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Clinical 2 (Sam) > 5 - ACS Part 2 > Flashcards

5 - ACS Part 2 Flashcards

1
Q

What is DAPT?

A

dual anti platelet therapy

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2
Q

2 options for treating a STEMI?

A

1) fibrinolytics

2) primary PCI

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3
Q

2 options for treating a UA/NSTEMI?

A

**assess risks
THEN either:

1) early invasive strategy (surgery)
2) ischemia guided strategy (medicine)

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4
Q

What is the initial treatment once ACS is suspected but we don’t know which type (UA, STEMI or NSTEMI)?

A

MONA

  • morphine
  • oxygen
  • nitrates
  • ASA 325 mg
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5
Q

Describe what points are given for to determine a patient’s TIMI Risk Score

A

1 point is given for each of the following:

  • > 65 yo
  • > 3 risk factors for CAD
  • prior coronary stenosis > 50%
  • ST deviation on ECG
  • > 2 anginal events in prior 24 hours
  • use of aspirin in prior 7 days
  • elevated cardiac biomarkers

**see slide 10

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6
Q

If they have a TIMI score >2, what should happen?

A

they should be considered for early invasive strategy (surgery)

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7
Q

If they have a TIMI score of 0 or 1, what should happen?

A

they would be considered for ischemia guided strategy (medicine)

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8
Q

What is entailed in early invasive strategy?

A
  • Angiography +/- revascularization (PCI) within 24 hours

- Indicated for high risk patients (TIMI risk score > 2, or presence or other high risk characteristics)

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9
Q

What is entailed in ischemia-guided strategy?

A
  • medical management
  • patients with low risk features
  • may be referred for revascularization if schema worsens or if new high risk features occur
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10
Q

Who is a CABG indicated for?

A

-high risk patients with multi vessel disease may be referred for CABG (hold DAPT 5-7 days prior to surgery if possible)

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11
Q

Antiplatelets:

Options?

A

ASA
Ticagrelor
Clopidogrel
Prasugrel

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12
Q

ASA:

Initial dose

A

160-325 mg STAT (chewed)

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13
Q

ASA:

Maintenance dose

A

80-325 mg daily

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14
Q

Ticagrelor:

Initial dose

A

180 mg LD

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15
Q

Ticagrelor:

Maintenance dose

A

90 mg BID

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16
Q

Clopidogrel:

Initial dose

A

150-300 mg LD

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17
Q

Clopidogrel:

Maintenance dose

A

75 mg daily

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18
Q

Prasugrel:

Initial dose

A

60 mg LD

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19
Q

Prasugrel:

Maintenance dose

A

10 mg daily

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20
Q

Who is DAPT indicated for?

A
  • UA/NSTEMI patients who underwent early invasive strategy with PCI should receive DAPT as outlined for STEMI patients
  • For patients with ischemia-guided strategy (medical management), current guidelines recommend DAPT with ASA plus ticagrelor or clopidogrel
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21
Q

How long is DAPT indicated for?

A

for 1 year in all ACS patients whether they are treated medically, with PCI or CABG

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22
Q

MOA of GP 2b/3a inhibitors

A

block binding of fibrinogen to GP 2b/3a receptor on platelet surface, therefore inhibit platelet aggregation

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23
Q

What are examples of GP 2b/3a inhibitors

A
  • abciximab
  • eptifibatide
  • tirofiban
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24
Q

What is the dose of enoxaparin?

A

1mg/kg SC Q12H (max 100 mg) until PCI or hospital discharge shown to decrease risk of death, MI and stroke

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25
Q

Advantage of enoxaparin?

A

easier to give, no monitoring, lower incidence of HIT ?, similar cost to UFH

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26
Q

Dose of UFH?

A

60 units/kg LD then 12 units/kg/hr infusion

  • titrate to APTT 1.2-2x control
  • until PCI or 48 hrs
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27
Q

What is the standard heparin?

A

LMWH = standard

*if it’s someone who is morbidly obese and we can’t dose properly or they are known to have chronic failure - switch to UFH

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28
Q

Describe fondaparinux

A

indirect-acting factor Xa inhibitor

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29
Q

Dose of Fondaparinux?

A

2.5mg SC once daily (until PCI or hospital discharge)

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30
Q

What advantage does fondaparinux have over enoxparin?

A

lower rate of major bleeding

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31
Q

Goals of adjunct therapy

A
  • reduce the risk of short term and long term complications associated with ACS
  • slow progression of coronary heart disease and minimize the risk of future cardiovascular events and other morbidities
  • improve mortality and restore QOL
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32
Q

List 4 ACS complications

A
  • heart failure
  • cardiogenic shock
  • arrhythmias
  • pericarditis
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33
Q

Describe how heart failure could occur after an ACS

A

LV myocardium may be ischemic, stunned, hibernating or irrevocably injured after MI

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34
Q

Describe how cardiogenic shock could occur after an ACS

A
  • Decreased cardiac output & evidence of tissue hypoxia in presence of adequate intravascular volume
  • Often due to extensive LV infarction
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35
Q

Describe how arrhythmias could occur after an ACS

A

-arrhythmias may occur post MI due to ischemia and severe HF

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36
Q

Describe pericarditis after an ACS

A
  • uncommon and usually presents within 72 hour post MI

- symptoms usually resolve within 3-4 days

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37
Q

What is the treatment for pericarditis?

A

ASA 650 mg po QID or NSAIDs

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38
Q

Why are BB used in ACS?

A
  • prevent extension of infarction by reducing oxygen demand

- decrease cardiovascular mortality, recurrent nonfatal MI and all-cause mortality

39
Q

When should BB be initiated after an MI?

A

within 24 hours after onset of MI unless contraindicated

40
Q

BB:

Start at low dose and titrate to maintain resting HR of ____ bpm

A

55-60

41
Q

What conditions would make someone contraindicated to get a BB?

A
  • hypotension
  • bradycardia
  • acute heart failure
  • cardiogenic shock
  • asthma
  • 2nd or 3rd degree AV block
42
Q

Metoprolol:

Initial dose

A

25mg BID

43
Q

Metoprolol:

Max dose

A

100mg BID

44
Q

Atenolol:

Initial dose

A

12.5-25 mg daily

45
Q

Atenolol:

Max dose

A

100 mg daily

46
Q

Carvedilol:

Initial dose

A

3.125 mg BID

47
Q

Carvedilol:

Max dose

A

25 mg BID

48
Q

Why are ACEi used in ACS?

A

-minimize ventricular remodelling, reduce oxygen demand and myocardial wall stress by reducing after load or preload

49
Q

When should someone start an ACEi after MI?

A

within 24 hour of MI once BP has been stabilized unless CI

50
Q

What types of patients should we use ACEi with caution?

A

those with renal impairment and hyperkalemia

51
Q

What do we monitor for BB?

A
  • BP
  • HR
  • signs/symptoms of HF
52
Q

What do we monitor for ACEi?

A
  • SCr
  • electrolytes
  • watch for hyperkalemia (K > 5.5)
53
Q

Ramipril:

Initial dose

A

1.25 - 2.5 mg daily

54
Q

Ramipril:

Target dose

A

10mg/day

55
Q

Enalapril:

Initial dose

A

2.5mg BID

56
Q

Enalapril:

Target dose

A

10-20 mg BID

57
Q

Lisinopril:

Initial dose

A

2.5-5 mg daily

58
Q

Lisinopril:

Target dose

A

40 mg daily

59
Q

Captopril:

Initial dose

A

6.25 TID

60
Q

Captopril:

Target dose

A

25-50 mg TID

61
Q

Who are ARBs indicated for?

A

People who cannot tolerate ACEi

62
Q

Monitoring of an ARB is the same as an ____

A

ACEi

63
Q

Candesartan:

Initial dose

A

4 mg daily

64
Q

Candesartan:

Target dose

A

32 mg daily

65
Q

Telmisartan:

Initial dose

A

40 mg daily

66
Q

Telmisartan:

Target dose

A

80 mg daily

67
Q

Valsartan:

Initial dose

A

20 mg BID

68
Q

Valsartan:

Target dose

A

160 mg BID

69
Q

Statins: If not at max dose already, titrate to achieve _____% reduction in LDL

A

50-60

70
Q

Monitoring for statins?

A
  • Lipid panel (LDL-C, chol, HDL-C)
  • LFTs
  • CK
  • signs and symptoms of myopathy and rhabdomyolysis
71
Q

Atorvastatin doses

A

20-80 mg daily

72
Q

Fluvastatin doses

A

20-80 mg daily

73
Q

Pravastatin doses

A

20-40 mg daily

74
Q

Lovastatin doses

A

20-80 mg daily

75
Q

Simvastatin doses

A

20-80 mg daily

76
Q

Rosuvastatin doses

A

5-40 mg daily

77
Q

What types of patients should get an MRA (mineralocorticoid receptor antagonist)?

A

for consideration in patients with significant LV dysfunction (EF < 40%)

78
Q

Should caution MRAs in what types of patients?

A

CrCl < 30

K > 5

79
Q

When should K+ be monitored when on an MRA

A

at baseline and then within 1 week of initiation

80
Q

Spironolactone:

Initial dose

A

12.5 mg daily

81
Q

Spironolactone:

Target dose

A

25 mg daily

82
Q

Eplerenone:

Initial dose

A

25 mg daily

83
Q

Eplerenone:

Target dose

A

50 mg daily

84
Q

What are some modifiable CHD risk factors?

A
  • smoking cessation
  • hypertension
  • dyslipidemia
  • obesity
  • sedentary lifestyle
  • stress
85
Q

List some non-pharm therapies

A
  • weight management
  • physical exercise
  • smoking cessation
  • ICD (implantable cardioverter defibrillator)
  • stress management/depression screening
86
Q

Goals for weight management?

A
  • BMI 18.5 - 25
  • Waist circumference (<100 cm males & < 90 cm in females)
  • Goal of 5-10% weight reduction
87
Q

Goals for exercise?

A

30-60 mins of moderate-vigorous physical exercise 3-5x per week

*This may change based on each individual’s starting exercise habits

88
Q

How much does smoking cessation lower risk of recurrent MI after 2 years?

A

by half !!!!

89
Q

Are omega 3 fatty acids beneficial for preventing cardiovascular disease?

A

No evidence, but don’t tell patients to stop taking them

90
Q

Are antioxidants such as vitamins A, C, E and beta carotene beneficial for preventing cardiovascular disease?

A

No

91
Q

How about folic acid with/without vitamin B6 of B12? Is it good for preventing cardiovascular disease?

A

NOPE

92
Q

Why is hormonal therapy not indicated in post menopausal women post MI?

A

may increase CV risk

93
Q

Post MI patients need to avoid _____

A

NSAIDs, including selective COX2 inhibitors

94
Q

Post MI:
For active, ongoing users of cocaine and meth, ____ ________ should be avoided due to risk of potentiating coronary spasm

A

beta blockers

Clinical 2 (Sam) (18 decks)

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