible, resulting in decreased platelet activation. indicated for patients with a history of MI or PAD. Boxed warning: use is contraindicated in patients with history of stroke, TIA, ICH, active bleeding. Warning: do not use in severe liver impairment. SE: bleeding, anemia, pregnancy (B). No antidote. It is a substrate of 3A4 and inhibitor of P-gp.

19

A patient, while gardening, experiences massive chest pain, diaphoresis, shortness of breath and left arm pain.  Emergency medical personnel is contacted and arrives at the scene.  What test should the emergency medical personnel perform?

A. Treadmill stress testing
B. Echocardiogram
C. Heart computed tomography
D. 12-lead electrocardiogram
E. Right heart catheterization

D. Emergency medical personnel should perform a 12-lead electrocardiogram (ECG) in the field in patients experiencing symptoms of ACS.

20

The provider orders Reopro. What is the appropriate therapeutic substitution?

A. Abciximab
B. Tirofiban
C. Enoxaparin
D. Bivalirudin
E. Eptifibatide

A.

tirofiban (Aggrastat)

bivalirudin (Angiomax)

eptifibatide (Integrilin)

21

Which of the following medications works by irreversible binding to their target receptor?

A. Integrilin
B. Brilinta
C. Lopressor
D. Aggrastat
E. ReoPro

E. ReoPro is an irreversible inhibitor.

Integrilin (eptifibatide)

Brilinta (ticagrelor)

Aggrastat (tirofiban)

22

An 87 year old male presents to the Emergency Department with complaints of mid-sternal chest pain. He has had intermittent chest pain for two days with some nausea and diaphoresis. The patient is diagnosed with a Non-ST Segment Elevation Myocardial Infarction (NSTEMI). Which of the following are standard components that may be used to treat a patient with an acute coronary syndrome characterized as NSTEMI? (Select ALL that apply.)

A. Morphine
B. Lorazepam
C. Phenobarbital
D. Aspirin
E. Oxygen

A, D, E. Look for drugs in the acronym MONA, which represent standard care for a myocardial infarction: Morphine, Oxygen, Nitrates and Aspirin (MONA).

MONA

morphine: reduce pain to help reduce anxiety, has vasodilation properties

oxygen: O2 via nasal cannula (only if patient is desaturating O2 <90%)

nitrates: SL tabs/spray, 1 dose and if pain persist call 911, then take 2 more doses every 5-10 minutes (max 3 doses)

aspirin: 162-325mg, must chew the aspirin dose for quick onset

23

Patients with acute coronary syndrome may receive a glycoprotein IIb/IIIa receptor antagonist. These may be given in support of a PCI intervention. Choose the correct statement concerning the glycoprotein IIb/IIIa receptor antagonists:

A. Do not use if patient has a major risk for bleeding.
B. They are safe to use within 1 week of major surgery.
C. They are safe to use in patients with thrombocytopenia.
D. They are safe to use with severe uncontrolled hypertension.
E. Do not use if patient has an INR of 1.1.

A. The glycoprotein IIb/IIIa receptor antagonists include abciximab, eptifibatide and tirofiban. They are not safe to use in patients with major risk for bleeding, low platelets, uncontrolled hypertension and within a short period of any major surgery as they can increase bleeding risk.

Glycoprotein IIb/IIIa Receptor Antagonists: blocks platelet glycoprotein IIb/IIIa receptor, which is the binding site for fibrinogen, von Willebrand factor, and other ligands to block platelet aggregation and prevent thrombosis. Eptifibatide and tirofiban have reversible blockade and abciximab has irreversible blockade. all agents are IV. CI: thrombocytopenia (platelets <100,000), history of bleeding diathesis, recent (within 6 weeks) GI or GU bleeding of clinical significance (abciximab), active internal bleeding, recent (within 4-6 weeks) major surgery or trauma (4 weeks for tirofiban/eptifibatide and 6 weeks for abciximab), increase prothrombin time, history of stroke within 2 years (abciximab), history of stroke within 30 days or any history of hemorrhagic stroke (eptifibatide/tirofiban), severe uncontrolled hypertension, hypersensitivity to murine proteins (abciximab), dependency on renal dialysis (eptifibatide). SE: bleeding, thrombocytopenia (esp. abciximab), hypotension. Do not shake vials upon reconstitution.

abciximab (ReoPro): irreversible blockade. requires filter for administration

eptifibatide (Integrilin): reversible blockade

tirofiban (Aggrastat) reversible blockade

24

Ronald is being discharged from the hospital after he suffered a myocardial infarction.  Upon discharge, he will continue taking his Lopressor therapy which was started yesterday.  How long is it recommended that Ronald take his Lopressortherapy?

A. 6 months
B. 1 year
C. 2 years
D. 3 years
E. Indefinitely

D. Per the ACC/AHA guidelines, beta blocker therapy should be given for 3 years S/P MI.

Secondary Prevention in s/p MI

Aspirin: 81-325mg daily indefinitely (if taking ticagrelor, ASA dose <100mg/day)

P2Y12 inhibitor: clopidogrel, prasugrel, ticagrelor for up to 1 year

Beta blockers: daily for 3 years

ACE-I: daily indefinitely

Aldosterone antagonists: indefinitely if they have LVEF <40% without significant renal impairment

Statin: high intensity if ≤75 years of age, moderate intensity if >75 years of age

Nitroglycerin: PRN only

Control risk factors: smoking cessation, physical activity, diet and weight management

25

Alden is being discharged from the hospital after he suffered a myocardial infarction.  He received 2 bare metal stents yesterday.  Upon discharge, he will continue taking his Prasugrel therapy which was started yesterday.  How long is it recommended that Alden take his Prasugrel therapy?

A. 6 months
B. 1 year
C. 2 years
D. 3 years
E. Indefinitely

B.

Secondary Prevention in s/p MI

Aspirin: 81-325mg daily indefinitely (if taking ticagrelor, ASA dose <100mg/day)

P2Y12 inhibitor: clopidogrel, prasugrel, ticagrelor for up to 1 year

Beta blockers: daily for 3 years

ACE-I: daily indefinitely

Aldosterone antagonists: indefinitely if they have LVEF <40% without significant renal impairment

Statin: high intensity if ≤75 years of age, moderate intensity if >75 years of age

Nitroglycerin: PRN only

Control risk factors: smoking cessation, physical activity, diet and weight management

26

Janet, a 54 year old female (ht. 5'5', wt. 168 pounds, SCr 2.2 mg/dL) is being discharged from the hospital after suffering a myocardial infarction.  She is being discharged on Lopressor 25 mg PO BID, Altace 5 mg PO daily, aspirin 81 mg PO daily,Crestor 20 mg PO daily, and Plavix 75 mg PO daily.  Which of the following recommendations should be made regarding her medication therapy?

A. Increase the dose of Plavix
B. Add on Aldactone
C. Decrease the dose of Lopressor
D. Add on Nitrostat PRN
E. Decrease the dose of Crestor

D.

Secondary Prevention in s/p MI

Aspirin: 81-325mg daily indefinitely (if taking ticagrelor, ASA dose <100mg/day)

P2Y12 inhibitor: clopidogrel, prasugrel, ticagrelor for up to 1 year

Beta blockers: daily for 3 years

ACE-I: daily indefinitely

Aldosterone antagonists: indefinitely if they have LVEF <40% without significant renal impairment

Statin: high intensity if ≤75 years of age, moderate intensity if >75 years of age

Nitroglycerin: PRN only

Control risk factors: smoking cessation, physical activity, diet and weight management

27

Which of the following NSAIDs would be considered the safest in patients who are S/P MI?

A. Celecoxib
B. Naproxen
C. Diclofenac
D. Meloxicam
E. Etodolac

B. Naproxen has been shown to have the lowest cardiovascular risk of the NSAIDs (other than aspirin of course).

Boxed warning: GI bleeding, CVD risk (COX-2 highest risk), do not use preoperatively to CABG

CI: NSAID hypersensitivity, nasal polyps, asthma, no aspirin in children <16 years due to Reye's syndrome (mental retardation)

SE: dyspepsia, heartburn (take with food to decrease nausea), increase blood pressure, GI irritation/bleeding, renal impairment, severe skin rash (stop drug immediately and seek medical help), tinnitus

COX-2 selective: lower risk for GI problems, but higher risk of MI/stroke (avoid with CVD risk). COX-2 remember C-MEN for drugs in this class: celecoxib, meloxicam, etodolac, nabumetone

celecoxib (Celebrex): most selective COX-2, CI in sulfonamide allergy

meloxicam (Mobic)

etodolac (Lodine)

nabumetone (Relafen)

28

A patient at the hospital is receiving aspirin for chest pain. What is the primary reason for using aspirin in a patient with chest pain?

A. Inhibits platelet aggregation
B. Provides moderate degree of analgesia
C. Increases mortality in patients with STEMI
D. Prevents flushing
E. Reduces anxiety

A. Aspirin provides very mild analgesia and is not used for this purpose in treating a patient with chest pain. Aspirin reduces mortality in patients with STEMI. It inhibits platelet aggregation, stabilizes plaque and arrests thrombus formation.

MONA

morphine: reduce pain to help reduce anxiety, has vasodilation properties

oxygen: O2 via nasal cannula (only if patient is desaturating O2 <90%)

nitrates: SL tabs/spray, 1 dose and if pain persist call 911, then take 2 more doses every 5-10 minutes (max 3 doses)

aspirin: 162-325mg, must chew the aspirin dose for quick onset

29

The provider orders Integrilin. What is the appropriate therapeutic substitution?

A. Tirofiban
B. Enoxaparin
C. Bivalirudin
D. Eptifibatide
E. Abciximab

D.

tirofiban (Aggrastat)

bivalirudin (Angiomax)

abciximab (ReoPro)

30

Which of the following medications has an antidote?

A. Plavix
B. Brilinta
C. Activase
D. Zontivity
E. None of the above medications have an antidote.

E. Patients must be monitored for bleeding and other adverse effects because no direct antidote exists for these agents.

31

James is a 57 year old male (6'1", 275 pounds) who presents to the emergency department with a NSTEMI.  He was given aspirin 325 mg in the field and was started on a nitroglycerin drip at 100 mcg/min.  He oxygen saturation is 94% and he has received morphine sulfate 2 mg IV x 2 in the past 30 minutes.  He is transferred to the cardiac catheterization laboratory and angioplasty confirmed a 90% blockage of his left anterior descending (LAD) artery.  The cardiac interventionalist wants to start P2Y12 inhibitor therapy prior to starting the PCI.  Which of the following regimens would be most appropriate for this patient?

A. Plavix 900 mg PO x 1
B. Effient 10 mg PO x 1
C. Effient 60 mg PO x 1
D. Brilinta 80 mg PO x 1
E. Brilinta 90 mg PO x 1

C.

clopidogrel LD: 300-600mg PO x1

prasugrel LD: 60mg PO x1

ticagrelor LD: 180mg PO x1

32

Maureen was diagnosed with acute STEMI. The physician is determining if she is a candidate for fibrinolysis. Which of the following are relative contraindications to fibrinolysis? (Select ALL that apply.)

A. Hgb > 11 g/dL
B. Pregnancy
C. Active peptic ulcer
D. Current use of anticoagulants: the higher the INR, the higher the risk
E. Intracranial hemorrhage

B, C, D. Pregnancy, active PUD, concurrent anticoagulant use are all relative contraindications to the use of fibrinolytics.

Fibrinolytics: they cause fibrinolysis by binding to fibrin in a thrombus (clot) and converting entrapped plasminogen to plasmin. CI: Absolute (active bleeding, or bleeding diathesis, any prior intracranial hemorrhage, recent intracranial or intraspinal surgery or trauma in last 3 months, intracranial neoplasm, arteriovenous malformation, or aneurysm, aortic dissection, severe uncontrolled hypertension unresponsive to emergency therapy, ischemic stroke within past 3 months except acute ischemic stroke within 4.5 hours), Relative (pregnancy, active peptic ulcer, current use of anticoagulants). SE: bleeding, hypotension, intracranial hemorrhage, fever

alteplase (Activase, t-PA)

tenecteplase (TNKase)

reteplase (Retevase, r-PA)

33

A patient with a STEMI arrives at a hospital without PCI facilities.  If a STEMI patient cannot be transferred within a specified time frame to receive PCI, the patient should receive fibrinolytic therapy at the presenting hospital.  What is the specified time frame for transfer?

A. 30 minutes
B. 60 minutes
C. 120 minutes
D. 4.5 hours
E. STEMI patients are not candidates for fibrinolytic therapy

C. Fibrinolytic therapy may be administered if the STEMI patient is not at a PCI-capable hospital or is not able to receive PCI within 120 minutes from presentation to the hospital.

34

Maureen, a 58 year-old female, has just been told she had a silent heart attack. She feels quite healthy and cannot understand how this occurred. She feels demoralized. Maureen does not smoke but lives with her husband in an apartment. He smokes two packs per day. Maureen’s blood pressure, which she checks occasionally when she stops at the pharmacy, runs around 154/92 mmHg. Her lipid panel at the last physical had a total cholesterol of 222 mg/dL. She does not recall the other numbers.  Her mom is deceased due to colon cancer and her father passed away earlier this year with COPD.  Which of the following risk factors for coronary heart disease are known to be present in this patient? (Select ALL that apply.)

A. Hypertension
B. Family History
C. Age
D. Diabetes
E. Hyperlipidemia

A, C, E. Risk factors include age (men 45 years or greater, women 55 years or greater or had an early hysterectomy), family history of coronary event before age 55 years (men) or before age 65 years (women), smoking, hypertension, hyperlipidemia, diabetes, known coronary artery disease, and sedentary lifestyle.

 

35

Susie is a 61 year old female (5'3", 115 pounds) who presents to the emergency department with a NSTEMI.  Her past medical history is significant for diabetes, hypertension, multiple TIAs and a hip fracture.  She was given aspirin 325 mg in the field and was started on a nitroglycerin drip at 50 mcg/min.  Her oxygen saturation is 93% and she has received morphine sulfate 1 mg IV x 1 in the past 30 minutes.  She is transferred to the cardiac catheterization laboratory and angioplasty confirmed an 85% blockage of her left marginal artery.  The cardiac interventionalist wants to start P2Y12 inhibitor therapy prior to starting the PCI.  Which of the following regimens would be most appropriate for this patient?

A. Activase 90 mg IV x 1
B. Effient 5 mg PO x 1
C. Effient 60 mg PO x 1
D. Brilinta 180 mg PO x 1
E. Brilinta 90 mg PO x 1

D. This patient has a contraindication to the use of Effient and Activase does not work by P2Y12 inhibition.

Activase (alteplase): fibrinolytic

Effient (prasugrel):  P2Y12 inhibitor, but CI in history of TIA/stroke

36

Zontivity works by which of the following mechanisms?

A. P2Y12 inhibitor on platelets
B. Platelet activating factor-1 inhibitor on platelets
C. Glycoprotein IIb/IIIa inhibitor on platelets
D. Plasmin activated receptor-1 inhibitor on platelets
E. Protease activated receptor-1 inhibitor on platelets

E.

vorapaxar (Zontivity): PO, reversible antagonist of protease-activated receptor-1 (PAR-1) expressed on platelets, but its long half life makes it effectively irreversible, resulting in decreased platelet activation. indicated for patients with a history of MI or PAD. Boxed warning: use is contraindicated in patients with history of stroke, TIA, ICH, active bleeding. Warning: do not use in severe liver impairment. SE: bleeding, anemia, pregnancy (B). No antidote. It is a substrate of 3A4 and inhibitor of P-gp.

37

Which of the following medications work by blocking the binding of fibrinogen, von Willebrand factor, and other ligands at the glycoprotein IIb/IIIa receptor?

A. Eptifibatide
B. Fondaparinux
C. Bivalirudin
D. Ticagrelor
E. Vorapaxar

A. Eptifibatide is a glycoprotein IIb/IIIa receptor antagonist.

Glycoprotein IIb/IIIa Receptor Antagonists: blocks platelet glycoprotein IIb/IIIa receptor, which is the binding site for fibrinogen, von Willebrand factor, and other ligands to block platelet aggregation and prevent thrombosis. Eptifibatide and tirofiban have reversible blockade and abciximab has irreversible blockade. all agents are IV. CI: thrombocytopenia (platelets <100,000), history of bleeding diathesis, recent (within 6 weeks) GI or GU bleeding of clinical significance (abciximab), active internal bleeding, recent (within 4-6 weeks) major surgery or trauma (4 weeks for tirofiban/eptifibatide and 6 weeks for abciximab), increase prothrombin time, history of stroke within 2 years (abciximab), history of stroke within 30 days or any history of hemorrhagic stroke (eptifibatide/tirofiban), severe uncontrolled hypertension, hypersensitivity to murine proteins (abciximab), dependency on renal dialysis (eptifibatide). SE: bleeding, thrombocytopenia (esp. abciximab), hypotension. Do not shake vials upon reconstitution.

abciximab (ReoPro): irreversible blockade. requires filter for administration

eptifibatide (Integrilin): reversible blockade

tirofiban (Aggrastat) reversible blockade

38

Which of the following statements are true regarding the use of ACE inhibitors in patients with UA/NSTEMI? (Select ALLthat apply.)

A. They should be administered within the first 24 hours unless there is a contraindication
B. They reduce preload and afterload as well as prevent cardiac remodeling
C. An ARB can be substituted if the patient is intolerant to an ACE inhibitor
D. They should be avoided in patients with hypokalemia
E. They should not be used in combination with beta blockers

A, B, C. ACE inhibitors are recommended within the first 24 hours of an MI. ARBs are reasonable if a patient is intolerant to an ACE inhibitor.

GAP-BA

glycoprotein (GP) IIb/IIIa inhibitors: blocks fibrinogen, prevent platelet aggregation

anticoagulants: UFH/LMWH

p2Y12 inhibitor:

beta blocker: helps with remodeling

ACE-I: oral to decrease BP, help with remodeling

39

Gene uses the following medications daily: clopidogrel and aspirin for CAD, losartan for blood pressure, lovastatin for cholesterol, zolpidem for sleep, omeprazole for heartburn and bupropion to help him stop smoking. The pharmacist notes that the following drugs have an interaction that requires the prescriber to be notified:

A. Clopidogrel and omeprazole
B. Clopidogrel and lovastatin
C. Clopidogrel and bupropion
D. Zolpidem and omeprazole
E. Lovastatin and omeprazole

A. Clopidogrel is a prodrug that is converted by the CYP 2C19 enzyme to an active metabolite. The metabolism of clopidogrel to its active metabolite can be impaired by genetic variations in CYP 2C19 and by concomitant medications that interfere with CYP2C19. Avoid use with strong or moderate CYP 2C19 inhibitors, including omeprazole, esomeprazole, cimetidine, fluconazole, ketoconazole, voriconazole, etravirine and fluoxetine.

P2Y12 Inhibitors: binds to the adenosine diphosphate (ADP) P2Y12 receptor on platelet surface which prevents ADP-mediated activation of the GPIIb/IIIa receptor complex resulting in a reduction of platelet aggregation. prasugrel and ticagrelor is indicated for reduction of thrombotic events in patients with ACS.

clopidogrel (Plavix): irreversible binding, prodrug (2C19). Boxed warning: effectiveness depends on the activation to an active thiol metabolite mainly by 2C19. Poor metabolizes exhibit higher cardiovascular events than patients with normal 2C19 function. CI: active bleed (PUD, ICH). Warning: avoid 2C19 inhibitors (omeprazole, esomeprazole), thrombotic thrombocytopenic purpura (TTP) has been reported (fever, weakness, extreme skin paleness, purple skin patches, yellowing of the skin/eyes, neurological changes. SE: bleeding, bruising, rash, pruritus. Discontinue 5 days prior to major surgery

40

Maureen received an electrocardiogram (ECG) which showed ST segment elevation in the precordial leads (V2-V6). Her blood work was positive for troponin I and CK-MB. She was diagnosed with an ST segment elevation myocardial infarction (STEMI) and went to the cath lab to receive a primary percutaneous coronary intervention (PCI). The coronary angiogram found complete occlusion by thrombosis of the left anterior descending (LAD) coronary artery. Which of the following signs indicate the patient has had an ST segment elevation myocardial infarction (STEMI)? (Select ALL that apply.)

A. ST segment elevation on ECG
B. T-wave inversion on ECG
C. Positive cardiac enzymes
D. Negative CK-MB
E. Increased blood pressure

A, C. A STEMI diagnosis is made if there is chest pain, positive cardiac enzymes and ST segment elevation on ECG. The critical difference between STEMI and NSTEMI (including unstable angina) is that STEMI requires a faster response for reperfusion. Time is of the essence in order to break up the blockage and re-establish blood flow to that section of the heart.

Unstable Angina: chest pain (NSTE-ACS, non-ST segment elevation acute coronary syndrome)

NSTEMI: chest pain, increased troponins (NSTE-ACS, non-ST segment elevation acute coronary syndrome)

STEMI: chest pain, increase troponins, ECG changes (ST segment elevation)

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