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Pharmacotherapy III > Acute Coronary Syndrome > Flashcards

Acute Coronary Syndrome Flashcards

1
Q

What is the difference between UA and AMI?

A

AMI has necrosis of cardiac muscle

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2
Q

In UA, is vessel completely occluded?

A

Nope

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3
Q

What causes a Type I MI?

A

ASCAD plaque rupture, clot formation, coronary thrombosis; SUPPLY problem

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4
Q

What causes a Type 2 MI?

A

Increased O2 demand or decrease O2 supply (coronary artery spasm, embolism, anemia, arrhythmias, hypertension, hypotension)

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5
Q

How long does it take for full necrosis to occur?

A

6 hours

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6
Q

What is ventricular remodeling?

A

Scarring in heart after MI–doesn’t function as well

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7
Q

What agent can reduce scarring post-MI?

A

ACE Inhibitor!

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8
Q

What are the symptoms of ACS?

A

Chest pain at rest for more than 20 minutes
Feels like angina
Also: N/V, diaphoresis, SOB, impending doom

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9
Q

How long do you have to do ECG after MI/

A

Within 10 minutes of presentation

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10
Q

In STEMI, ST is ____ and ___ wave appears

A

ST is elevated; Q wave appears

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11
Q

What are the cardiac enzymes that indicate MI?

A

Troponin T and Troponin I–elevation corresponds with size of MI

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12
Q

When should Cardiac Troponin be measured?

A

In ED and 3-6 hours after symptoms (and maybe later)

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13
Q

What are the TIMI Risk factors?

A 
Age > 65
3 or more risk factors
Known CAD
>2 episodes of chest discomfort within 24 hours
>0.5 mm ST-segment depression
\+ biochemical marker
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14
Q

What does the TIMI score mean?

A

0-2: Low
3-4: Medium
5-7: High

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15
Q

What is the difference between Unstable angina, NSTEMI, and STEMI?

A

UA: maybe relieved by NTG; No ECG unusualy; negative cardiac markers
NSTEMI: Not usually relieved by NTG; no STE, rarely Q waves; POSITIVE cardiac markers
STEMI: Not usually relieved by NTG; STE; Q waves present; POSITIVE cardiac markers

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16
Q

How are all ACS’s treated initially?

A 
MONA!
Morphine
Oxygen
Nitrates
Aspirin
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17
Q

Dosing for Morphine in ACS?

A

2-4 mg IV q5-30 minutes

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18
Q

When do you give oxygen?

A

if O2 sat <90%

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19
Q

When do you NOT use nitrates?

  • SBP:
  • ___ change from baseline
  • HR between __ and __
  • Use of ___ within 24-48 hours
A
  • SBP <90
  • 30 mmHg change from baseline
  • HR between 50-100 bpm
  • Use of PDEIs within 24-48 hours
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20
Q

How often to monitor BP and HR when using nitrates?

A

q2h

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21
Q

Dose of IV nitrates during ACS?

A

5-10 mcg/min titrated to 75-100 mcg/min (for symptom relief or limiting side effects)

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22
Q

Which class of meds should NOT be used for pain management during MI?

A

NSAIDs!!! (APAP, morphine sulfate, NTGs a-okay!)

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23
Q

What drug classes are used to treat STEMI w/PCI (after MONA therapy)?

A
  • Antiplatelets (P2Y12 inhibitors or GPIIb/IIIa)

- Anticoagulants

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24
Q

Which antiplatelets are used for STEMI w/PCI?

A

Clopidogrel, Prasugrel, or ticagrelor

Prasugrel or ticagrelor preferred

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25
Q

When is prasugrel contraindicated??

A

History of TIA/stroke

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26
Q

When are all P2Y12 inhibitors contraindicated?

A

History of hemorrhagic stroke
Concurrent use of anticoagulants
Moderate-severe liver disease

27
Q

When is prasugrel used w/extreme caution?

A

Pts under 60 kg

Pts older than 75 years

28
Q

How long are P2Y12 inhibitors used after STEMI w/PCI?

A

12 months

29
Q

How long before elective CABG should prasugrel b d/ced?

A

7 days

30
Q

How long before elective CABG should clopidogrel and ticagrelor be d/ced?

A

5 days

31
Q

What are the GPIIb/IIIa inhibitors?

A

Eptifibitide
Abciximab
Tirofiban

32
Q

What are Contraindications to GPIIb/IIIa Inhibitors?

A

-Internal bleeding, major surgery, stroke w/in 30 days
-Hx of hemorrhagic stroke
-Intracranial neoplasm, AV malformation
Acute pericarditis
Uncontrolled HTN
THROMBOCYTOPENIA

33
Q

Which of the anticoags is administered as a bolus only?

A

Enoxaparin

34
Q

What anticoags are used for STEMi w/PCI?

A

Bivalirudin
Enoxaparin
Heparin

35
Q

When are fibrinolytics used for medical reperfusion?

A

When patients can’t be transferred and treated within 120 minutes (PCI)

36
Q

How does fibrinolytic therapy work (MoA)?

A

It activates plasminogen to plasmin, which dissolves fibrin clots

37
Q

What is the dosing for reteplase?

A

10 units IV then 10 units IV 30 minutes later

38
Q

What is the dosing for alteplase?

A

15 mg bolus, then 0.75 mg/kg over 30 minutes, then 0.5 mg/kg over 1 hour

39
Q

What is the dosing for tenecteplase?

A 
<60 kg: 30 mg IV
60-69.9 kg: 35 mg IV
70-79.9 kg: 40 mg IV
80-89.9 kg: 45 mg IV
>90 kg: 50 mg IV
40
Q

What are the contraindications to fibrinolytics?

A
  • Malignant IC neoplasm
  • Active bleeding
  • Severe uncontrolled HTN
  • TIA w/in 3 months
  • Facial trauma or head trauma w/in 3 months
  • Aortic dissection
  • Cerebral vascular lesion
  • Hemorrhagic stroke
  • SK: not used within 6 months, or previous allergy
41
Q

What are MPs for fibrinolytics?

A
  • Evidence for reperfusion (symptoms relief, ECG normalizing, Reperfusion arrhythmia possible)
  • Signs of bleeding
  • Baseline CBC, platelet count, INR/aPTT
  • Mental status changes q2h
42
Q

What antiplatelets are used for STEMI w/out PCI?

A

ASA & clopidogrel (300 mg LD on day 1)

43
Q

How long to administer DAPT after STEMI w/out PCI?

A

14 days to 1 year

44
Q

What anticoags are used for STEMI w/out PCI?

A

Heparin
LMWH (enoxaparin)
fondaparinux

45
Q

How long should anticoag therapy last for STEMi w/out PCI?

A

2-8 days

46
Q

What is the maximum dose for heparin?

A

Bolus: 4000 units
Infusion: 1000 units/hr

47
Q

What is the rate of infusion for heparin dose?

A

12 units/kg /hr

48
Q

What is the bolus dose of heparin?

A

60 units/kg

49
Q

How is enoxaparin dosed?

A

30 mg IV bolus

1 mg/kg SC q12h

50
Q

How long should Beta-blockers be used?

A

3 years

51
Q

How long should beta-blockers be used if LEF <40%?

A

still 3 years?

52
Q

How does Beta blocker help after MI/

A

Limits myocardial damage and mortality; reduces risk of reinfarction, makes it harder to develop V fib

53
Q

When should IV Beta-blocker not be used?

A

Unstable blood pressure (low)

54
Q

When should IV beta-blocker be used?

A

High blood pressure

55
Q

Which patients benefit the most from ACEI therapy post-MI/

A

Pts with DM, CKD, LVEF <40

56
Q

Should ACEI be given IV or oral?

A

ORAL - not IV within 24 hours

57
Q

How long is ACEI used if LVEF <40%?

A

forever

58
Q

What patients may benefit from aldosterone antagonists?

A

LVEF <40% w/HF symptoms or diabetes

59
Q

When is aldosterone antagonist contraindicated?

A

Cr >2.5 in men or >2 in women

K >5 mEq/L

60
Q

Which antiplatelets are used for UA/NSTEMI?

A

Clopidogrel or ticagrelor

61
Q

Which anticoags are used for UA/NSTEMI with PCI?

A

Heparin
Bivalirudin
LMWH
Fondaparinux

62
Q

Which anticoags are used for UA/NSTEMI w/out pCI?

A

Heparin
LMWH
fondaparinux

63
Q

When should fondaparinux be avoided?

A

CrCl <30mL/min

Pharmacotherapy III (12 decks)

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