6. ACS Flashcards
1
Q
What are the key characteristics of stable angina? (5)
A
- reproducible pain
- improves with rest
- lasts < 10 minutes
- ECG normal
- no ↑ in cardiac enzymes
2
Q
What are the key characteristics of unstable angina? (5)
A
- occurs with increased frequency or less activity
- may not be relieved with rest or NTG
- lasts > 10 minutes
- associated with ECG changes without ST segment elevation
- no ↑ in cardiac enzymes
3
Q
What are the key characteristics of NSTEMI? (5)
A
- occurs with increased frequency or less activity
- may not be relieved with rest or NTG
- lasts > 10 minutes
- associated with ECG changes without ST segment elevation
- increase in cardiac enzymes
4
Q
What are the key characteristics of STEMI? (3)
A
- complete occasion resulting in constant pain
- associated with ECG changes: ST segment elevation
- increased cardiac enzymes
5
Q
What are the initial therapies in ACS?
A
- ECG monitoring
- IV access
- ONAM
6
Q
What does the ONAM acronym stand for?
A
- oxygen
- nitroglycerin
- antiplatelets
- morphine
7
Q
What is the therapeutic goal of nitroglycerine administration?
A
relieve myocardial ischemia via coronary vasodilation
8
Q
There is no reduction in mortality in ACS with the use of nitroglycerine. (T/F)
A
True
9
Q
How many times can you repeat SL NTG?
A
3x q 5 minutes
10
Q
What should be monitored after administration of NTG?
A
- HR
- BP
- ECG
- chest pain/ symptoms
11
Q
Mean arterial pressure should be ______ to maintain coronary perfusion.
A
> 65 mmHg
12
Q
What are the ADRs of NTG?
A
headache
13
Q
IV NTG is highly recommended in MI patients with what comorbidities?
A
- HF
- persistent ischemia
- HTN
14
Q
What is the therapeutic goal of antiplatelet therapy?
A
- limit infarct size
- reduce recurrent ischemia/infarction
- improve survival
15
Q
What are the antiplatelet agents for acute therapy?
A
- Aspirin
- Clopidogrel
- Prasugrel
- Ticagrelor
- Cangrelor
16
Q
What is the dosage of Aspirin in acute therapy?
A
162 - 325 mg chewed and swallowed
17
Q
Why might clopidogrel be used instead of aspirin?
A
Aspirin allergy
18
Q
What is the dose of clopidogrel in acute therapy?
A
300 - 600 mg PO once
19
Q
Why might dual antiplatelet therapy be deferred?
A
Patient has unknown coronary anatomy
20
Q
What is the dose of prasugrel in acute therapy?
A
60 mg PO once
21
Q
Prasugrel has a higher, more consistent level of platelet inhibition over clopidogrel. (T/F)
A
True
22
Q
What medication is reserved for those going to cath lab for PCI.
A
Prasugrel
23
Q
What is the dose of ticagrelor in acute therapy?
A
180 mg PO once
24
Q
What is the route of administration of cangrelor?
A
IV
25
What medication is reserved for patients who aren't on oral DAPT at the time of PCI?
cangrelor
26
What medication should be administered to UA/NSTEMI patients as soon as possible after hospital presentation?
Aspirin
27
What medication should be continued indefinitely after administration in the hospital after UA/NSTEMI?
Aspirin
28
What is the continued daily dose of clopidogrel for those who are unable to take aspirin?
75 mg
29
Why might a patient be unable to take daily aspirin?
- hypersensitivity (asthma)
| - gastrointestinal intolerance
30
What is the therapeutic goal of analgesia in ACS?
pain control and relief of anxiety
31
What is the pain associated with MI caused by?
ischemia
32
What is the analgesic agent of choice in ACS?
IV morphine sulfate
33
Why is morphine sulphate the analgesic agent of choice in ACS?
- blocks SNS discharge from CNS
- peripheral artery dilation
- reduces myocardial demand
34
What is the initial dose of IV morphine in ACS?
2 - 5 mg every 15 minutes
35
What is the maintenance dose of IV morphine in ACS?
4 - 8 mg every 4-6 hrs
36
What should be monitored during IV administration of morphine in ACS?
- pain relief
- hypotension
- respiratory depression
- allergic reactions
37
What are the controversial aspects of administration of morphine to ACS patient?
- does not improve survival
- chest pain is a marker of disease progression
- drug seeking behaviors
38
Why might a clinician want to withhold analgesia so that a patient experiences chest pain?
recurrent pain is a marker of ischemia and can be used to prioritize escalation of care
39
What is the conventional DAPT strategy?
ASA + P2Y12 Inhibitor
40
Which antiplatelet medication might interact with aspirin?
ticagrelor
41
In what patients should prasugrel not be used?
- age > 75 years
- weight < 60 kg
- "little old ladies"
42
What OTC medication should not be used with clopidogrel?
omeprazole
43
Separating administration of omeprazole and clopidogrel will prevent drug interaction. (T/F)
False: cannot be taken within the same day
44
Avoid using other potent CPY_____ _______ with clopidogrel.
- 2C19
| - inhibitors
45
In what patients is prasugrel contraindicated?
history of stroke or TIA
46
When is it acceptable to administer prasugrel to a patient > 75 years old?
- STEMI
| - diabetes mellitus
47
At what maintenance dose of aspirin does an interaction with ticagrelor occur?
> 100 mg
48
What is the dose of heparin for ACS?
LD: 60 u/kg (max 4000 u)
MD: 12 u/kg/h (max 1000 u/h)
49
What is the dose of enoxaparin for ACS?
1 mg/kg every 12 hours
50
What is the dose of dalteparin for ACS?
120 u/kg every 12 hours (max 10,000 u/h)
51
What is the most commonly used LMWH agent for ACS?
enoxaparin
52
What is the dose of fondaparinux for ACS?
2.5 mg daily
53
Fondaparinux is used with both medical management and PCI. (T/F)
False: only medical management
54
What is the dose of bivalirudin for ACS before going to cath lab?
"up-front" bolus: 0.1 mg/kg
| drip: 0.25 mg/kg/h
55
What is the dose of bivalirudin for ACS when in the cath lab?
- bolus in cath lab: 0.5 mg/kg
| - drip: 1.75 mg/kg/h
56
What must be monitored with the administration of unfractionated heparin?
aPTT
57
What is the antidote for heparin?
protamine
58
What is the method of elimination of LMWH?
renal
59
What is the method of elimination of fondaparinux?
renal
60
Before undergoing PCI, GP IIb/IIIa inhibitors cannot be used in conjunction with PGY12 inhibitors. (T/F)
True: only use GP IIb/IIIa inhibitors if PGY12 inhibitors are not used
61
The goal is __% platelet inhibition during PCI.
90
62
What is the main adverse effect of GP IIb/IIIa inhibitors?
bleeding
63
Abciximab can only be used up-front for PCI. (T/F)
True
64
Thrombolytics promote thrombolysis by hydrolyzing the _______-_______ peptide bond in plasminogen to form ___________.
- arginine560 - valine561
| - active plasmin
65
Which thrombolytic agent might cause an allergic reaction?
streptokinase
66
Which thrombolytic agent is not fibrin selective?
streptokinase
67
Which thrombolytic shows the best reperfusion?
reteplase (rPA)
68
What are the contraindications thrombolytics? (6)
- active internal bleeding
- history of CVA
- recent surgery or trauma
- intracranial neoplasm or aneurysm
- known bleeding disorder
- severe uncontrolled HTN (SBP > 180)
69
Why should anticoagulants and anti platelets be used with thrombolytics?
prevents re-occlusion (recurrent MI)
70
In a STEMI, is thrombolysis or PCI preferred?
PCI
71
What are the 2 strategies of PCI?
- bare metal stent
| - drug-eluting stent
72
For secondary prevention of ACS, at least how many medications should a patient be on?
4
73
What are the indication for aspirin in secondary prevention of ACS?
- all patients pose-MI or UA
| - anyone with CAD
74
What are the indication for statins in secondary prevention of ACS?
all patients post-ACS
75
What are the indication for β blockers in secondary prevention of ACS?
all patients post-ACS with no contraindications
76
What are the indication for ACE-I/ARBs in secondary prevention of ACS?
- Low EF
- HTN
- DM
- renal dysfunction
77
What are the indication for aldosterone antagonists in secondary prevention of ACS?
- Low EF and HF symptoms
| - DM
78
What is the minimum duration of DAPT with a bare metal stent?
4 weeks
79
What is the minimum duration of DAPT with a drug-eluting stent?
1 year
80
What are the drugs being eluted in a drug-eluting stent?
anti-proliferative (tacrolimus, cyclosporin, everolimus)
81
There is a benefit of continuing DAPT if DAPT score is what?
≥ 2
82
DAPT should be stopped if DAPT score is what?
< 2
83
Older age contributes to a _____ DAPT score.
lower
84
What is the purpose of HMG CoA reductase inhibitors post-ACS?
- slows progression of CAD with hyperlipidemia
| - plaque stabilization
85
If cangrelor is administered, when can the patient be switched to ticagrelor?
can transition to ticagrelor at any time
86
What medication should be started immediately after cangrelor is stopped?
clopidogrel or prasugrel
87
What is the MOA of Vorapaxar?
PAR-1 antagonist
88
What is the black box warning/ contraindications for Vorapaxar?
- history of stroke, TIA, or ICH
| - active bleeding
89
What is the dose of Vorapaxar?
2.08 mg PO daily
90
What medications are harmful post-ACS?
- hormone therapy with estrogen
| - NSAIDs
