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Cardio 1228 > Acute Coronary Syndrome (edited) > Flashcards

Acute Coronary Syndrome (edited) Flashcards

(107 cards)

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1
Q

What usually causes the imbalance seen in ACS?

A

Plaque build up in the coronary arteries
Plaque ruptures -> clot forms -> reduction in blood flow -> ischemia (reduced blood flow)-> compromising proper cardiac functioning may lead to cardiac muscle cell death (myocyte necrosis)

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2
Q

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

A 
Troponins I and T
Creatinine kinase (CK) myocardial band (MB)
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3
Q

What clinical conditions encompasses ACS?

A

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

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4
Q

What are the common clinical xtics of UA/NSTEMI?

A

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

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5
Q

What are the clinical symptoms of ACS?

A
  • Chest pain that feels like pressure or tightness>=10 min
  • SOB-severe dyspnea
  • diaphoresis
  • syncope/pre-syncope
  • palpitations
  • Pain can radiate to arms, back, neck, jaw, or epigastric (females, diabetic, elderly may not experience classic symptoms)
  • Pain usually not relieved by nitroglycerin sublingual tablets/ spray/ rest - if not relieved after 1st dose or worse 5 minutes after dose (Call 911)
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6
Q

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

A

Immediately call 911

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7
Q

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

A

12-lead ECG

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8
Q

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

A

Percutaneous coronary intervention (PCI) capability

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9
Q

Risk factors for ACS

A 
Age (men > 45; women > 55 years or early hysterectomy)
FH of coronary event before 55yrs (men); 65yrs (women)
Smoking
HTN
dyslipidemia
Diabetes
Chronic angina
Known coronary artery dx
lack of exercise
excessive alcohol
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10
Q

What factors may precipitate ACS?

A 
Exercise
Cold weather
Extreme emotions
Stress
Sexual intercourse
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11
Q

Diagnosis of UA

A

Chest pain

NEGATIVE cardiac enzymes (neg troponin I & T TnI, TnT)

None or transient ECG changes(ST depression or T inversion)

=partial blockage

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12
Q

Diagnosis of NSTEMI

A

Chest pain

POSITIVE cardiac enzymes (Troponins, CK-MB-creatine kinase myocardial enzyme-less sensitive markers-might be monitored though)

None or transient ECG changes(ST depression or T inversion)
=partial blockage

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13
Q

Diagnosis of STEMI

A

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)

=complete blockage

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14
Q

What’s the difference btw UA and NSTEMI diagnosis?

A

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

UA - negative cardiac enzymes

NSTEMI - positive cardiac enzymes

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15
Q

What’s the difference btw NSTEMI and STEMI diagnosis?

A

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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16
Q

What’s the aim of acute tx of ACS?

A
  • Stabilizing pt’s condition
  • Relieving pain from ischemia
  • Reducing myocardial damage and further ischemia-prevent MI expansion
  • prevent death
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17
Q

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

A

MONA (given prn)

Morphine- decreases O2 demand=pain relief

Oxygen when SaO2<90% on room air

Nitroglycerin-decrease O2 demand IV for persistent pain

Aspirin- inhibits platelet agg (non-enteric chewable 162-325 immediately; maintenance 81-162 indefinitely)

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18
Q

What meds may be given in select pts?

A

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

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19
Q

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

A

Beta blocker w/o ISA (unless low output state, cariogenic shock risk, or HR<45; if HFrEF- use bis, carve, metoprolol succ)

+ ACE I

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20
Q

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

A

Fibrinolytic

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

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21
Q

When is a fibrinolytic given?

A

STEMI pt

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

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22
Q

What’s the tx for UA and NSTEMI?

A

UA/NSTEMI: MONA + GAP-BA +/- PCI
STEMI: MONA + GAP-BA + PCI or Fibrinolytic

Morphine
Oxygen
Nitrates
Aspirin

GP IIb/IIIa receptor antagonists (Tirofiban-P, Eptifibatide, Abciximab) TEA
Anti-coagulants: heparin, LMWH (Enoxaparin, Dalteparin, fondaparinux) bivalirudin are preferred in STEMI
P2Y-12 inhibitors: prasugrel - if pt is going for PCI; Ticagrelor or clopidogrel - med management +/- PCI

Beta blockers
ACE-I

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23
Q

MOA of morphine used in ACS?

A

Arterial and venous DILATION -> reduction in myocardial O2 demand

Pain relief

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24
Q

Dosing of morphine

A

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

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25
Antidote of Morphine
Naloxone (Narcan)
26
When should supplement oxygen be admin in ACS?
SaO2 < 90% OR Respiratory distress
27
MOA of nitrates
DILATES coronary arteries and improves collateral blood flow -> reduce cardia O2 demand by reduced PRELOAD
28
Dose of nitrates
NTG (SL tabs or spray) = 0.4mg (1 dose) Q 5 mins...max 3 doses
29
What's the indication for NTG IV?
Relief of ongoing ischemia discomfort HTN Mgt of pulmonary congestion
30
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)
31
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
32
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
33
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
34
If pt is intolerant to aspirin, what's the alternative?
Clopidogrel (Plavix) Prasugrel (Effient) Ticagrelor (Brilinta)
35
MOA of GP IIb/IIIa receptor antagonist?
Blocks fibrinogen binding to GP IIa/IIIb receptors on platelets, preventing PLT aggregation
36
What agents make up GP IIa/IIIb?
TEA Tirofiban (Aggrastat) Eptifibatide (Integrilin) Abciximab (ReoPro)
37
Uses of GP IIa/IIIb rec antagonists?
Medical mgt or those going for PCI +/- stent
38
Which GP IIa/IIIb is to be given ONLY if PCI is planned?
Abciximab
39
What agents make up P2Y-12 inh?
Clopidogrel (Plavix) Prasugrel (Effient) Ticagrelor (Brillinta) Cangrelor (Kangreal)
40
Which P2Y-12 inh are used for ONLY if undergoing PCI?
Prasugrel | Cangrelor-only if P2Y12 naive and not getting GP IIb/IIIa inhibitor
41
MOA of beta blockers?
DECREASE oxygen demand due to reductions in BP, HR, and contractility May reduce the magnitude of infarction
42
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 brady (HR<45)
43
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
44
MOA of ACE-I?
Inh ACE and blocks pdt of Angiotensin II Prevents cardiac remodeling Reduce preload and afterload
45
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)
46
Why is it recommended to NOT use IV ACE-I within the first 24hrs?
Due to risk of hypotension
47
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)
48
List the agents that make up GP IIb/IIIa
Tirofiban (Aggrastat) Eptifibatide (Integrilin) Abciximab (ReoPro)
49
What's the brand name of Abciximab?
ReoPro
50
What's the brand name of Eptifibatide?
Integrilin
51
What's the brand name of Tirofiban?
Aggrastat
52
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) surgery Increased Prothrombin time (PT) Hx of stroke (2yrs Reopro, 30days Integrillin) Severe uncontrolled HTN
53
What time frame is considered wrt hx of stroke and GP IIb/IIIa?
Abciximab (ReoPro) hx of stroke w/in 2 years Eptifibatide (Integrilin) hx of stroke w/in 30 DAYS OR any hx of hemorrhagic stroke Tirofiban (Aggrastat) any stroke hx
54
What C/I is unique to Abciximab (ReoPro)?
Hypersensitivity to murine proteins
55
Name the main SE of GP IIb/IIIa
Bleeding, Thrombocytopenia (both highest in Reopro) Hypotension
56
Name monitoring parameters for GP IIb/IIIa
Hgb Hct Platelets S/sx of bleeding Scr
57
Which GP IIb/IIIa has the highest risk for thrombocytopenia?
Abciximab (ReoPro)
58
What's peculiar about Abciximab (ReoPro)?
Must filter with administration
59
How soon do platelet count return after d/c of GP IIb/IIIa?
Eptifibatide (Integrilin), Tirofiban (Aggrastat) = 4-8 hours Abciximab (ReoPro) = 24-48 hrs
60
Which GP IIb/IIIa binds IRREVERSIBLY to block platelet aggregation?
Abciximab (ReoPro) Others (Eptifibatide and Tirofiban) bind reversibly
61
Name the drugs that make up P2Y-12 inhibitors
Clopidogrel (Plavix) Prasugrel (Effient) Ticagrelor (Brilinta) cangrelor (Kengreal)
62
Which P2Y-12 inh are prodrugs? Implication?
Clopidogrel (Plavix) and prasugrel (Effient) Both are prodrugs- classified as thienopyradines IRREVERSIBLE binding
63
Which P2Y-12 inh is NOT a prodrug? Implication?
Ticagrelor (Brilinta) Faster onset and offset (faster offset b/c it's NOT a prodrug)
64
What's the dosing of Clopidogrel (Plavix)?
Loading D - 300 to 600mg MD - 75mg PO daily
65
What's the dosing of Clopidogrel (Plavix ) for PCI?
600mg
66
When is no LD req for Clopidogrel (Plavix) use?
STEMI treated with fibrinolytic in pt>75 yrs
67
What determines effectiveness of Clopidogrel (Plavix)?
Activation to active metabolite by CYP 2C19 (Plavix is a prodrug) avoid with omeprazole & esomeprazole
68
Which allele is considered to be fully functional metabolism?
CYP2C19*1 *2 and *3 (have reduced functions)
69
C/I of all P2Y-12 inh
Active bleeding-all Hx of TIA or stroke-prasugrel Severe hepatic impairment-ticagrelor
70
SE of both Clopidogrel (Plavix) and Prasugrel (Effient)?
Bleeding-more with prasugrel Bruising Rash TTP (rare)-clopidogrel
71
Which P2Y-12 inh has the higher risk for bleeding?
Prasugrel (Effient)
72
When is prasugrel (Effient) used in pts >= 75years?
Only in high risk pts (DM and prior MI)
73
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) cangrelor effects gone 1 hr after D/C
74
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) and should be avoided
75
What SE are unique to ticagrelor (Brilinta)?
Dyspnea (> 10%) Increased Scr, Uric acid (hyperuricemia)
76
Which NSAID is used with P2Y-12 inh?
81mg aspirin
77
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) However be careful because there is no antidote for P2Y12 inhibitors
78
What meds should be avoided with use of Clopidogrel?
Strong/ moderate 2C19 inhibitors Omeprazole and Esomeprazole
79
What dose of simvastatin and lovastatin should be avoided with p2y-12 inh?
> 40mg
80
What's the tx for STEMI?
MONA + GAP-BA + PCI or Fibrinolytic therapy
81
What's the preferred tx btw PCI and fibrinolytic therapy?
PCI, if facilities are available
82
What's the timeframe to perform a PCI, if the facilities exist?
Within 90 mins, (door to balloon time)
83
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
84
List agents that are called fibrinolytics.
Fibrinolytics RAT- only given for STEMI when PCI can't be done within 120 minutes of 1st medical contact Reteplase (r-PA) (Retevase) Alteplase (t-PA, rt-PA, Activase) Tenecteplase (TNKase) Fibrinolytics should be given 30 minutes of hospital arrival (door to needle)
85
SE of fibrinolytics
Bleeding Hypotension Intracranial hemorrhage
86
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
87
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
88
What's the dose and duration for P2Y-12 inh?
``` Med Manage: Take for at least 12 months Plavix (Clopidogrel) - 75 mg QD OR Ticagrelor - 90mg BID + 81mg aspirin PCI: Take for at least 12 months clopidogrel OR ticagrelor OR prasugrel +81 mg aspirin ```
89
When do u consider using p2y-12 inh for longer than 12 months?
Handling DAPT, not at high risk of bleeding, AND had coronary stent placed
90
What Grp of pts MUST have ACE-I?
EF < 40% HTN CKD Diabetes
91
What's the target INR for Warfarin alone? Warfarin + Aspirin / W + A + p2y-12 inh?
2. 5-3.5 | 2. 0-2.5
92
What's NOT recommended for pain post ACS?
NSAIDs (risk of reinfarction and death) Use tylenol, nonacetylated salicylates, tramadol, or low dose narcotics first. If not sufficient...naproxen has lowest CV risk
93
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)
94
Can Clopidogrel (Plavix) be taken with food?
Can be taken with or without food
95
List the meds to CONTINUE when pts goes for CABG surgery?
Aspirin UFH
96
When is Plavix and ticagrelor DISCONTINUED when pts goes for CABG surgery?
5 days b4
97
When is Prasugrel DISCONTINUED when pts goes for CABG surgery?
7 days b4
98
When is Eptifibatide/Tirofiban DISCONTINUED when pts goes for CABG surgery?
4 HRs b4
99
When is Abciximab DISCONTINUED when pts goes for CABG surgery?
12 HRs b4
100
When is enoxaparin DISCONTINUED when pts goes for CABG surgery?
12-24 hrs b4 .... Dose with UFH
101
When is fondaparinux DISCONTINUED when pts goes for CABG surgery?
24 hrs b4 .... Dose with UFH
102
When is bivalirudin DISCONTINUED when pts goes for CABG surgery?
3 hrs b4 .... Dose with UFH
103
Describe s/sx of TTP (rare SE of p2y-12 inh)
Extreme skin paleness Purplish spots or skin patches (purpura) Jaundice Mental status changes
104
Can alcohol be drank with Plavix? Why/why not?
No Alcohol can increase risk of bleeding
105
What is ACS?
ACS refers to a set of clinical disorders that result from an IMBALANCE btw myocardial oxygen demand and supply
106
cangrelor transition
cangrelor given bolus prior to PCI, then infused for 2 hrs or duration of procedure (whichever is longer) - -> ticagrelor 180mg given during o immediately after stopping cangrelor infusion - ->prasugrel 60mg or clopidogrel 600mg given immediately AFTER stopping cangrelor infusion (DO NOT give prior to stopping)
107
vorapaxar
Zontivity Protease activated receptor 1 antagonist (PAR-1) Reversibly binds PAR1 receptor on platelets (long t1/2 makes it essentially irreversible) indicated to reduce thrombotic CV events in pts with MI Hx or PAD In trials it was used in combo with clopidogrel and/or aspirin but it is not yet incorporatedinto clinical guidelines

Cardio 1228 (17 decks)

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