Acute Coronary Syndrome

Question 1

RF of ACS

Answer 1

Men >45YO or Women >55YO
1st degree relatives with coronary events
Smoking
HTN
Known CAD
DLD
DM
Chronic stable angina
Lack of exercise
Excessive alcohol

Question 2

Sx of ACS

Answer 2

Chest pain (pressure squeezing) lasting ≥10 min, severe, dyspnea, diaphoresis

Pain that radiates to the arms, back, neck, jaw or epigastric region

Question 3

How is ACS typically diagnosed

Answer 3

12-lead ECG (at the site of medical contact)
Troponins
CK-MB

Question 4

What is a PCI

Answer 4

Inflating a small balloon inside a coronary artery to widen and improve blood flow

Question 5

Tx strategy for NSTEMI

Answer 5

Medication alone or with PCIT

Question 6

Tx strategy for STEMI

Answer 6

PCI is recommended 90 minute of hospital arrival or within 120 min of medical contact

If not possible within 120 mi then fibrinolytic should be given within 30 min of hospital arrival

Question 7

Drug treatment for ACS

Answer 7

Morphine: pain relief
Oxygen: if <90%
Nitrates:
Aspirin: Non-enteric, chewable 162-325 mg immediately, 81 mg indefinitely

GPIIb/IIIa
Anticoagulants
P2Y12 inhibitors

Beta-blockers
ACE Inhibitors

Question 8

MOA of nitrates

Answer 8

Dilates coronary arteries → ↓ preloaded reducing chest pain

Question 9

When to initiate nitrates

Answer 9

0.4 mg Q5M x 3 doses

CI: PDE5I and SBP <90

Question 10

When should BB and ACEI be administered?

Answer 10

Within 24 hrs as needed

Question 11

Why initiate BB

Answer 11

↑ long term survival

B-1 selective

Question 12

When should ACE be initiated

Answer 12

Within 24 hr if patient EF <40%

Question 13

MOA of aspirin

Answer 13

Irreversibly inhibits COX1 and 2 → Decreases the production of TXA2

Question 14

MOA of P2Y12 inhibitor

Answer 14

Bind to ADP P2Y12 inhibitor preventing the activation of the GIIb/IIIa complex

Question 15

MOA of GIIb/IIIa receptor antagonist

Answer 15

Blocks the complex that evokes platelet aggregation

Question 16

MOA of PAR1 antagonist?

Answer 16

Bind tho thrombin receptor (PAR) preventing platelet activation and aggregation

Question 17

P2Y12 inhibitors

Answer 17

Clopidogrel (Plavix)
Prasurgaral (Effient)
Ticagrelor (Brillinta)

Question 18

LD and MD of Clopidorgel

Answer 18

LD: 300-600 mg once
MD: 75 mg QD

Question 19

BBW fo Clopidogrel

Answer 19

Prodrug that requires CYP2C19 for activation

Caution in inhibitors → prevent activation

Question 20

ADR of P2Y12 inhibitors

Answer 20

Bleeding
Omeprazole and esomeprazole (they are CYP2C19 inhibitors) → Clopidogrel
TTP
Dyspepsia (Ticegrellor)

Question 21

CI of P2Y12 inhibitors

Answer 21

Serious bleeding

TIA and stroke (Prasugrel)

Question 22

When to stop P2Y12 inhibitors before elective surgery

Answer 22

Clopidogrel: 5 days
Prasugrel: 7 days (Don’t use for CABG)
Ticagrelor: 5 days (Don’t use for CABG)

Question 23

DDI of Ticegrelor

Answer 23

Avoid strong CYP3A4 inhibitors and inducers

Avoid simvastatin and lovastatin >40 mg /day

Question 24

Prasurgel

Answer 24

Effient

Question 25

Ticagrelor

Answer 25

Brillinta

Question 26

What are the GIIIb/IIa receptor antagonists?

Answer 26

Eptifibatide (Integrillin) Tirofiban (Aggrastat) Abciximab

Question 27

Indications for Abciximab

Answer 27

PCI +/- stent

Question 28

What is GIIIb/IIa receptor antagonist given with, during PCI

Answer 28

Heparin

Question 29

ADR of GIIIb/IIa receptor antagonist

Answer 29

Bleeding, thrombocytopenia

Question 30

PAR-1 antagonist

Answer 30

Vorapaxar

Question 31

Indication for Vorapaxar

Answer 31

Hx of MI or PAD

Question 32

MOA of fibrinolytics

Answer 32

Breakdown clot by binding to fibrin and converting plasminogen to plasmin

Question 33

Alteplase

Answer 33

Activase

Question 34

Tenectiplase

Answer 34

TNKase

Question 35

CI of fibrinolytics

Answer 35

Serious bleeding (internal), Hx of recent stroke, uncontrolled HTN Altelase CI and dosing differ with ischemic stroke

Question 36

ADR of fibrinolytics

Answer 36

Bleeding → ICH

Question 37

What is in alteplase

Answer 37

Recombinant tissue plasminogen activator (tPA, rtPA)

Question 38

Reteplase

Answer 38

Retavase

Question 39

Drugs to initiate for secondary ACS prevention? Duration

Answer 39

1. Aspirin 81 mg indefinitely 2. P2Y12 inhibitor w/ ASA x 12 months 3. NTG indefinitely 4. Beta-blocker x 3 yrs (indefinitely in HF or HTN management) 5. ACEI indefinitely (HF, CKD, diabetes, HTN) 6. Aldosterone inefinitely (HF or DM) 7. High-intensity statin indefinitely (≥75YO mod or high statin)

Question 40

CI of aldosterone antagonsit

Answer 40

sCr >2.5 (males), >2.0 (female) K ≥5 mEq/L

Question 41

P2Y12 indicated for PCI

Answer 41

Ticagrelor, Prasurgrel, Clopidogrel

Question 42

Dosing of ticagrelor

Answer 42

90 mg BID for 1 yr → 60 mg PO BID