Acute Coronary Syndrome

Question 1

what usually causes acute Coronary Syndrome ACS

Answer 1

plaque buildup (atherosclerosis) –> in the coronary arteries

Question 2

what is atherosclerosis

Answer 2

plaque build in arteries

Question 3

name 2 types of ACS

Answer 3

NSTEMI
* non-ST segment elevation ACS

STEMI
* ST-segment revelation MI

Question 4

What is PCI? Percutaneous coronary intervention

Answer 4

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

usually a stent (metal mesh) is placed to keep the artery open

a non-surgical option used to improved blood flow to the heart (minimally invasive)

Question 5

NSTE-ACS: 2 treatment options in general terms

Answer 5

medicines alone or

PCI (an early invasive strategy)

Question 6

STEMI - treatment options (2) in general terms

Answer 6

PCI or Fibrinolysis

Question 7

What classes of drugs are use in treatment of ACS

Answer 7

Anti-anginal
* MONA - morphine, oxygen, nitrates

Anti-platelets
* aspirin
* plavix, prasugrel, ticagrelor

Anti-coagulants
* GP2b/3a antagonists
* Alteplase (Activase)

Question 8

NSTE-ACS and STEMI: acronym for treatment

Answer 8

NSTE-ACS: MONA-GAP-BA +/- PCI

STEMI: MONA-GAP-BA + PCI or fibrinolytic (preferred - alteplase)

MONA
* morphine
*oxygen
*nitrate
*Aspirin (325 mg chewable)

GAP
* GP2b/3a (eptifibatide - Integrillin)
* Anticoagulant: enoxaparin, heparin & bivalirudin (preferred in STEMI)
* P2y12 inhibitors: clopidogrel, prasugrel, ticagrelor

BA
* Beta-blocker (nebivolol, metoprolol ER, carvedilol)
* Ace-inhibitor

Question 9

differences in treatment of NSTE-ACS vs STEMI

Answer 9

treatment for STEMI - must use PCI or fibrinolytic (preferred)

NSTE-ACS: PCI (optional) and no fibrinolytic

Question 10

eptifibatide

Brand and class or moa

Answer 10

Integrilin (Brand d/c in US)

GP2b/3a receptor antagonists
* prevent platelet aggregation (can stick to each other)

Question 11

ASPIRIN moa

Answer 11

irreversibly INHIBITS cox-1 and cox-2

• decreases production of thromboxane A2 (TXA2) and prostaglandin (PG)

TXA2 - inducer of platelet aggregation
* potent vasoconstrictor also

Question 12

P2Y12 inhibitors: moa

• clopidogrel (plavix)
• Prasugrel (Effient)
• ticagrelor (Brilinta)

Answer 12

Binds to the platelet ADP-P2y12 receptors –> prevents ADP mediated (causes) activation of the GP2b/3a receptor complex on platelets

• ADP - adenosine diphosphate

GP2b/3a - platelet aggregations with fibrinogen

• clopidogrel: prodrug –> needs CYP2C19 to convert to active drug
• Omeprazole and esomeprazole (2C19 inhibitor)
• Prasugrel - also a prodrug
• higher bleeding risk than plavix
• only INDICATED for ACS managed with PCI (stent)
• Effient - has stent in drug name
• Ticagrelor (Brilinta)
• do not use ASA > 81 mg (decrease efficacy, except ASA 325 mg in first dose of ACS tx)
• 3A4 substrate (lovastatin, simvastatin keep dose < 40 mg)
• tablets can be crushed NG tube

Question 13

Plavix loading dose

Answer 13

300 to 600 mg

• 600 mg –> use if patient PCI

Question 14

Plavix drug intxn to remember

Answer 14

Omeprazole and Esomeprazole

2C19 inhibitors

plavix is a prodrug - requires 2C19 conversion to active metabolite

Question 15

Prasugrel (Effient) loading dose

Answer 15

60 mg PO (no later than 1 hour after PCI)

MD: 10 mg daily WITH aspirin

Question 16

how to dispense prasugrel

Answer 16

in original container

Question 17

when is prasugrel use in ACS

Answer 17

ONLY indicated for ACS management with PCI (balloon and stent)

• if CABG –> do not use if CABG likely

Question 18

when not to use Ticagrelor (Brilinta) in ACS treatment

Answer 18

if CABG likely –> do not use

Question 19

which P2Y12 can be use if CABG likely

Answer 19

Plavix

• avoid prasugrel (Effient) and Ticagrelor (Brilinta)

Question 20

Eptifibatide
* brand
* class
* indication

Note

Answer 20

Integrilin

GP2b/3a (glycoprotein) receptor antagonist

for medical (medication) management of ACS or pt receiving a PCI +/- stent

if use in PCI –> give with heparin

Question 21

contraindication to eptifibatide (2)

Answer 21

Thrombocytopenia
* low platelet count

Severe uncontrolled hypertension
* bleeding risk

Question 22

another name for Alteplase (Activase)

Answer 22

tPA

• tissue plasminogen activator
• converts plasminogen to plasmin

Question 23

what is plasmin

Answer 23

protein in blood that dissolves clot

Question 24

time frame to give alteplase (fibrinolytics)

Answer 24

within 30 minutes of hospital arrival

Question 25

in a patient with STEMI that received fibrinolytic (alteplase); what is the preferred P2Y12?

Answer 25

Plavix * guideline recommend using plavix in patient who received fibrinolytics (alteplase)

Question 26

secondary prevention of ACS * ASA - how long to take it * P2Y12 - how long to take it

Answer 26

ASA - indefinitely Medical management: * Plavix or Ticagrelor (Brilinta) for 12 months PCI (stent): * any P2Y12 for 12 months

Question 27

best NSAID for pain in patient with ACS

Answer 27

Naproxen * avoid cox-2 specific (celebrex) - highest risk for CV

Question 28

What is CAD? coronary artery disease

Answer 28

plaque build up within the inner wall of coronary arteries ** atherosclerosis**

Question 29

what is prinzmetal angina?

Answer 29

vasospastic angina ** coronary artery vasospasm**

Question 30

treatment of stable angina involves what 2 general classes of drugs

Answer 30

Antiplatelet - prevent plaque build up * ASA * Plavix * Xarelto (low dose) + ASA Anti-anginal * Beta-blocker * DHP or NDH CCB * Long acting nitrates (Imdur) * Ranolazine - can be added if still symptomatics

Question 31

ASA moa

Answer 31

inhibits COX-1 and COX-2 (occurs inside platelet) Decrease prostaglandin and thromboxane A2 (TXA2) * TXA2 - a potent vasoconstrictor and inducer of platelet aggregration

Question 32

Plavix moa

Answer 32

P2Y12 inhibitors * blocks binding of ADP (released by platelets) to P2Y12 receptors * this binding causes platelets to express GP2b/3a receptors on surface * GP2b/3a binds to fibrin --> platelet aggregation

Question 33

interaction with Plavix to remember

Answer 33

omeprazole and esomeprazole inhibits 2C19 2C19 converts Plavix (a prodrug) to active metabolites

Question 34

Ranolazine moa

Answer 34

decreases myocardial oxygen demand * not for acute treatment of chest pain * no clinical effect on HR or BP **can be used with amiodarone and plaquenil - remember CFP case**

Question 35

Contraindication to NTG (2)

Answer 35

Hypotension Tachycardia * PDE-5 inhibitors - sildenafil and vardenafil 24 hrs apart - tadalafil 48 hours apart * can be use in emergency situation, must monitor BP

Question 36

Ranolazine drug intxn concepts

Answer 36

Ranolazine is a CYP 3A4 substrate interact with strong 3A4 inhibitor and inducer ** G love PACMAN --> inhibitors** ** PS PORCS --> inducers**

Question 37

how to use NTG spray

Answer 37

do not shake Prime pump before 1st use, if not used in 6 weeks spray onto or under tongue, close mouth, do not inhale do not spit/rinse mouth for 5 minutes