IHD - ACS √

Question 1

What are the diagnostic for STEMI

Answer 1

ST elevation
Biomarkers +

Question 2

What are the diagnostic for NSTEMI

Answer 2

ST depression or T-wave inversion
Positive biomarkers

Question 3

What are the Diagnostic for unstable Angina

Answer 3

ST depression or T wave inversion
Positive biomarkers

Question 4

ACS clinical symptoms

Answer 4

Chest pain - that could radiate
Nausea
Sweating
Impending doom
Low grade fever
4th heart sounds
3rd heart sounds

Question 5

What does BBB (brachial branch block )

Answer 5

1 or 2 mm raise in 2 or more leads (1-6 lead)

Question 6

When do you take cardiac draws in the hospital

Answer 6

Every 6-8 for 3-4 draw bc some biomarkers are later in onset

Question 7

What is the most important function of the heart ?

Answer 7

LV function and if you cant fix it you get a scar that can cause death if it ruptures

Question 8

What does everyone get if they have STEMI or NSTEMI

Answer 8

Oxygenation only if < 90%
ECG leads monitoring
Glycemic control (<180 glucose)
Pain relief
Stool softeners
Vital Monitoring

Question 9

Chest discomfort last ≥10mins flow chart (pic)

Answer 9

Question 10

does it matter where in the hospital the patient is?

Answer 10

yes bc it helps give perspective
ED - Thrombolysis
Cath lab - PCI
ICU/Ward - Secondary prevention

Question 11

STEM flow chart for treatment (pic)

Answer 11

Usually do fibrinolytic or primacy PCI, Happens in the ED

Question 12

What is given to all STEMI patients

Answer 12

M- + or - morphine 1-5mg IV every 5-30mins (may or may not give due to chest pain relief being unknown wether it be nitro or morphine, usually 3 dose may or may not give M)

O - only give below 90%

N- Nitro .4mg every 5 mins for 3 dose (tachyphylaxis sign of nitrate intolerance, usually not in STEMI pts)

A - aspirin give 325 ( #1 drug to use )

Heparin (#2 drug to use)

+/- Metropolol, PY12 inhibitor, Statin

Question 13

What anticoagulant is the drug of choice

Answer 13

Heparin

Question 14

When would I use morphine but what do i risk as well

Answer 14

usually a patient that has high anxiety bc it raises heart rate but it can mask the pain of the chest and a DDI with clopidogrel

Question 15

When would i consider giving O2

Answer 15

<90, HF or dyspnea

Question 16

5 nitro contraindications

Answer 16

1. SBP < 90
2. 30 mmHg lower than baseline
3. PDE-5i
4. RV infarct
5. hypertrophic heart
   Limit: anginal pain, LV failure, severe hypertension

Question 17

Heparin STEMI dosing for Fibrinolysis

Answer 17

Fibirnolysis
Bolus - 60 unit/kg/IV max 4000
Main - 12 unit/kg/IV max 1000 units

Question 18

Heparin Stemi Primary PCI or medical management

Answer 18

PCI and medical management
Bolus - 60 unit/kg/IV max 5000
Main - 12 unit/kg/IV max 1000 units

Question 19

Anti X and aPPT goal for Heparin STEMI/NSTEMI

Answer 19

Anti Xa - 0.3 - 0.6
aPPt - 50-70

Question 20

In a STEMI when would I consider Beta Blockers

Answer 20

HR is in the 130 and ongoing STEMI
high O2 Demand
Hypertension
on going ischemia

Question 21

When do we avoid BB in STEMI

Answer 21

Advance age 70+
Bradycardia < 60 bpm
Hypotensive pt SBP < 120
Prolonged PR interval >0.24 sec or 2nd/3rd degree Heart block
Active asthma or airway disease

Question 22

Reperfusion flowchart for STEMI

Answer 22

Question 23

Do we prefer PCI or thrombolytic in reperfusion

Answer 23

PCI because a much higher flow so much so that we withhold treatment with fibrinolytic for 30mins max

Question 24

What is the fibrinolysis door to needle time

Answer 24

≤ 30 mins

Question 25

If I can't get to a cath lab when would I use Fibrinolysis

Answer 25

within 12 hours with elevation and can not be brought to the cath lab

Question 26

What is the biggest risk of Fibrinolytics and which populations are more at risk?

Answer 26

ICH 75 + Female Cerebral vascular disease elevated SBP/DBP HTN

Question 27

Which fibrinolytic have the lowest bleeding rate

Answer 27

Alteplase

Question 28

Which fibrinolytic is recommended for STEMI

Answer 28

Tenecteplase because fast dosing ( iv over 5 seconds) <60 kg 30 mg 60-69 35 mg 70-79 40 mg 80-89 45 mg >90 50 mg

Question 29

Alteplace dosing for STEMI

Answer 29

15 mg over 1 - 2 mins 0.75 kg/min over 30 mins 0.5 kg/min over 60 mins

Question 30

What are the 3 criteria for successful fibrinolytic

Answer 30

1. > 50% reduction in ST segments of the ECG 2. Relief of chest pain 3. Appearance of reperfusion arrhythmias

Question 31

What are some options for antithrombotic during PCI

Answer 31

1. Heparin as mono 2. Heparin and cangrelor 3. Stop heparin start Bivalirudin mono 4. Stop heparin start Bivalirudin and cangrelor 5. RARE use of glycoproteins IIb/IIIa add on to one above (salvage or bailout)

Question 32

Why do most providers switch to Bivalirudin from heparin in PCI?

Answer 32

less bleeding and same outcome

Question 33

Bivalirudin dosing

Answer 33

LD: 0.75mg per kg Main: 1.75 mg per kg/hr DC after cath lab If cont 1.75 mg/kg/hr over 4 hours then 0.2 mg/kg/hr up to 20 hrs

Question 34

How do we monitor bleeding time in the cath lab

Answer 34

ACT

Question 35

Which PGy12i is preferred for fibrinolysis

Answer 35

Clopidogrel 600mg

Question 36

Clopidogrel dosing

Answer 36

LD 300 - 600mg MD 75 mg QD

Question 37

Prasugrel Dosing

Answer 37

LD 60mg MD 10mg if <60kg 5 mg QD

Question 38

Ticagrelor dosing

Answer 38

LD 180 mg MD 90 mg BID

Question 39

Cangrelor dosing

Answer 39

LD 30 mcg/kg IV MD 4 mcg/kg/min

Question 40

Clopidogrel indications

Answer 40

NSTEMI, medical STEMI and Fibrinolytic STEMI, PAD NO PCI

Question 41

How many days do you need to stop Antiplatelet before surgery

Answer 41

5 days

Question 42

What DDI do we need to worry about with clopidogrel

Answer 42

PPI inhibit 2C19 but Omeprazole and esomeprazole the worst and must change Use pantoprazole

Question 43

What do we worry about with Plavix

Answer 43

Clopidogrel Genetic variation is a huge consideration why we only use for medical management and not primary PCI

Question 44

Which has more bleeding prasugrel or Clopidogrel?

Answer 44

Prasugrel

Question 45

What is Effient

Answer 45

Prasugrel

Question 46

Prasugrel Indication

Answer 46

Primary PCI

Question 47

which patient sub populations does prasugrel work better in?

Answer 47

male under the age of 65 who have daibetes

Question 47

2 Benefits of Prasugrel

Answer 47

more potent no genetic variablility

Question 48

What important consideration do we take with Prasugrel

Answer 48

Effient Elderly ≥ 75 have increase fatal bleeding events ( not a X contra but try to avoid but risk analysis with high risk pts) Low body weight < 60kg lower to 5mg daily

Question 49

What is an absolute contradiction for Prasugrel

Answer 49

history of TIA (transient ischemic attack) / stroke

Question 50

How many days do we need to hold Effient for surgery

Answer 50

7 days

Question 51

What is Ticagrelor

Answer 51

Brilinta

Question 52

Brilinta DDI

Answer 52

CYP 3A4/5 Pgp Aspirin

Question 53

What previous bleeding contraindicates Ticagrelor

Answer 53

ICH

Question 54

Ticagrelor indication

Answer 54

PCI or non invasie medical treatment

Question 55

What do we do with Brilinta and Aspirin

Answer 55

They have to be on 81mg to be effective Antiplatelet Okay to give the 325 upon admission and will not have an effect on Ticagrelor

Question 56

What is the best pro of Ticagrelor

Answer 56

its speed

Question 57

What sensation do pts feel on Ticagrelor

Answer 57

SOB but doesn’t actually affect their breathing intake

Question 58

Antiplatelet oral comparison chart (PIC)

Answer 58

Question 59

What is brand of Cangrelor

Answer 59

Kengreal

Question 60

What is the wow factor of Cangrelor

Answer 60

100% inhibition within 2 mins Full platelet recovery in 1 hour

Question 61

Dosing for Kengreal

Answer 61

30 mcg/kg bolus 4 mcg/kg/min for at least 2 hours

Question 62

Switching to outpt for pts on cangrelor

Answer 62

Brilinta 180mg any time Effient 60mg and plavix 600 - Need to wait after infusion

Question 63

What are the Glycoprotien IIb/IIa inhibitor

Answer 63

Tirofiban Eptifibatide

Question 64

Which glycoprotein IIa/IIIb cant be used for PCI STEMI

Answer 64

Tirofiban

Question 65

Secondary therapy ACEi indication

Answer 65

HF HTN AMI (acute phase post infraction of left ventricle) Nephropathy Cardiovascular protection

Question 66

When can i start after 24HRs for ACEi

Answer 66

HTN, LEVF ≥40%, DM, CKD

Question 67

What is indication is important for ACEi to start

Answer 67

MUST USE WITHIN 24hrs AMI - STEMI that has LVEF ≤40%

Question 68

What is the one thing in treatment of NSTEMI that differs from STEMI

Answer 68

No use of fibrinolytic and risk stratify the pt

Question 69

Risk cut offs for NSTEMI

Answer 69

Question 70

Anticoagulation decisions between heparin, enoxaparin and fondaparinux

Answer 70

Usually heparin but if low risk not much to do after PCI easier for pt to switch to enoxaparin

Question 71

What is the treatment for medical management

Answer 71

Question 72

what is the treatment for CABG

Answer 72

Question 73

When would i use CABG

Answer 73

multiple blocked vessels