ACS: NSTEMI

Question 1

Type of MI
Atherosclerotic plaque rupture, ulceration, fissure, ore erosion with resulting intraluminal thrombus in >/=1 coronary arteries leading to decreased mocardial blood flow &/or distal embolization & subsequent myocardial necrosis

Answer 1

Type I

Question 2

Type of MI
myocardial necrosis when condition other than coronary plaque instability causes imbalance b/t myocardial oxygen supply & demand (hypotension, HTN, tachy/bradyarrhythmias, anemia, hypoxemia, coronary artery spasm, spontaneous coronary artery dissection (SCAD), coronary embolism, & myocardial dyfxn)

Answer 2

Type 2

Question 3

Type of MI
death when biomarkers not available & types 4 & 5 MI (r/t PCI & CABG)

Answer 3

Type 3

Question 4

Differential Dx of ACS in setting of acute CP
Cardiac

Answer 4

Myopericarditis
Cardiomyopathies
Tachyarrhythmias
Acute HF
HTN emergency
Aortic valve stenosis
Takotsubo syndrome
coronary spasm
cardiac trauma

Question 5

Differential Dx of ACS in setting of acute CP
Pulmonary

Answer 5

PE
Tension PTx
Bronchitis, Pneumonia
Pleuritis

Question 6

Differential Dx of ACS in setting of acute CP
Vascular

Answer 6

Aortic dissection
Symptomatic aortic aneurysm
Stroke

Question 7

Probability of Ischemia
Central
Pressure
Squeezing
Gripping
Heaviness
Tightness
Exertional/stress-related
Retrosternal

Answer 7

High

Question 8

Probability of Ischemia
Left sided
Dull
Aching

Answer 8

Moderately High

Question 9

Probability of Ischemia
Stabbing

Answer 9

Moderate

Question 10

Probability of ischemia
Right-sided
Tearing
Ripping
Burning

Answer 10

Mild

Question 11

Probability of Ischemia
Sharp
Fleeting
Shifting
Pleuritic
Positional

Answer 11

Low

Question 12

Summary of Recommendations for Early Hospital Care
Administer Supplemental O2 only with what?

Answer 12

SpO2 < 90%
Respiratory distress
Other high-risk features for hypoxemia

Question 13

Summary of Recommendations for Early Hospital Care
Administer sublingal NTG how often and how many doses for continuing ischemic pain and then assess the need for what?

Answer 13

5min x 3
IV NTG

Question 14

Summary of Recommendations for Early Hospital Care
Administer IV NTG for?

Answer 14

persistent ischemia
HG
or HTN

Question 15

Summary of Recommendations for Early Hospital Care
Nitrates are contraindicated with recent use of what?

Answer 15

A phosphodiesterase inhibitor

Question 16

Summary of Recommendations for Early Hospital Care
IV morphine sulfate may be reasonable for what?

Answer 16

continued ischemic CP despite maximally tolerated anti-ischemic medications

Question 17

Summary of Recommendations for Early Hospital Care
Initiate oral beta blockers w/n 24 hours in the absence of?

Answer 17

HF
low-output state
risk for cardiogenic shock
other contraindications to BB use

Question 18

Summary of Recommendations for Early Hospital Care
Use of what is recommended for beta-blocker therapy w/ concomitant NSTE-ACS, Stabilized HF, and reduced systolic fxn?

Answer 18

sustained-release metoprolol succinate
carvedilol
bisoprolol

Question 19

Summary of Recommendations for Early Hospital Care
Administer initial therapy with non-DHP CCBs w/ recurrent ischemia and contraindications to BB in the absence of what?

Answer 19

LV dysfxn
increased risk for cardiogenic shock
PR interval > 0.24s,
second or third degree AV block w/o a cardiac pacemaker

Question 20

Summary of Recommendations for Early Hospital Care
Administer oral non-DHP CCB w/ recurrent ischemia after use of what in the absence of contraindications?

Answer 20

BB
Nitrates

Question 21

Summary of Recommendations for Early Hospital Care
Long-acting CCB and nitrates are recommended for patients w/ what?

Answer 21

coronary artery spasm

Question 22

Summary of Recommendations for Early Hospital Care
Initiate or continue high-intensity statin therapy in patients w/ what?

Answer 22

no contraindications

Question 23

Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
Aspirin
Non-enteric-coated aspirin to all patients promptly after presentation?
Aspirin maintenance dose continued indefinitely?

Answer 23

162-325mg

81-325mg

Question 24

Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS
P2Y12 inhibitors: Clopidogrel
Loading dose followed by daily maintenance dose in patients unable to take aspirin?

Answer 24

75mg (loading dose 300-600mg)

Question 25

Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS P2Y12 inhibitor, in addition to ASA, for up to 12 mo for patients treated initially w/ either an early invasive or initial ischemia guided strategy?

Answer 25

Clopidogrel - loading dose of 300-600 mg, then 75mg daily Ticagrelor - 180 mg loading dose, then 90 mg BID

Question 26

Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS GP IIb/IIIa inhibitor in patients treated with an early invasive strategy and DAPT w/ intermediate/high-risk features (eg positive troponin) Preferred options are?

Answer 26

Eptifibatide Tirofiban

Question 27

Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS Parenteral anticoagulation and fibrinolytic therapy SC enoxaparin for duration of hospitalization or until PCI is performed

Answer 27

1mg/kg SC q 12h (reduce dose to 1mg/kg/d SC in patients w/ CrCl < 30ml/min) Initial 30 mg IV loading dose in selected patients

Question 28

Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS Parenteral anticoagulation and fibrinolytic therapy Bivalirudin until diagnostic angiography or PCI is performed in pts w2/ early invasive strategy only

Answer 28

Loading dose 0.1 mg/kg followed by 0.25mg/kg/h Only provisional use of GP IIb/IIa inhibitor in patients also treated w2/ DAPT

Question 29

Summary Recommendations for Initial Antiplatelet/Anticoagulation Therapy in Patients with definite or likely NTSE-ACS Parenteral anticoagulation and fibrinolytic therapy IV UFH for 48h or until PCI is performed

Answer 29

Initial loading dose 60 IU/kg (max 4000 IU) w/ initial infusion of 12 IU/kg/h (max 1000 IU/h) Adjust to therapeutic aPTT range

Question 30

What scoring system provides an estimation of the 6mo mortality for patients w/ ACS based on patients risk factors?

Answer 30

The GRACE scoring system

Question 31

Factors Associated w/ Appropriate Selection of Early invasive strategy or Ischemia-guided strategy in patients w/ NSTE-ACS Immediate invasive (w/n 2 hr)

Answer 31

Refractory angina S/sx of HF or new or worsening mitral regurge Hemodynamic instability Recurrent angina or ischemia at rest or w/ low-level activites despite intensive medical therapy Sustained VT or VF

Question 32

Factors Associated w/ Appropriate Selection of Early invasive strategy or Ischemia-guided strategy in patients w/ NSTE-ACS Ischemia-guided strategy

Answer 32

Low-risk score (eg, TIMI [0-1], GRACE [<109]) Patient or clinician preference in the absence of high-risk features

Question 33

Factors Associated w/ Appropriate Selection of Early invasive strategy or Ischemia-guided strategy in patients w/ NSTE-ACS Early invasive (w/n 24hr)

Answer 33

None of the above, but GRACE risk score > 140 Temporal change in Tn New or presumably new ST depression

Question 34

Factors Associated w/ Appropriate Selection of Early invasive strategy or Ischemia-guided strategy in patients w/ NSTE-ACS Delayed invasive (w/n 25-72h)

Answer 34

None of the above but DM & Renal insufficiency (GFR < 60mL/min/1.73msquared) Reduced LV Systolic fxn (EF <40%) Early post-infarction angina PCI w/n 6mo Prior CABG GRACE risk score 109-140; TIMI score >/= 2

Question 35

In patients who have received prior anticoagulation therapy during PCI Enoxaparin For prior treatment w/ enoxaparin, if last SC dose was administered 8-12 h earlier or if < 2 therapeutic SC doses of enoxaparin have been administered an IV dose of enoxaparin at what dose should be given?

Answer 35

0.3mg/kg

Question 36

In patients who have received prior anticoagulation therapy during PCI Enoxaparin If the last SC dose was administered w/8 h, what dose should be given?

Answer 36

no additional enoxaparin should be given

Question 37

In patients who have received prior anticoagulation therapy during PCI Bivalirudin For patients who have received UFH, wait 30 min then give what loading dose and what infusion dose?

Answer 37

Loading dose - 0.75mg/kg Infusion dose - 1.75mg/kg/h

Question 38

In patients who have received prior anticoagulation therapy during PCI Bivalirudin For patients already receiving bivalirudin infusion give how much additional loading dose and increase infusion dose to how much?

Answer 38

loading dose - 0.5mg/kg infusion dose - 1.75mg/kg/h

Question 39

In patients who have received prior anticoagulation therapy during PCI UFH IV GPI planned: additional UFH as needed (eg 2000-5000 U) to acieve ACT of what?

Answer 39

200-250s

Question 40

In patients who have received prior anticoagulation therapy during PCI UFH No IV GPI planned: additional UFH as need (eg 2000-5000 U) to achieve ACT of ____ for HemoTec, or ____ for Hemochron

Answer 40

250-300s 300-350s

Question 41

NSTE-ACS Definite or Likely Ischemia-Guided Strategy Initiate what?

Answer 41

DAPT and Anticoagulant therapy

Question 42

NSTE-ACS Definite or Likely Early Invasive Strategy initiate what? Can consider what if high risk?

Answer 42

DAPT and anticoagulation therapy GPI

Question 43

NSTE-ACS Definite or Likely If medical therapy is ineffective and patient goes for PCI w/ Stenting Initiate/continue what? GPI indicated if not treated with what at time of PCI?

Answer 43

DAPT and anticoagulation therapy Bivalirudin

Question 44

NSTE-ACS Definite or Likely If medical therapy is ineffective and patient goes for CABG initiate/continue what? and discontinue what?

Answer 44

ASA therapy P2Y12 inhibitor and GPI