Acute Coronary Syndrome

Question 1

What is the cause of Acute Coronary Syndromes [ACS]?

Answer 1

• Plaque build up [atherosclerosis] where the plaque breaks off making a clot that reduces blood flow [ischemia]
• This causes the imbalence of oxygen supply and demand

Question 2

What are some of the risk factors for ACS?

Answer 2

• Age: Men > 45y & Women > 55y
• Family Hx
• Smoking
• Hypertension
• Known CAD
• Dyslipiedmia
• Diabetes
• Chronic Stable Angina
• Lack of exercise
• Excessive Alcohol

Question 3

What are some of the signs and symptoms for ACS?

Answer 3

• Chest Pain [pressure/squeezing] that last > 10 mins (can go into arm, neck, jaw, back…)
• Dyspnea, Diaphoresis, Fainting

Question 4

What is something that someone should do if they are experiencing chest pain?

Drug?

Answer 4

• Take NTG; 1 dose every 5 mins up to 3 doses
• If giving a second dose call 911

Question 5

What are the 2 diagnosis of ACS?

Answer 5

• STEMI
• NSTEMI or UA

Question 6

What is the first thing that should be done when a medical person shows up?

Answer 6

• 12 lead ECG within 10 mins
• If having MI [NSTEMI or STEMI] then go to hospital for PCI

Question 7

What are some of the biochemical markers that we look for when we thing someone has ACS?

Cardiac Enzymes

Answer 7

• Troponins I and T
• Should be gotten at presentation and 3-6 hours after

CK-MB and Myoglobin are less sensitive but still good to watch

Question 8

What is a PCI?

Answer 8

• Putting a small balloon into the coronary artery to open the artery and increase blood flow
• A stent is put into it to hold ot open

Question 9

What is the “door to balloon” and “door to needle”?

When treating a STEMI

Answer 9

• Door to Balloon: PCI is preferred within 90 minutes of getting to hospital OR 120 mins if seen by medical person first
• Door to Needle: When PCI cant happen within 120 mins then fibrinolytic used within 30 mins

Question 10

What are the drug combos that are used for the treatment of ACS?

Answer 10

• Antianginal [decrease oxygen demand]
• Anticoagulant [prevents clots]
• Antiplatelets [prevents clots]

Question 11

What is MONA-GAP-BA?

Answer 11

• M: Morphine
• O: Oxygen
• N: Nirates
• A: Aspirin
• G: GPIIb/IIa
• A: Anticoags
• P: P2Y12
• B: Beta Blockers
• A: ACEi

Question 12

What is important to know about Nitrates when it comes to giving MONVA-GAP-BA for someone?

Answer 12

• Antianginal: dilates coronary arteries = decreased blood flow = decreased chect pain
• SL NTG 0.4mg given every 5mins x3 doses
• DO NOT give IV if SBP < 90
• PDE5-i are contraindicated

Question 13

What is important to know about Asipirin when its related to MONA-GAP-BA?

Answer 13

• Antiplatelet
• Give non-enteric coated aspirin [chewable] immediately
• Maintainacne give 81mg forever

Question 14

What is important to know about GPIIb/IIIa antagonists when it is realted to MONA-GAP-BA?

Answer 14

• Antiplatelet
• Drugs are Abciximab, Eptifibate, Triofiban

Question 15

What is important to know about Anticoagulants when it is related to MONA-GAP-BA?

Answer 15

• Inhibit clotting factor
• LMWH [Exnoaparin], UFH, Bivalirudin [preferred in STEMI]

Question 16

What is important to know about P2Y12 Inhibitors in MONA-GAP-BA?

Answer 16

• Antiplatelet
• Clopidogrel, Prasugrel, Ticagrelor

Question 17

What is important to know about Beta Blockers in relation to MONA-GAP-BA

Answer 17

• Antiangial: Decrease HR, BP, Contractility
• Oral, Low Dose BB [B1 w/o ISA] started within 24h

Question 18

What is important to know about ACEi in relation to MONA-GAP-BA?

Answer 18

• Blocks production of Ang II
• Oral started within 24h and continued forever

Question 19

What are some of the durgs you should avoid in an acute setting on ACS?

Answer 19

• NSAIDS
• Nifedipine IR [increase mortality]

Question 20

What are the Antiplatelet drugs that are used ACS and what is there MOA?

Answer 20

• Aspirin: irreversibly inhibtis COX 1&2 decreasing TXA2
• P2Y12: binds to ADP P2Y12 preventinh GPIIb/IIIa
• GPIIb/IIIa: blocks GPIIb/IIIa stoping activation
• Protease-activated Receptor 1: binds to PAR-1 preventing platelet aggregation

Question 21

What are the P2Y12 Inhibitors that are used for ACS?

Answer 21

• Clopidogrel [Plavix]
• Prasugrel [Effient]
• Ticagrelor [Brillinta]

Question 22

What is the difference between the P2Y12 Inhibitors?

Clopid & Pras Vs Ticag

Answer 22

• Clopidogrel & Prasugrel are prodrugs that have IRREVERSBLE in binding
• Ticagrelor is no a prodrug and is reversilbe

Question 23

What is the boxed warning for Clopidogrel?

Answer 23

• Prodrug so it depends on 2C19 to version [Poor Metabolizers have increased cardio events]

`

Question 24

What are the contraindications for Clopidigrel?

Answer 24

• Serious Bleeding

Question 25

What are the warnings for Clopidogrel?

Answer 25

- Bleeding; stop 5 days before surgery - DO NOT use with Omprazole or Esomprazole

Question 26

What are the Boxed Warnings for Prasugrel?

Answer 26

- BLEEDING [not for >75yo] - DO NOT start if doing a CABG; stop 7 days before surgery

Question 27

What is something important to note about dispensing Prasugrel?

Answer 27

- MUST be in orginial container

Question 28

What are the contraindications for Prasugrel?

Answer 28

- Serious bleeding, Hx of TIA or Stroke

Question 29

What is important to note about the dosing for Ticagreolr?

Answer 29

- MD: 90mg PO BID for 1 year THEN 60mg BID

Question 30

What is the boxed warning for Ticagrelor>

Answer 30

- After initial aspirin dose fo 162-325mg, DO NOT exceed more that 100 because it decreases efficacy of ticagrelor - AVOID in CABG; stop 5 days before surgery

Question 31

What are the contraindications for Ticagrelor?

Answer 31

- Serious Bleeding Risk

Question 32

What is important to know about Cangrelor?

Answer 32

- Injectable - Go to one of the ORAL ones after PCI

Question 33

What are the GPIIb/IIIa Antagonists that are used?

Answer 33

- Eptifibatide - Tirofiban - Abiciximab ## Footnote Eptifibatide and Tiroban are reverible blockers and are used for Medical Mangament or PCI +/- stent Abicixiamb is not available

Question 34

What are the contraindications for the GPIIb/IIIa Antagonists

Answer 34

- Thrombocytopenia, Hx of bleeding, Stroke within last 30 days

Question 35

What are the side effects for GPIIb/IIIa Antagonists

Answer 35

- Bleeding, Thrombocytopeina

Question 36

What are the fibrinolytics used for?

Answer 36

- "Clot Breakdown" by binding to fibrin and converting Plasminogen into plasmin - ONLY for STEMI

Question 37

When should a fibrinolyitc be used?

Answer 37

- within 30 mins of getting to hospital if PCI is < 120 mins [Door to Needle]

Question 38

What are the Fibrinolytics that are used?

Answer 38

- Altaplase [Activase] - Tenectiplase [TNKase] - Reteplase

Question 39

What are the contraindications for the fibrinolytics?

Answer 39

- Active internal bleeding, Hx of stroke, Severe uncontrolled HTN

Question 40

What are the side effects of Fibrinolytics?

Answer 40

- Bleeding [including Intracranial hemorrhage]

Question 41

What are some other notes for Fibrinolytics? ## Footnote -

Answer 41

- Alteplase contraindications and dosing are different for stroke

Question 42

What are some of the drugs that are used indefinitely in secondary prevention of ACS?

Answer 42

- Aspirin [81mg] - Beta Blockers [normally 3y unless HF or HTN] - NTG [SL Tab or TL Spray] - ACEi [EF < 40%, HTN, CKD, Diabetes] - Statins [High Intensity] - Aldosterone Antagonist [EF < 40%, HF, Diabetes]