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Flashcards in lecture 10 Deck (82):
1

signs and symptoms of ACS is generally

non-sensitive and non-specific

2

typical symptoms of ACS

chest, arm, jaw/neck, or epigrastric pain/discomfort with exertion or at rest

3

atypical symptoms of ACS

SOB, jaw/back pain, N/V, dizziness, "cold sweat", dyspepsia-like sensation or anorexia, hypotension, crackles in lung fields

4

women atypical ACS symptoms

SOB, jaw/back pain, nausea

5

DM ACS atypical symptoms

symptoms may be reduced due to autonomic neuropathy

6

elderly ACS atypical symptoms

symptoms may also include altered mental status

7

what does MONA stand for

morphine, oxygen, nitrate, aspirin

8

ER based aspirin

- 162-325mg CHEWED PO once
- give additional ASA if pt takes a lower dose at home
- decreases mortality**

9

ER based oxygen

- prn to maintain O2 sats>90%

10

what agents are used in ER to manage chest pain?

SL NTG
morphone
IV NTG

11

ER based SL NTG

0.4mg SL Q5min prn chest pain up to 3 doses
- avoid if exposed to PDE-5 inhibitors

12

ER based morphine

-2-5mg IV q5min prn chest pain NOT relieved by SL NTG
- analgesia+ vasodilation + decreased sympathetic tone
- hold for sedation & hypotension

13

ER based IV NTG

- to relive chest pain if NOT relieved by SL NTG &/or morphine
- hold for hypotension, tachycardia, bradycardia, arrhythmia
- do not immediately DC, must titrate down if possible

14

ER based beta blockers

oral BB's should be initiated w/in the first 24 hours

15

what is the only agent that decreases mortality?

aspirin!

16

definition of acute MI

- rise or fall of a cardiac toponin w/ one value >99th percentile w/ one of the following:
- symptoms of new angina (angina)
- new ST changes or left bundle branch block on EKG
- new onset Q waves
- imaging evidence of loss of myocardium/wall motion abnormality
- ID of coronary thrombus by angiography or autopsy

17

ECG helps distinguish

NSTEMI from STEMI
- NSTEMI can be ST elevation <20 minutes*

18

STEMI is either managed with

percutaneous coronary intervention (PCI/stenting) or fibrinolysis

19

goal of STEMI therapy

restoration of complete blood flow to occluded artery w/in 90 min of arriving at the hospitals

20

after____ of symptoms STEMI interventions are unlikely beneficial since ischemic tissue cannot be salvaged

24 hours

21

PCI

involves angioplasty &/or stenting

22

goal of PCI

- w/in 90 minutes of medical contact
- preferred method due to 90+% coronary patency after procedure

23

fibrinlysis

pharmacological dissolution of the clot occluding the coronary artery

24

goal of fibrinolysis

- w/in 30 minutes of arriving at hospital (if PCI cannot be performed)
not preferable to PCI (50-60% patency)
- typically transferred to PCI-capable hospital for angiography after administration

25

NSTE-ACSI can be classified as

high risk or low-medium risk

26

high risk NSTE-ACSI should be managed

early
- angiography +/- PCI w/in 12-24 hours

27

moderate risk NSTE-ACSI are managed with

an ischemia guided strategy

28

low risk NSTE-ACSI are

frequently sent home for our patient workup

29

goal of NSTE-ACSI treatment

identification & appropriate management of high & moderate risk pts to minimize loss of myocardium, prevent death & control chest pain & related symptoms

30

NSTE-ACSI risk stratification- candidates of early invasive management

- GRACE score >140
- elevated troponin
- ST depression (>1mm)

31

early invasive management

- high risk pts
- start antithrombotics, coronary angiography
+/- PCI should be performed w/in 24 hours

32

delayed invasive management

- medium risk pt
- start on antithrombotics, coronary angiography
+/- PCI w.in 24-72 hours

33

ischemia guided management

- low risk pt
- initial antithrombotics therapy & will have further diagnostics to determine if angiography/PCI is required

34

medical management

- pt/physician preference
- some pts do not wish or have blockages that are not amenable to catherization w/PCI.
- they will be placed on standard antithrombotics & secondary preventable measures

35

what does CABG stand for?

coronary artery bypass grafting

36

antiplatelets

aspirin
P2Y12 inhibitors
glycoprotein IIb/IIIa inhibitors

37

anticoagulants

heparinoids
direct thrombin inhibitors
factor Xa inhibitors

38

fibrinolyteics

alteplase
reteplase
tenecteplase

39

in general each patient will receive

ASA, a P2Y12 inhibitor and an anticoagulant
- everyone needs (MON)A-PA!**

40

those with NSTE-ACS undergoing ischemia guided therapy/medical management

- are generally at low risk of ischemic events and do not require multiple, expensive, highly potent agents

41

those undergoing PCI

- are at high risk of thrombosis
- need highly potent antithrombotic therapy
- GP2b/3a inhibited may be added for PCI

42

those undergoing fibrinolysis

- only STEMI
- high risk of bleeding
- use less potent agents (plavix instead of effient, arixtra inctead of heparin, no 2b3a inhibitors)

43

absolute CI to effient use

history of stroke (CVA) or TIA

44

P2Y12 inhibitor drugs

clopidogrel (Plavix)
prasugrel (effient)
ticagrelor (brilinta)

45

aspirin therapy

started in the ER and continued for EVERYONE

46

plavix is an option for

all NSTE-ACS and STEMI PCI and fibrinolysis

47

effient is an option for

PCI ONLY!
- mod-high risk NSETMI & STEMI
- too potent for fibrinolysis
- fewer ischemic events but more major bleeding than plavix
- do not give loading dose until pts has angiography that shows need for stening

48

brillinta is an option for

all NSTE-ACS (incl. ischemic guided & medical management) as well as STEMI
- NOT with fibrinolysis
- fewer ischemic events & similar bleeding to plavix
- reduced mortality compared to plavix
- may cause dyspnea or ventricular pauses

49

GP IIb/IIIa inhibitors

abciximab (reopro)
tirofiban (aggrastat)
eptifibrate (integrillin)

50

GP IIb/IIIa inhibitors are used

when planning/performing PCI

51

GPIIb/IIIa inhibitors are omitted when

bivarlirudin (angiomax) is used as the anticoagulant for PCI

52

GPIIb/IIIa inhibitors have virtually the time CI as

fibrinalytics

53

monitor bleeding with GPIIb/IIIa

platelets at baseline/2/4/12 hours

54

how long can abciximab (reopro) be used for

up to 12 hours

55

how long ca tirofiban (aggrastat) be used for

up to 18-24 hours

56

how long can eptifibatide (integrillin)be used for

up to 18-24 hours

57

heparinoid drugs

heparin (UFH)
enoxaparin (Lovenox)- LMWH

58

factor Xa inhibitor

fondaparinux (Arixtra)

59

direct thrombin inhibitor

bivalirudin (Angiomax)

60

HIT

- heparin-induced thrombocytopenia
- heparin and enoxaparin can lead to thrombocytopenia from an immune-mediated activation of platelets
- activation of platelets leads to increased risk of blood clots in the legs & lungs despite plts ebing low
- risk of HIT: heparin>enoxaparin>fondaparinux(~0%)> bivalirudin(0%)

61

heparin titration

- heparin dosing is very individualized due to variable PD
-aPTT used to characterize degree of anticoagulation by heparin

62

enoxaparin

- similar rates of thrombosis & less bleeding than heparin
- **for NSTEMI PCI: give additional 0.3mg/lg IV if going to PCI & nearing next dose
- in fibrinolysis: complicated dosing based on age & capped for overweight pts

63

fondaparinux

- typically used in those not going to cath lab
- lower dose= less bleeding
- for PCI, is insufficient & heparin will be added

64

bivalirudin

- used for PCI
- not GP2b/3Ai's
-fibrinolysis: when used at normal doses, caused increase in intracranial hemorrhage & bleeding

65

rt-PA agent

alteplase (activase)
1 bolus= continuous infusion

66

rPA agent

reteplace (ratavase)
2 bolus

67

TNK-tPA agent

tenecteplase (TNKase)
1 bolus

68

fibrinolytics are only

fibrin-specific & should be combined with ASA(162-325 once in ER), clopidogrel(300mg loading dose) & and anticoag(heparin, enoxaparin or fondaparinux)

69

before fibrinolytic use

patients should ALWAYS be screened for contraindications!!

70

absolute CIs to fibrinolytics

active internal bleeding
intracranial bleed (ever)
intracranial tumor or aneurym or AV malformation
aortic dissection
head/facial trauma (3mo)
prior ischemic stroke (3mo)

71

relative CI to fibrinolytics

severe HTN (>180/110)
dementia
current warfarin use
bleeding diathesis
active peptic ulcer
prior ischemic stroke (>3mo)
major surgery (3wks)
prior internal bleeding (2-4wks)
traumatic or prolonged CPR (>10min)

72

fibrinolytics are only used in people with

STEMI

73

secondary preventio of ACS: includes control of

- hypertension/prevention of HF
- dyslipidemia
diabetes
lifestyle

74

life style modification for secondary prevention of ACS

- obesity/diet/alcohol
-exercise at least 30-60 min of mod-intensity at least 5/wk
- medical rehab recommended after ACS

75

secondary ACS prevention: beta blockers

- prefer to initiate w/in 24 hours but caution in thsoe with risk factors or displaying cadiogenic shock/acute HF
-gradually titrated in pts with mod-severe HF or < LVEF

76

secondary ACS prevention: ACEI/ARB

- prefer to initiated w/in 24 hours but do not initiate early IV ACEI due to risk of hypotension

77

secondary ACS prevention: aldosterone antagonists

- eplerenone or spironolactone
- for those with LVEF 5mEq/dL

78

secondary ACS prevention: dyslipidemia

- high dose statin in ALL ACS pts regardless of baseline LDL
- recommended w/in 24 hours
- plaque stabilizing effect-> decreased mortality

79

stents placed during PCI are

"platelet-philic" and require some duration of dual antiplt therapy for minimum of 1 year

80

antithrombotic therapy for those in medical management or fibrinolysis

- significantly benefit from 2-4 wks of dual antiplt therapy & probably from 12 months of DAPT

81

prevention of GI bleeding in those with increased risk of GI bleeding

1. history of GI bleeding or chronic anticoag- give PPI
2. advanced age, steroid or NSAID use- PPI is reasonable
3. all others are unlikely to benefit

82

triple antithrombotic therapy

ASA+ P2Y12I+ anticoagulant
- e.g someone with ACS & AFib
- risk of bleeding goes up significantly
- target warfarin INR 2-2.5
- ASA <81mg
- minimal safety datd for prasugrel, ticagrelor, dabigatran, rivaroxaban, apixaban