Acute Coronary Syndrome Flashcards by Blade Joneson

What usually causes the imbalance seen in ACS?

Plaque build up in the coronary arteries

Plaque ruptures -> clot forms -> reduction in blood flow -> ischemia -> compromising proper cardiac functioning

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What biochemical markers are released into the blood stream as a result of ischemia?

Troponins I and T
Creatinine kinase (CK) myocardial band (MB)

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What clinical conditions encompasses ACS?

Unstable angina (UA)
Non-segment elevation myocardial infarction (NSTEMI)
Segment elevation myocardial infarction (STEMI)

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What are the common clinical xtics of UA/NSTEMI?

Transient ST-segment DEPRESSION
T-wave INVERSION
NO changes seen in ECG

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What are the clinical symptoms of ACS?

Chest pain that feels like pressure or tightness
SOB
Pain in other areas such as left upper arm or jaw
Pain usually not relieved by nitroglycerin sublingual tablets/ spray/ rest

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Once a person experiences sx of ACS, what must they do first?

Immediately call 911

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What must be performed on the patient at the site of FIRST medical contact?

12-lead ECG

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What must the hospital have for a pt with ACS to be transported there?

Percutaneous coronary intervention (PCI)

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Risk factors for ACS

Age (men > 45; women > 55 years or early hysterectomy)
FH of coronary event before 55yrs (men); 65yrs (women)
Smoking
HTN
Hyperlipidemia
Diabetes
Chronic angina
Known coronary artery dx

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What factors may precipitate ACS?

Exercise
Cold weather
Extreme emotions
Stress
Sexual intercourse

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Diagnosis of UA

Chest pain

NEGATIVE cardiac enzymes

No or transient ECG changes

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Diagnosis of NSTEMI

Chest pain

POSITIVE cardiac enzymes (Troponins, CK-MB)

No or transient ECG changes

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Diagnosis of STEMI

Chest pain

Positive cardiac enzymes (Troponins, CK-MB)

ST elevation or NEW left bundle branch block (LBBB) (>= 0.1 mV of ST segment elevation in 2 or more contiguous ECG leads)

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What’s the difference btw UA and NSTEMI diagnosis?

Same (chest pain, no or transient ECG changes) EXCEPT

UA - negative cardiac enzymes

NSTEMI - positive cardiac enzymes

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What’s the difference btw NSTEMI and STEMI diagnosis?

Same (chest pain, positive cardiac enzymes - Troponins and CK-MB)
Except

NSTEMI - no or transient ECG changes

STEMI - ST segment changes or new left bundle branch block (LBBB) of >= 0.1 mV of ST segment elevation of >= 2 contiguous ECG leads

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What’s the aim of acute tx of ACS?

Stabilizing pt’s condition

Relieving pain from ischemia

Reducing myocardial damage and further ischemia

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What’s meds are given to stabilize pt and treat pain with all ACS?

MONA =

Morphine

Oxygen

Nitroglycerin

Aspirin

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What’s initiated to reduce myocardial damage and prevent further ischemia in ACS?

Anti-thrombotic therapy, usually dual oral Antiplatelet + anticoagulant with heparin, LMWH OR bivalirudin

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What meds may be given in select pts?

GP IIb/IIIa antagonist (Tirofiban, Eptifibatide, Abciximab) TEA

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What must all pts receive within 24 hrs of presentation, if no contraindication?

Beta blocker + ACE I

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What may be given to pts presenting with STEMI? When must this be done?

Fibrinolytic

Done when pt can’t be transferred to a PCI capable hospital

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When is a fibrinolytic given?

STEMI pt

Done when pt can’t be transferred to a PCI capable hospital

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What’s the tx for UA and NSTEMI?

MONA + GAP-BA

Morphine
Oxygen
Nitrates
Aspirin

GP IIb/IIIa receptor antagonists (Tirofiban, Eptifibatide, Abciximab) TEA
Anti-coagulants (heparin, LMWH eg Enoxaparin, Dalteparin,
fondaparinux, bivalirudin
P2Y-12 inhibitors (Clopidogrel/ prasugrel - if pt is going for PCI)
(Ticagrelor - for ALL pts except those going for
CABG surgery)

Beta blockers
ACE-I

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MOA of morphine used in ACS?

Arterial and venous DILATION -> reduction in myocardial O2 demand

Pain relief

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Dosing of morphine

2 to 8 mg IV repeated at 5 to 15 minutes intervals PRN

Antidote of Morphine

Naloxone (Narcan)

When should supplement oxygen be admin in ACS?

SaO2 < 90% OR Respiratory distress

MOA of nitrates

DILATES coronary arteries and improves collateral blood flow -> reduce cardia O2 demand by reduced PRELOAD

Dose of nitrates

NTG (SL tabs or spray) = 0.4mg (1 dose) Q 5 mins...max 3 doses

What's the indication for NTG IV?

Relief of ongoing ischemia discomfort HTN Mgt of pulmonary congestion

C/I to nitrates use

SBP < 90 mmHg HR < 50 BPM OR > 100 BPM (tachycardia) Pt on PDE-5 inh for erectile dysfunction (w/in 24 hrs of sildenafil/vardenafil; OR 48 hrs of tadalafil OR 12 hrs of Avanafil)

What meds may C/I the use of nitrates?

PDE-5 inh Not within 12 hrs Avanafil Not within 24 hrs for sildenafil/vardenafil Not within 48 hrs for tadalafil

How soon after using the ff meds can one use nitrates? Tadalafil Sildenafil Avanafil Vardenafil

Tadalafil - 48 hrs Sildenafil/vardenafil - 24 hrs Avanafil - 12 hrs

What's the dose of the initial Aspirin given? What's the maintenance dose?

LD: 162 - 325mg (2-4 tabs of 81mg) MD: 81mg daily

If pt is intolerant to aspirin, what's the alternative?

Clopidogrel (Plavix) Prasugrel (Effient) Ticagrelor (Brilinta)

MOA of GP IIb/IIIa receptor antagonist?

Blocks fibrinogen binding to GP IIa/IIIb receptors on platelets, preventing PLT aggregation

What agents make up GP IIa/IIIb?

TEA Tirofiban (Aggrastat) Eptifibatide (Integrilin) Abciximab (ReoPro)

Uses of GP IIa/IIIb rec antagonists?

Medical mgt or those going for PCI +/- stent

Which GP IIa/IIIb is to be given ONLY if PCI is planned?

Abciximab

What agents make up P2Y-12 inh?

Clopidogrel Prasugrel Ticagrelor

Which P2Y-12 inhibitor is given to ALL pts? C/I?

Ticagrelor CABG surgery

Which P2Y-12 inh are used for ONLY PCI?

Clopidogrel Prasugrel

MOA of beta blockers?

DECREASE oxygen demand due to reductions in BP, HR, and contractility May reduce the magnitude of infarction

In UA/NSTEMI - What are the C/I that may prevent staring beta blockers (usu started within 24 hrs of presentation)?

Signs of HF Evidence of low output state Increased risk for cardiogenic shock Other relative C/I to B-B e.g. PR interval > 0.24 secs, 2nd and 3rd degree heart block

When is it reasonable to use oral long acting non-dihydropyridine calcium antagonists?

Pts with recurrent ischemia w/o C/I AFTER B-b and nitrates have been fully used

MOA of ACE-I?

Inh ACE and blocks pdt of Angiotensin II Prevents cardiac remodeling Reduce preload and afterload

C/I to use of ACE-I within 24 hrs of pt presentation?

Hypotension (SBP < 100) Intolerance to ace-I (use ARB in this case)

Why is it recommended to NOT use IV ACE-I within the first 24hrs?

Due to risk of hypotension

What meds should be avoided in ACS pt in an acute setting?

All NSAIDs except Aspirin Immediate release form of dihydropyridine Ca channel blocker eg Nifedipine IV fibrinolytic therapy (unless pt has STEMI/LBBB)

List the agents that make up GP IIb/IIIa

Tirofiban (Aggrastat) Eptifibatide (Integrilin) Abciximab (ReoPro)

What's the brand name of Abciximab?

ReoPro

What's the brand name of Eptifibatide?

Integrilin

What's the brand name of Tirofiban?

Aggrastat

Name the C/I to GP IIb/IIIa receptor antagonists.

Thrombocytopenia (platelets < 100,000) Hx of bleeding diathesis (predisposition) Active internal bleeding Recent (within 6 weeks) of surgery Increased Prothrombin time (PT) Hx of stroke Severe uncontrolled HTN

What time frame is considered wrt hx of stroke and GP IIb/IIIa?

Abciximab (ReoPro) = hx of stroke w/in 2 years Eptifibatide (Integrilin) and = hx of stroke w/in 30 DAYS Tirofiban (Aggrastat) OR any hx of hemorrhagic stroke

What C/I is unique to Abciximab (ReoPro)?

Hypersensitivity to murine proteins

Name the main SE of GP IIb/IIIa

Bleeding Thrombocytopenia Hypotension

Name monitoring parameters for GP IIb/IIIa

Hgb Hct Platelets S/sx of bleeding Scr

Which GP IIb/IIIa has the highest risk for thrombocytopenia?

Abciximab (ReoPro)

What's peculiar about Abciximab (ReoPro)?

Must filter with administration

How soon do platelet count return after d/c of GP IIb/IIIa?

Eptifibatide (Integrilin) = 2-4 hours Tirofiban (Aggrastat) = 4-8 hrs Abciximab (ReoPro) = 24-48 hrs

Which GP IIb/IIIa binds IRREVERSIBLY to block platelet aggregation?

Abciximab (ReoPro) Others (Eptifibatide and Tirofiban) bind reversibly

Name the drugs that make up P2Y-12 inhibitors

Clopidogrel (Plavix) Prasugrel (Effient) Ticagrelor (Brilinta)

Which P2Y-12 inh are prodrugs? Implication?

Clopidogrel (Plavix) and prasugrel (Effient) IRREVERSIBLE binding

Which P2Y-12 inh is NOT a prodrug? Implication?

Ticagrelor (Brilinta) Faster onset and offset (faster offset b/c it's NOT a prodrug)

What's the dosing of Clopidogrel (Plavix)?

LD - 300 to 600mg MD - 75mg PO daily

What's the dosing of Clopidogrel (Plavix ) for PCI?

600mg

What's the alternative dosing for Clopidogrel (Plavix)?

LD: 600 mg 150mg daily for 6 days Then 75 mg daily

When is no LD req for Clopidogrel (Plavix) use?

If ACS is managed medically w/o stenting

What determines effectiveness of Clopidogrel (Plavix)?

Activation to active metabolite by CYP 2C19 (Plavix is a prodrug)

Which allele is considered to be fully functional metabolism?

CYP2C19*1 *2 and *3 (have reduced functions)

C/I of all P2Y-12 inh

Active bleeding Hx of TIA or stroke Hx of ICH Severe hepatic impairment

SE of both Clopidogrel (Plavix) and Prasugrel (Effient)?

Bleeding Bruising Rash TTP (rare)

Which P2Y-12 inh has the higher risk for bleeding?

Clopidogrel (Plavix)

When is prasugrel (Effient) used in pts >= 75years?

Only in high risk pts eg DM and prior MI

Are P2Y-12 inh used in CABG pts?

All - don't start in pts likely to undergo CABG surgery D/c 5 days prior to any major surgery (Clopidogrel and ticagrelor) D/c 7 days (prasugrel)

What's the recommended aspirin dose to be used with Ticagrelor (Brilinta)?

75-100 mg daily (81mg) > 100mg of Aspirin reduces effectiveness of ticagrelor (Brilinta)

What SE are unique to ticagrelor (Brilinta)?

Dyspnea (> 10%) Increased Scr, Uric acid Bradyarrhythmias

Which NSAID is used with P2Y-12 inh?

81mg aspirin

How to manage bleeding on P2Y-12 inhibitors?

Avoid d/c, if possible (stopping p2y-12 inh, esp w/in first few months after ACS increases risk of subsequent cardiovascular events)

What meds should be avoided with use of Clopidogrel?

Strong/ moderate 2C19 inhibitors Omeprazole and Esomeprazole

What dose of simvastatin and lovastatin should be avoided with p2y-12 inh?

> 40mg

What's the tx for STEMI?

MONA + GAP-BA + PCI or Fibrinolytic therapy

What's the preferred tx btw PCI and fibrinolytic therapy?

PCI, if facilities are available

What's the timeframe to perform a PCI, if the facilities exist?

Within 90 mins, (door to balloon time)

What's the timeframe to perform fibrinolytics, if the facilities to perform PCI doesn't exist?

30 mins (door to needle). Guidelines find that fibrinolytics is still beneficial when given 12-24 hours

List agents that are called fibrinolytics.

Fibrinolytics RATS Reteplase (r-PA) (Retevase) Alteplase (t-PA, rt-PA, Activase) Tenecteplase (TNKase) Streptokinase (Streptase)

SE of fibrinolytics

Bleeding Hypotension Intracranial hemorrhage Fever

List meds that are used for long-term medical mgt (secondary prevention MI).

Aspirin P2Y-12 (Clopidogrel, prasugrel, ticagrelor) NTG (PRN) B-B (daily for 3 years) ACE-I High intensity statin (Atorvastatin 80mg is preferred) Warfarin. (If req) Pain relief (avoid NSAIDs) Lifestyle

What's the time frame for receiving high doses of aspirin (162-325mg)? Bare metal stent Sirolimus-eluting stent Paclitaxel-eluting stent

BMS - 1 month SES - 3 months PES - 6 months All these then cont on low dose aspirin (81mg) indefinitely

What's the dose and duration for P2Y-12 inh?

Plavix (Clopidogrel) - 75 mg QD Ticagrelor - 90mg BID (for at least a month and up to 1 yr)

When do u consider using p2y-12 inh for longer than 12 months?

In pts ff drug eluting stent placement (Sirolimus or Paclitaxel)

What Grp of pts MUST have ACE-I?

EF < 40% HTN CKD Diabetes

What's the target INR for Warfarin alone? Warfarin + Aspirin / W + A + p2y-12 inh?

2. 5-3.5 | 2. 0-2.5

What's NOT recommended for pain post ACS?

NSAIDs (risk of reinfaction and death)

Gen recommendations for lifestyle post-mi?

Control HTN, DM, smoking cessation Phy activities (30-60 mins/day for 5-7 days a week) New guideline just recommends weightloss only (NOT to limit fat intake)

Can Clopidogrel (Plavix) be taken with food?

Can be taken with or without food

List the meds to CONTINUE when pts goes for CABG surgery?

Aspirin UFH

When is Plavix and ticagrelor DISCONTINUED when pts goes for CABG surgery?

5 days b4

When is Prasugrel DISCONTINUED when pts goes for CABG surgery?

7 days b4

When is Eptifibatide/Tirofiban DISCONTINUED when pts goes for CABG surgery?

4 HRs b4

When is Abciximab DISCONTINUED when pts goes for CABG surgery?

12 HRs b4

When is enoxaparin DISCONTINUED when pts goes for CABG surgery?

12-24 hrs b4 .... Dose with UFH

When is fondaparinux DISCONTINUED when pts goes for CABG surgery?

24 hrs b4 .... Dose with UFH

When is bivalirudin DISCONTINUED when pts goes for CABG surgery?

3 hrs b4 .... Dose with UFH

Describe s/sx of TTP (rare SE of p2y-12 inh)

Extreme skin paleness Purplish spots or skin patches (purpura) Jaundice Mental status changes

Can alcohol be drank with Plavix? Why/why not?

No Alcohol can increase risk of bleeding

What is ACS?

ACS refers to a set of clinical disorders that result from an IMBALANCE btw myocardial oxygen demand and supply

Acute Coronary Syndrome Flashcards

(108 cards)