MT2_10_Acute Coronary Syndrome

Question 1

What are the main causes of ACS?

Answer 1

• atherosclerotic rupture
• narrowing after PCS
• vasopasms
• coronary artery dissection

Question 2

What happens with a plaque ruptures?

Answer 2

• collagen: activates platelet aggregation

- tissue factor: coagulation cascade for thrombus formation (activates factor 10) over platelets

Question 3

EKG: T Wave Inversion

Answer 3

• ischemia

- UA/NSTEMI

Question 4

ST Depression

Answer 4

• subendocardial ischemia

- UA/STEMI

Question 5

ST Elevation

Answer 5

• ACUTE infarct
• revertive damage/injury
• STEMI

Question 6

Q Waves

Answer 6

• transmural infarct, prior MI

- dead myocardial tissue, not reversible

Question 7

When does analgesics come into play when it comes to therapy? What is the DOC? Why? monitor?

What if the patient is hemodynamically unstable?

Answer 7

• if NTG does not work
• morphine: releases histamine, vasodilation, anxiolytic
• monitor decrease in BP, HR, RR, caution in RV infarction
• fentanyl (due to less histamine release)

Question 8

How much O2 to give to a patient?

Answer 8

2-4 L/min

Question 9

MOA of Nitro?

• Dose?
• Monitor?
• AE
• CI

Answer 9

muscle relaxant and vasodilator, decrease in preload and after load

• 0.4mg tab q5min 3x
• AE/monitor: headache, hypo, tacky
• CI: use with PDE5inhibitor, RV infarction, SBP less than 90

Question 10

For aspirin, monitor for___and CI in____

Answer 10

• bleeding, CBC

- aspirin allergy (use clopidogrel)

Question 11

For a bare metal stent, when is it indicated?

Answer 11

• pts with compliance issues
• high bleed risk
• larger arteries

Question 12

For a drug eluting stent, what is it for?

Answer 12

• to prevent tissue growth, and narrower vessels (DM patients)

Question 13

Comparing BMS and DES

• risk of restenosis (tissue grows over stent)
• stent thrombosis (formation of blood clot)
• antiplatelet therapy
• long-term mortality benefit

Answer 13

• higher for BMS
• higher DES
• longer for DES
• same mortality benefit
• DES has reduction in target lesion revasc.

Question 14

What is the indication for fibrinolytic therapy? In a STEMI patient? The do we not use it?

Answer 14

• delay in primary PCI within 2 hours of onset, onset of symptoms was less than 12 hours ago
• if the symptoms happened 12-24 hours ago and there is evidence of ongoing ischemia (ECG) and there is a large area myocardium at risk
• do not use if ST depression

Question 15

What is the MOA of fibrinolytic?

Answer 15

• catalyze plasminogen to plasmin which breaks down fibrin

Question 16

Absolute CI of fibrinolytic?

Answer 16

• prior brain bleed, current bleeds, brain lesions, brain tumors
• stroke within 3 months, except acs within 4.5 hours
• aortic dissection
• uncontrolled HTN
• head/facial trauma within 3 months
• intracranial or spinal surgery

-steptokinase use 6 months prior

Question 17

For TPA, what is the dose?

Answer 17

• 15mg bolus
• .75mg/kg 30 min (max 50)
• .5 mg/kg in one hour

Question 18

If the fibrinolytic doesn’t work, when should you consider a PCI?

Answer 18

• if there is no relief of chest pain
• no resolution of ST elevation greater than 70%
• lack of reperfusion arrhythmias

Question 19

What to monitor for when giving a fibrinolytic? (4)

Answer 19

• blleding
• CBC
• INR
• aPTT (with heparin)

Question 20

Class I indication for fibrinolytic therapy is a STEMI pt presents within __ hours of symptom onset and time of delay to PCI greater than __min

Answer 20

• 12

- 120

Question 21

After STEMI or fibrinolytic, what to you do? With what agents?q

Answer 21

• prevent clot expansion

- (anti platelet) aspirin, P2y12 inhibitor, (GP2B3A inhibitor), and an anticoagulant

Question 22

When is ASA indicated, monitor for…? Dose

Answer 22

• ALL ACS patients
• monitor for bleeding and CBC
• 165-325 loading, then 81 QD

Question 23

For dual anti platelet therapy, what are the indications?

Answer 23

• in all ACS patients for 12 months

- PCI w stent to prevent thrombosis

Question 24

Indication of clopidogrel

Dosing

Hold

BBW

What if patient is on a PPI?

Answer 24

• ALL patients with ACS, alternative to aspirin
• LD: 300mg, 600 for stent, no LD if greater than 75, less than 75 300
• all MD is 75mg

Hold 5 days prior surgery

• BBW: variant 2C19 alleles, reduce conversion to active metabolite
• weigh risk vs benefits, pantoprazole> omeprazole, which inhibits 2C19 the most

Question 25

For prasugrel, what is the indication? - why is it "better" than clopidogrel - Dose - Hold - CI BBW

Answer 25

- ACS w PCI ONLY - faster inhibition of platelets bc only one single CYP conversion - LD 60mg, 10mg PO QD 1Y (less than 60, 5mg) - hold 7 days - CI: hx of stroke or TIA - BBW: greater than 75 years old

Question 26

Compared to Plavix, how does ticagrelor work? - Dose - Hold - CI - BBW

Answer 26

- similar, but it is reversible so you can recover platelets if need be, NOT a prodrug - 180 mg, 90mg BID 1year, 60mg BID after - hold 5 days before - CI: hepatic impairment, brain bleeds - use w aspirin less than 100

Question 27

For cangrelor, what is the main indication?

Answer 27

- adjunct to PCI, in patients not treated with other P2y12 inhibitors of GP2B3A inhibitors - reversible! inhibition happens within 2 minutes, platelet function returns in one hour

Question 28

Indication for Vorapaxar? Dose CI

Answer 28

- hx of MI or PAD - 2.08 mg PO daily w aspirin and/or clopidogrel - CI: stroke, TIA, intracranial bleeding - DO NOT USE in ACS or prior to PCI

Question 29

How long should patients on a DAPT?

Answer 29

- drug eluting stent: at least 3-6months - 12 years - bare metal stent: at least 1 month, for one year - non invasive ticagrelor or clopidogrel up to 12 months all with aspirin

Question 30

When risk stratifying ACS NSTEMI, what has to be present? (just one is needed)

Answer 30

- prolonged chest pain - hemodynamic instability - dynamic ST changes on EKG - Heart failure symptoms - new/worsening regurgitation mitral

Question 31

What are the GP2B3A inhibitors, and what is their indication? Why do we use these agents? - Can it be used in PCI? - What if pt is getting CABG - MUST BE - Monitor - CI

Answer 31

- Abciximab, Eptifibatide, Tirofiban - binds to the GP receptors on activated platelets to prevent fibrinogen cross linking, therefore no platelets - only use if patients are at high risk, unable to get a PCI right away - yes - can get these drugs, if scheduled within 5-7 days - given with another anti platelet - monitor: bleeding - CI: active bleeding within 30 days, hx of stroke in 30 days, severe HTN (>200/110), major surgery within 6 weeks

Question 32

For Abciximab (Reopro), what is the indication, and is adjustment needed?

Answer 32

- PCI ONLY - ab binds to receptor, causing hinderance - no renal adjustment is needed

Question 33

For Eptifibatide, what is the indication?adjust?

Answer 33

- ACS w.wo PCI - synthetic peptide that blocks the inhibitor - adjust if clearance is less than 50, to 1mcg/kg/min

Question 34

For tirofiban, indication?really adjust?

Answer 34

- ACS w/wo PCI | - renal adjust, clearance is less than 60, 0.075 mcg/kg/min

Question 35

For anticoagulation therapy, what can be used?

Answer 35

Heparin: UFH, LMWH DTI: bivalirudin, argatroban Factor 10a inhibitor: fonda

Question 36

When is UFH indicated?Dosing?Monitoring?

Answer 36

all patients with ACS - LD: 60U, MD12U /kg - titrate to 1.5-2x baseline aPTT - monitor bleeding, CBC, ACT,/aPTT

Question 37

For LMWH, when is it indicated?

Answer 37

- all patents with ACS, more affinity to 10a - enox: less than 75, 30mg IV bolus, then 1mg.kg SQ Q12 - BBW: spinal/epidermal hematomas - monitor: bleeding, CBC, CrCl, anti-10a sometimes

Question 38

When are DTI indicated? Monitor? What are the drugs?

Answer 38

- alternative to UFH, LMWH in patents with HIT and antithrombin III deficiency - monitor bleed, CBC, ACT/aPTT bivalirudin, agatriban, fonda

Question 39

What is the dose for bivalirudin?

Answer 39

0.75 mg/kg/hr, then 1.75 until end of infusion if CrCL is less than 30, 1mg/kg/hr

Question 40

Dosing for agatriban? | When to avoid?

Answer 40

350 mcg/kg bolus 3-5 min AST/ALT greater than 3x normal falsely elevated INR if needed for post PCI, 2-10 mcg/kg/min, closely monitor aPTT