ACS (from Rx 2019) Flashcards
(40 cards)
RM is a 56 year old male being discharged from the hospital after a myocardial infarction. One of his discharge medications isLopressor.According to guidelines, how long will RM need to takeLopressor?
A 6 months B 1 year C 2 years D 3 years E Indefinitely
D-3 years
Per the ACC/AHA guidelines, beta blocker therapy should be given for 3 years after an MI. If there are other evidence-based reasons to continue the beta blocker (heart failure, atrial fibrillation, etc.), then it may be continued beyond 3 years.
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-Celecoxib
NSAIDs (except aspirin), regardless of COX selectivity, should be avoided in patients with ACS. If safer agents (acetaminophen, tramadol, small doses of opioids) are not effective, naproxen is generally considered to have the lowest cardiovascular risk (but there is still risk).
Which of the following medications is an intravenous P2Y12 inhibitor?
A Cangrelor(Kengreal) B Clopidogrel(Plavix) C Prasugrel(Effient) D Tenecteplase(TNKase) E Vorapaxar(Zontivity)
A-Cangrelor(Kengreal)
Kengrealis the only intravenous P2Y12 inhibitor. Prasugrel, clopidogrel, and ticagrelor are all PO
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 medications that may be used to treat a patient with an acute coronary syndrome characterized as NSTEMI? (SelectALLthat apply.)
A Morphine B Olanzapine C Meperidine D Aspirin E Nitroprusside
A Morphine
D Aspirin
Look for drugs in the acronym MONA, which represent standard care for a myocardial infarction: Morphine, Oxygen, Nitrates (nitroglycerin in various formulations) and Aspirin (MONA). Additonal medications will be added to MONA depending on the clinical situation.
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-Reduces preload, provides analgesia and reduces myocardial oxygen demand
Morphine reduces preload (venous dilation), provides analgesia and reduces myocardial oxygen demand. Be careful as morphine can lower blood pressure, leading to hypotension
Which of the following side effects is common withBrilinta?
A-Tachyarrhythmias B-Decreased serum creatitine C-Hepatic impairment D-Dyspnea E-Puffy eyes
D-Dyspnea
Dyspnea is a common side effect withBrilinta,occuring in more than 10% of patients
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? (SelectALLthat apply.)
A-Increases blood pressure B-Reduces preload C-Dilates coronary vessels and increases blood flow D-Relieves chest pain E-Helps with fibrinolysis
B-Reduces preload
C-Dilates coronary vessels and increases blood flow
D-Relieves chest pain
Nitroglycerin dilates coronary vessels and increases blood flow, reduces preload and provides relief of chest pain.
The provider ordersReoPro. What is the appropriate genericsubstitution?
A-Abciximab B-Tirofiban C-Alteplase D-Bivalirudin E-Eptifibatide
A-Abciximab
Abciximabis the generic name ofReoPro
SR 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 Activase90 mg IV x 1 B Effient5 mg PO x 1 C Effient60 mg PO x 1 D Brilinta180 mg PO x 1 E Brilinta90 mg PO x 1
D-Brilinta180 mg PO x 1
This patient has a contraindication to the use ofEffient(history of TIA/stroke)andActivasedoes not work by P2Y12 inhibition. The correct loading dose ofBrilintais 180 mg x 1.
YC is a 77 year old male (6’3”, 315 pounds) who presents to the emergency department with a STEMI. 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 plans to startReoProfor this patient. Which of the following statements are correct regardingReoPro?
A-ReoProis a fibrinolytic.
B-Ticagrelor and prasugrel share the same mechanism of action asReoPro.
C-ReoPromust be filtered during administration.
D-ReoPromust be shaken upon reconstitution.
E-IVReoProshould be switched to the oral formulation as soon as possible due to cost.
C-ReoPromust be filtered during administration.
Abciximab(ReoPro)is a GIIb/IIIa inhibitor. It is a protein and should not be shaken during reconstitution. The medication requires filtering during administration and platelets must be monitored. GIIb/IIIa inhibitors are notavailable orally.
A woman calls the pharmacy in a panic. She thinks her husband may be having a heart attack. The pharmacist determines that the husband has a prescription forNitrostatat home. What instructions should the pharmacist provide?
A-Drive the patient to the emergency room immediately.
B-Prime the pump with 1-2 sprays if it hasn’t been used recently. Spray once onto the tongue every 5 minutes x 3 doses.Call 911 if the pain persists after the third dose of nitroglycerin.
C-Chew 1 tablet now, then place 1 tablet under the tongue every 5 minutes x 3 doses. Call 911 if the pain persists after the first dose of nitroglycerin.
D-Place one tablet under the tongue and let it dissolve. Use one tablet every 5 minutes x 3 doses.Call 911 if the pain persists after the third dose of nitroglycerin.
E-Place one tablet under the tongue and let it dissolve. Use one tablet every 5 minutes x 3 doses. Call 911 if the pain persists after the first dose of nitroglycerin.
E-Place one tablet under the tongue and let it dissolve. Use one tablet every 5 minutes x 3 doses. Call 911 if the pain persists after the first dose of nitroglycerin.
An ACS is a medical emergency. Use 1 dose of short-acting nitroglycerin (SL, spray or powder) immediately. Call 911 if the pain persists or is worse after the first dose. Use one dose Q5 min, but do not exceed 3 doses in 15 minutes. If aspirin is readily available, CHEW 162-325 mg of a non-enteric coated formulation immediately. Review the Ischemic Heart Disease chapter for additonal details about nitroglycerin formulations.
All of the following are antiplatelet agents that can be used in the treatment of an acute coronary syndrome EXCEPT:
A-Clopidogrel B-Dalteparin C-Eptifibatide D-Ticagrelor E-Aspirin
B-Dalteparin
Aspirin, P2Y12 inhibitors and glycoprotein IIb/IIIa receptor inhibitors can be globally called “antiplatelet agents” based on their mechanisms of action. Dalteparin is an anticoagulant.
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 < 1.1
A-Do not use if patient has a major risk for bleeding
The glycoprotein IIb/IIIa receptor antagonists are not safe to use in patients with major risk for bleeding, thrombocytopenia (low platelets), uncontrolled hypertension and within a short period of any major surgery as they can increase bleeding risk. GIIb/IIIa inhibitors are known to cause thrombocytopenia as a side effect, so it is important not to use them in patients who are severly thrombocytopenic at baseline. Many of the contraindications for GIIb/IIIa inhibitors are similar to those of fibrinolytics and relate to bleeding risk.
What causes an acute coronary syndrome?
A-Reduced blood flow to the brain caused by plaque buildup in the carotid arteries
B-Clot formation in the deep veins of the pelvis or legs
C-Abnormal electrical impulse conduction through the heart causing reduced myocardial oxygen supply
D-Reduced blood flow to the heart caused by plaque buildup in the coronary arteries
E-Rupture of the interventricular septum between the right and left ventricle
D-Reduced blood flow to the heart caused by plaque buildup in the coronary arteries
ACS symptoms result from a mismatch between myocardial oxygen supply and demand. Coronary atherosclerosis is the cause. ACS is a broad term that includes NSTE-ACS and STEMI. NSTE-ACS includes both NSTEMI and unstable angina (UA). It is good to compare and contrast the cause of ACS, stroke, VTE, arrhythmia and heart failure so the drug therapy will make sense.
GR received an electrocardiogram (ECG) which showed ST segment elevation in the precordial leads (V2-V6). In the emergency room her troponin I and CK-MB were positive. Her glucose, amylase and blood pressure were elevated, but other labs and vital signs were normal. She went to the cath lab for primary percutaneous coronary intervention (PCI). The coronary angiogram found 100% blockage of the left anterior descending (LAD) coronary artery. Which of the following indicate that GR has had an ST segment elevation myocardial infarction (STEMI)? (SelectALLthat apply.)
A-ST segment elevation on ECG B-T-wave inversion on ECG C-Positive cardiac enzymes D-Increased amylase E-Increased blood pressure
A-ST segment elevation on ECG
C-Positive cardiac enzymes
A STEMI diagnosis is made in patients with chest pain, positive cardiac enzymes and ST segment elevation on ECG. The T-wave is part of the ST segment, so a patient cannot have ST segment elevation and T-wave inversion. T-wave inversion is more typical of NSTEMI. 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.
RM 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 hisZestriltherapy which was started yesterday in addition to his hydrochlorothiazide for hypertension. How long is it recommended that RM take hisZestriltherapy?
A-6 months B-1 year C-2 years D-3 years E-Indefinitely
E-Indefinitely
An ACE inhibitor should be continued indefinitely for patients with HTN after an MI.
A patient, while gardening, experiences serious chest pain, diaphoresis, shortness of breath and left arm pain. Emergency medical personnel is contacted and arrive at the scene. What test should the emergency medical personnel perform?
A-Treadmill stress testing B-Echocardiogram C-Heart computed tomography D-12-lead ECG E-Right heart catheterization
D-12-lead ECG
Emergency medical personnel should perform a 12-lead ECG (electrocardiogram) in the field in patients experiencing symptoms of ACS.
FD 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-A prior intracranial hemorrhage B-Blood pressure of 165/98 C-Hypersensitivity to soy products D-Ischemic stroke 4 years ago E-Concurrent use of aspirin
A-A prior intracranial hemorrhage
Absolute contraindications to using a fibrinolytic for STEMI include any prior intracranial hemorrhage, active bleeding, recent stroke (usually defined as within 3 months), intracranial/intraspinal surgery or trauma in last 2-3 months and others. Severe uncontrolled hypertension (usually defined as > 175/110) is considered an absolute contraindication unless it can be controlled emergently before administring the fibrinolytic. Because of the risk of serious bleeding with fibrinolytics, careful risk/benefit assessment must be conducted. Fibrinolytics are also used for acute ischemic stroke. Contraindications differ for that indication.
Which of the following statements are true regarding clopidogrel? (SelectALLthat apply.)
A-It increases bleeding risk
B-It is metabolized to its active form by CYP 2C19
C-It should be discontinued 12 hours prior to major surgery
D-It binds irreversibly to the platelet
E-The typical maintenance dose is 300 mg daily
A-It increases bleeding risk
B-It is metabolized to its active form by CYP 2C19
D-It binds irreversibly to the platelet
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 PO daily for maintenance. It should be discontinued 5 days prior to major surgery.
MC a 58 year-old female, has just been told she had a silent heart attack. She cannot understand how this occurred. She does not smoke but lives with her husband who smokes two packs per day. Her PCP prescribedZocorabout 1 year ago, but she never filled the prescription. She sometimes checks her blood pressure at the community pharmacy and “the top number is usually 150-160 and the bottom number is usually 90-100”. She never worried about her health because she felt fine. Her mother passed away at age 61 due to colon cancer and her father passed away at age 82 with COPD. Which of the following risk factors for coronary heart disease are present in this patient? (SelectALLthat apply.)
A-Hypertension B-Family History C-Age D-Diabetes E-Dyslipidemia
A-Hypertension
E-Dyslipidemia
Risk factors include age (men > 45 years of age, women > 55 years of age or had an early hysterectomy), family history of coronary events before age 55 years (men) or before age 65 years (women), smoking, hypertension, dyslipidemia, diabetes, known coronary artery disease, chronic angina, excessive alcohol use and sedentary lifestyle.
A pharmacist covering the emergency department receives an order for “tPA 15 mg IV bolus, 50 mg over 30 min, then 35 mg over 1 hour. Total dose = 100 mg”. What drug is being ordered?
A-Abciximab B-Alteplase C-Epitifibatide D-Tenecteplase E-Tirofiban
B-Alteplase
Alteplase(Activase)is recombinant tissue plasminogen activator (rtPA or simple “tPA”). Correct dosing is critical due to bleeding risk. The accelerated infusion dosing for STEMI differs from the recommended dose for acute ischemic stroke (see Stroke chapter).
Which of the following are likely signs/symptoms of a heart attack? (SelectALLthat apply.)
A-Chest pain or pressure that lasts more than a few minutes B-Shortness of breath C-Incontinence D-Sweating E-Seizure
A-Chest pain or pressure that lasts more than a few minutes
B-Shortness of breath
D-Sweating
Many myocardial infarctions involve chest discomfort that lasts 10 minutes or more, or that goes away and comes back. The pain can radiate (or extend) to one or both arms, the back, neck, jaw or stomach and may be described as “squeezing” or “pressure”. Shortness of breath (dyspnea) and sweating (diaphoresis) may also occur.
What is the brand name of ticagrelor?
A-Activase B-Brilinta C-Effient D-Integrilin E-TNKase
B-Brilinta
JD is a 54 year old, otherwise healthy female (ht. 5’5’, wt. 168 pounds, SCr 2.2 mg/dL) being discharged from the hospital after a STEMI. Her ejection fraction was 56% before discharge from the hospital. She is being discharged onLopressor25 mg PO BID,Altace5 mg PO daily, aspirin 81 mg PO daily,Crestor20 mg PO daily andPlavix75 mg PO daily. Which of the following recommendations should be made regarding her medicationtherapy?
A-Increase the dose ofPlavix B-Add onAldactone C-Decrease the dose ofLopressor D-Add onNitrostatPRN E-Decrease the dose ofCrestor
D-Add onNitrostatPRN
All patients who have had an MI require a prescription for PRN nitroglycerin (SL tabs or spray). With an EF of 65%,Aldactoneis not warranted (but it is contraindicated at this level of SCr anyway). The medications are all dosed appropriately, given the information provided.
