Acute Coronary Syndromes Flashcards
(82 cards)
1
Q
What is an acute coronary syndrome?
A
A medical emergency; when plaque buildup (atherosclerosis) in the coronary arteries can rupture leading to a clot formation leading to sudden reduced blood flow to the heart; imbalance between myocardial supply and demand and/or cardiac muscle cell death due to reduced blood flow lead to symptoms
2
Q
What are risk factors for ACS?
A
- men >45/ women> >55 (or early hysterectomy)
- 1st-degree relative with a coronary event <55(men) or <65 (women)
- smoking
- HTN
- known coronary artery disease
- dislipidemia
- diabetes
- chronic stable angina
- lack of exercise
- excessive alcohol
3
Q
What are signs/symptoms of ACS?
A
- chest pain lasting ≥10 minutes (often described as pressure, squeezing, or discomfort); can radiate to the arms, back, neck, jaw, or epigastric region
- dyspnea
- diaphoresis (excessive sweating)
- syncope/presyncope
- palpitations
4
Q
What can precipitate ACS symptoms?
A
- minimal exertion
- exercise
- cold weather
- extreme emotions
- stress
- sexual intercourse
5
Q
What should patients with nitroglycerin do if symptoms occur?
A
use 1 dose of nitroglycerin every 5 minutes for up to 3 doses; if chest pain has not improved or gotten worse since the first dose they should call 911 immediately
6
Q
What medical emergencies fall under ACS?
A
- unstable angina
- non-ST-segment elevation myocardial infarction
- ST-segment elevation myocardial infarction
7
Q
What should be done if a patient is suspected of having ACS?
A
- 12-lead ECG should be performed and evaluated within 10 minutes at the first site of medical contact (EMS)
- urgently transport to a facility with percutaneous coronary intervention
8
Q
How are the types of ACS differentiated?
A
- cardiac enzymes (troponins TnI and TnT) at presentation and 3-6 hours
- ECG changes (ST elevation)
- partial or complete blockage
9
Q
What are the characteristics of unstable angina?
A
- chest pain
- partial blockage
- transient or no ECG changes or cardiac enzymes
10
Q
What are the characteristics of NSTEMI?
A
- chest pain
- partial blockage
- positive cardiac enzymes
- transient or no ECG changes ( ST segment depression or prominent T-wave inversion)
11
Q
What are the characteristics of STEMI?
A
- chest pain
- positive cardiac enzymes
- ST-segment elevation (≥ 2 continuous leads; leads looking at the same area of the heart)
12
Q
What are the treatment goals for ACS?
A
immediate relief of ischemia and preventing MI expansions and death
13
Q
What is a PCI?
A
coronary revascularization procedure that involves inflating a small balloon inside a coronary artery to widen it and improve blood flow; usually a stent is placed to keep an artery
14
Q
For what ACS is PCI appropriate?
A
- STEMI requires arteries be opened as soon as possible
- PCI can be considered UA or NSTEMI as an early invasive strategy
15
Q
How long after arrival to the hospital does PCI need to be performed to be preferred?
A
90 minutes (door-to ballon time) or within 120 minutes of medical contact
16
Q
What should be done if PCI is not performed within 120 minutes of first medical contact?
A
fibrinolytic therapy is recommended and should be given within 30 minutes of hospital arrival (door-to-needle time)
17
Q
How do antianginal agents treat ACS?
A
decrease myocardial oxygen demand or increase supply to relieve ischemia
18
Q
How do antiplatelet agents treat ACS?
A
inhibit platelet aggregation to prevent clot formation/growth
19
Q
How do anticoagulants treat ACS?
A
inhibit clotting factor to inhibit clot formation/growth
20
Q
How can treatment options for ACS be remembered?
A
MONA-GAP-BA
21
Q
What are the treatment options for UA or NSTEMI?
A
MONA-GAP-BA +/- PCI
22
Q
What are the treatment options for STEMI?
A
MONA-GAP-BA +/- PCI (preferred) or fibrinolytic
23
Q
What drugs should be given immediately and prn for ACS?
A
Morphine
Oxygen
Nitrates
Aspirin
24
Q
What drugs are considered after MONA in ACS?
A
G: GPIIb/IIIa antagonists
A: anticoagulants
P: P2Y12 inhibitors
25
What drugs are initiated within 24 hours of ACS and continued outpatient?
B: beta-blocker
A: ACEi
26
How is morphine sulfate dosed for chest pain due to ACS?
1. Not for routine use due to diminished antiplatelet effects
2. Unacceptable chest pain despite other treatment: 2-5mg IV Q5-30 min prn
3. Monitor: hypotension, N/V, sedation, and respiratory depression
27
When should O2 be used in ACS?
Arterial O2 saturation <90% or having respiratory distress
28
How is nitroglycerin dosed in ACS?
SL: 0.4mg every 5 min x 3 doses if not already administered in patients with HF, HTN, chest pain
IV: Considered in sx persist; DO NOT use if SBP<90/HR<50/right ventricular infarction; CI with PDE-5 inhibitors
29
How is aspirin dosed in ACS?
1. 162-325mg non-enteric coated, chewable aspirin given immediately
2. 75-100mg continued indefinitely
30
What drugs can be used for ACS if aspirin is not tolerated?
1. Clopidogrel
2. Ticagrelor
*** P2Y12 inhibitors are often used in addition to aspirin
31
What clinical benefits do beta blockers have with ACS?
1. Antianginal
2. Decrease BP/HP/contractility
3. Decreased ischemia, reinfarction, and arrhythmias
4. Prevents cardiac remodeling
5. Increases long term survival
32
What beta blockers are preferred for ACS?
1. PO low dose beta-1 selective blocker without intrinsic sympathomimetic activity (AMEBBA) within 1st 24 hours
2. If HFrEF use preferred beta blockers
3. IV beta blockers or DHP CCBs are a;ternatives
33
What clinical benefits do ACE inhibitors have for ACS?
1. Prevent cardiac remodeling
2. Reduced preload/afterload
34
What ACE inhibitors are preferred with ACS?
1. PO started within 24 hours and continued indefinitely in patients with LVEF<40%, HTN, DM, or stable CKD, unless CI
2. DO NOT use IV ACE inhibitor within 24 hours due to risk of hypotension
35
Which anticoagulants are preferred in ACS?
1. LMWHs (enoxaparin, dalteparin)
2. UFH and bivalirudin preferred for STEMI
36
What medications should NOT be given with acute ACS?
1. NSAIDs (aspirin) (unsure about selective COX-2) increases risk of mortality, reinfarction, HTN, cardiac rupture, renal insufficiency, and HF
2. IR nifedapine due to risk of mortality
37
What antiplatelet drugs are used in ACS?
1. Aspirin (COX-1 inhibitor)
2. P2Y12 inhibitors
3. GPIIb/IIIa inhibitors
4. PAR-1 inhibitor
38
What is the MOA of P2Y12 inhibitors (-grel)?
1. Bind to platelet P2Y12 receptors, preventing platelet-mediated activation of GPIIb/IIIa receptor complex
2. Clopidogrel/ Prasugrel: thienopyridine prodrugs that irreversibly bind to receptors
3. Ticagrelor: not a prodrug; irreversible binding
39
Which P2Y12 inhibitor is available IV?
Cangrelor (Kengreal)
40
How is clopidogrel dosed for ACS?
1. LD: 300-600mg PO or 600mg PO if getting PCI
2. MD: 75mg PO QD
3. >75 y/o and fibrinolytic administered for STEMI: NO LD, start MD
41
Prasugrel
Effient
42
What is prasugrel indicated for?
Only for ACS managed with PCI
43
What are BBWs with prasugrel?
1. significant/fatal bleeding
2. Not recommended >75 y/o unless DM or prior MI
3. DO NOT initiate if CABG is likely; STOP 7 days prior to elective surgery
44
What are CIs with prasugrel?
1. Active serious bleeding
2. History of TIA/ stroke
45
What are warnings with prasugrel?
1. Bleeding risk
2. Thrombotic thrombocytopenic purpura
3. Increase thrombis risk if premature D/C
46
What are SEs with prasugrel?
Well tolerated unless bleeding occurs (higher risk vs. clopidogrel)
47
How is prasugrel dosed/ stored/administered?
1. LD: 60mg PO (no later than 1h after PCI); once PCI is planned give dose promptly
2. MD: 10mg PO QD with aspirin
3. <60kg: 5mg PO QD w aspirin
4. Protect from moisture, dispense in original container
48
Ticagrelor
Brillinta
49
What are BBWs with Ticagrelor?
1. Serious/fatal bleeding
2. Do not exceed >100mg maintenance dose of aspirin, higher doses decrease effectiveness
3. STOP 5 days before any surgery; avoid if CABG likely
50
What are CIs with ticagrelor?
1. Active serious bleeding
2. History of intracranial hemorrhage
51
What are warnings with ticagrelor?
1. Bleeding risk
2. Severe hepatic impairment
3. Bradyarrhythmias
4. Thrombotic Thrombocytopenic Purpura
5. increased thrombis with premature D/C
52
What are SEs with ticagrelor?
1. Bleeding
2. Dyspnea (>10%)
3. Elevated SCr
4. Elevated uric acid
53
How is ticagrelor dosed?
1. LD: 180mg
2. MD: 90mg PO BID for 1 year, then 60mg BID
3. Tablets can be crushed and mixed with water (can be put down NG tube)
54
Cangrelor
Kengreal
55
What is cangrelor indicated for?
Only as an adjunct to PCI in patients who are P2Y12 inhibitor naive and are not receiving GPIIb/IIIa
56
What are CIs with cangrelor?
Significant active bleeding
57
What are SEs with cangrelor?
1. Bleeding
2. Effects are gone 1h after D/C, transition to PO P2Y12 inhibitors after PCI
58
How is cangrelor dosed?
1. LD: 30 mcg/kg IV bolus prior to PCI
2. MD: 4mcg/kg/min IV for 2h or for duration of procedure (whichever comes 1st)
59
What are DIs with P2Y12 inhibitors?
1. Additive bleeding (SNRIs/SSRI, NSAIDs)
2. Clopidogrel: avoid with omeprazole, esomeprazole, and other 2C19 inhibitors; enhanced effects of repaglinide can lead to hypoglycemia
3. Ticagrelor: monitor digoxin levels with any changes to therapy; avoid with Simvastatin, >40mg Lovastatin, and other strong 3A4 inducers/inhibitors
60
When are GPIIb/IIIa inhibitors used in ACS?
1. Eptifibatide/ Tirofiban: reversible blockade; medical management of ACS or used with heparin if receiving PCI +/- stent
2. Abciximab: irreversible blockade; indicated for PCI +/- stent with heparin
61
Eptifibatide
Integrellin
62
Tirofiban
Aggrastat
63
What are CIs with GPIIb/IIIa inhibitors?
1. Thrombocytopenia (PLT<100,000)
2. Hx of bleeding diathesis (predisposition)
3. Active internal bleeding
4. Severe uncontrolled HTN
5. Recent major surgery/trauma (w/in 4wk of tirofiban, 6wk of eptifibatide)
6. Hx stroke w/in 30 days/ any hx of hemorrhagic stroke (eptifibatide)
64
What are SEs with GPIIb/IIIa inhibitors?
1. Bleeding
2. Thrombocytopenia
65
What should be monitored with GPIIb/IIIA inhibitors?
1. Hgb/Hct
2. PLT (PLT function returns w/in 4-6h of D/C)
3. S/sx bleeding
4. renal function
66
How are GPIIb/IIIa inhibitors administered?
IV requires renal dosage adjustments
67
What is the protease-activated receptor-1 antagonist (Vorapaxar) indicated for?
Patients with a history of MI or peripheral artery disease (PAD) to reduce thrombotic CV events (CV death, MI, stroke, urgent coronary revascularization); Used in addition to aspirin +/- clopidogrel
68
Vorapaxar
Zontivity
69
What are BBWs with vorapaxar?
1. Bleeding risk (including intracranial hemorrhage/ fatal bleeding)
2. Do not use with a history of stroke, TIA, ICH, active serious bleeding
3. Do not use in severe liver impairment (warning)
70
What are SEs with vorapaxar?
1. bleeding
2. anemia
71
What are DIs with vorapaxar?
Avoid use with strong CYP3A4 inhibitors/inducers
72
What is the indication for fibrinolytics?
Only used for STEMI, should be given 30-60min door-to-needle time (improves survival); can be given within 12-24 h of STEMI sx onset if still symptomatic
73
What is the MOA of fibrinolytics?
Breakdown clot by binding to fibrin and turning plasminogen to plasmin
74
What are CIs with fibrinolytics?
1 Active internal bleeding/ predisposition
2. Hx recent stroke
3. Prior intracranial hemorrhage
4. Recent intracranial/spinal surgery/ trauma (last 2-3 mo)
5. Intracranial neoplasm/ arteriovenous malformation/aneurysm
6. Severe uncontrolled HTN (unresponsive to emergency therapy)
7. Alteplase CIs and dosing different for ischemic stroke***
75
What are SEs and monitoring for fibrinolytics?
1. Bleeding including intracranial hemorrhage
2. Hgb/Hct
3. s/sx bleeding
76
How is Alteplase dosed for ACS?
>67kg: 100mg IV over 1.5h given as a 15mg bolus, 50mg over 30min, then 35mg over 1h
≤67kg: 15mg bolus, then 0.75mg/kg (max 50mg) over 30 min, then 0.5mg/kg (max 35mg) over 1h (max 100mg total)
77
Alteplase
Activase
Recombinant tissue plasminogen activator (tPA, rtPA)
78
Tenecteplase
TNKase
79
Retaplase
Retavase
80
What drugs should patients be on for secondary prevention of ACS (clinical ASCVD)?
1. Aspirin 81mg indeifinitly
2. DAPT (clopidogrel/ticagrelor) for at least 12 mo, may continue longer with stent if tolerating therapy
3. Nitroglycerin SL/TL prn indefinitely
4. Beta blockers for 3 years or indefinitely if HF/HTN
5. ACE inhibitor indefinitely if EF<40, CKD, HTN, and MI with no CI
6. High intensity statin indefinitely (≥75 moderate or high)
7. Aldosterone antagonist indefinitely if EF≤40 + symptomatic HF/ DM receiving target doses of ACE and beta blocker; Avoid if severe renal impairment (SCr>2.5 in men and >2 in women, hyperkalemia >5)
81
How should patients with AFib and ACS be treated?
Triple antithrombotic therapy therapy for those requiring anticoagulation for AF and DAPT (clopidogrel preferred) after PCI+ stent, used for the shortest time possible; Use PPIs if hx of GI bleeding
82
What should be avoided after ACS?
NSAIDs, especially COX-2 selective, have the highest CV risk; Use acetaminophen, non-acylated salicylates, tramadol, low-dose
narcotics
