Acute Coronary Syndrome Flashcards by Molly Colquitt

what results in ACS

atherosclerosis in coronary arteries that can rupture = clots that cause sudden, reduced blood flow to heart; imbalance of myocardial oxygen supply and demand

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ACS risk factors

men >45 + women >55 (or early hysterectomy)
family history (1st degree with ACS <55 men or <65 women
smoking
hypertension
known CAD
dyslipidemia
diabetes
chronic stable angina
lack of exercise
excessive alcohol

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signs/symptoms of ACS

chest pain (pressure/squeezing) for >=10 min
severe dyspnea
diaphoresis
pain radiates to arms, back,neck, jaw, epigastric region

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what should be given in ACS at first

up to 3 doses sublingual nitroglycerin 5 minutes apart
if not improved or worse 5 min after 1st dose = call 911 immediately

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types of ACS

NSTE-ACS (unstable angina and NSTEMI)
STEMI

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symptoms in UA vs NSTEMI vs STEMI

chest pain same for all

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cardiac enzymes in UA vs NSTEMI vs STEMI

negative in UA
positive in NSTEMI/STEMI

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ECG changes in UA vs NSTEMI vs STEMI

none or transient ischemic changes (ST segment depression or prominent T-wave inversion in UA/NTEMI
ST segment elevation (mets defined criteria in >=2 contiguous leads (lead looking at same area of heart)

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blockage in UA vs NSTEMI vs STEMI

partial blockage in UA/NSTEMI
complete blockage in STEMI

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treatment goal

immediate relief of ischemia and preventing MI expansion

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PCI

inflating balloon inside coronary artery to widen and improve blood flow
usu stent keeps artery open

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NSTE-ACS treatment options

meds alone or PCI

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STEMI treatment options

blocked arteries must be opened ASAP
PCI preferred in can be within 90 minutes (door-to-balloon time) or within 120 minutes of first medical contact
if no PCI within 120 min of medical contact - use fibrinolytic therapy within 30 minutes of hospital arrival (door-to-needle time)
MONA-GAP-BA + PCI/fibrinolytic (PCI preferred)

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drug treatment options for ACS

MONA-GAP-BA
Morphine
Oxygen
Nitrates
Aspirin
-
GPIIb/IIa antagonists
Anticoagulants
P2Y12 inhibitors
-
Beta-blockers
ACEI

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antianginals MOA

dec myocardial oxygen demand

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antiplatelets MOA

prevent clot formation/growth

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anticoagulants

prevent clot formation/growth

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morphine clinical benefit

pain relief

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Nitrates MOA

dilate coronary arteries = inc blood flow
dec preload
dec chest pain

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nitrates clinical comments

SL nitroglycerin 0.4 mg X5 min X 3 doses
do not use IV NTG if SBP<90
nitrates CI with PDE-5 inhibors

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Aspirin clinical benefit

non-eteric-coated, chewable
162-325 ASA given to all immediately
do not use enteric coated or extended-release
continue ASA 81-162 mg daily

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GPIIIB/IIIA antagonists clinical comments

second-line
includes abcizimab, eptifibatide, and tirofiban

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antigocatulants clinical comments

LMWHs (enoxaparin)
UFH
bivalirudin

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P2Y12 clinical comments

clopidogrel
prasugrel
ticagrelor

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Beta-blockers

given within 24 hours inc long-term survival oral use b-1 selective without sympathomimetic activity preferred

ACEI

oral start within 1st 24 hours and continue indefinitely in all with LVEF<40% can use ARB if intolerant

meds to avoid in acute

NSAIDs except ASA (nonselective or COX-2 selective - do not give in hospitalization) IR nifedipine should not be used (inc mortality)

antiplatelet drugs MOA

inhibit platelet aggregation

ASA MOA

irreversibly inhibit COX-1 and -2 = dec TXA2

P2Y12 inhibitors MOA

clopidogrel, prasugrel, ticagrelor, cangrelor bind ADP P2Y12 receptor commonly used with ASA for DAPT require loading doses

GPIIb/IIIa receptor antagonists MOA

abciximab, eptifabatide, tirofiban block platelet glycoprotein IIb/IIa receptor

Protease-activated receptor-1 antagonist MOA

vorapaxar bind PAR-1 receptor

thienopyridines

clopidogrel and prasugrel prodrugs that irreversibly bind P2Y12 receptor

clopidogrel dosing

75 mg PO daily

clopidogrel BBW

prodrug metabolized by CYP450 2C19 - check CYP2C19 genotype

clopidogrel CI

serious bleeding

clopidogrel warnings

bleeding risk - stop prior to elective surgery do not use with omeprazole or esomeprazole thrombotic thrombocytopenic purpura

clopidogrel side effects

bleeding

prasugrel dosing

dispense in original container

prasugrel BBW

stop prior to elective surgery

prasugrel CI

serious bleeding history of TIA/stroke

prasugrel warnings

bleeding risk thrombotic thrombocytopenic purpura

prasugrel side effects

bleeding

ticagrelor dosing

90 mg BID for 1 year, then 60 mg BID

ticagrelor BBW

do not exceed ASA 100 mg stop before elective surgery

ticagrelor CI

serious bleeding

ticagrelor warnings

bleeding risk thrombocytopenic purpura

ticagrelor side effects

bleeding dyspnea

cangrelor dosing

injection

cangrelor notes

transition to oral P2Y12 inhibitors after PCI

P2Y12 inhibitor DI

additive bleeding risk: NSAIDs, warfarin, SSRIs, SNRIs

clopidogrel DI

avoid with CYP2C19 inhibitors esomeprazole and omeprazole

glycoprotein IIb/IIIa recepor antagonists names and side effects

abciximab, eptifibatide, tirofiban bleeding thrombocytopenia

fibrinolytics MOA/administration/names

clot breakdown by binding to fibrin and converting plasminogen to plasmin only for STEMI give within 30 min door-to-needle alteplase, Cathflo Activase, Tenecteplase (TNKase), reteplase

alteplase MOA

type of fibrinolytic recombinant tissue plasminogen activator (tPA)

fibrinolytics CI

active internal bleeding history of recent stroke severe uncontrolled HTN

fibrinolytics side effects

bleeding (ICH)

fibrinolytics monitoring

Hbg Hct s/sx of bleeding

fibrinolytics notes

alteplase dosing differs for ischemic stroke

secondary prevention of ACS drugs

ASA: 81 mg qd indefinitely unless CI P2Y12 inhibitor: medical therapy ticagrelor/clopidogrel w/ ASA 81 mg for >= 1 yr (clopidogrel preferred if STEMI with fibrinolytics); PCI-treated clopidogrel, prasugrel, ticagrelor with ASA 81 mg for >=12 months continuation considered in tolerant of DAPT and not high bleed risk nitroglycerin SL or PRN spray indefinitely BB: 3 years; indefinite if HF or for HTN ACEI: indefinitely if EF <40%, HTN, CKD/diabetes, consider for all with no CI aldosterone antagonist: indefinitely if HFrEF and symptomatic HF or diabetes on target ACEI and BB; CI: SCr >2.5 men 2 wome or K >5 statin: indefinitely high-intensity for most; >=75 yo: consider moderate or high-intensity

pain consideration

if other options insufficient, can use naproxen (nonselective NSAID); COX-2 selective should be avoided bc high CV risk

ACS + AFib consideration

dual to triple antithrombotic therapy if triple, use shortest time possible if history of GI bleed, give triple antithrombotic PPI

Acute Coronary Syndrome Flashcards

(62 cards)