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Cardio Renal II Midterm > Therapeutics - ACS (Acute Coronary Syndrome) Part 1 > Flashcards

Therapeutics - ACS (Acute Coronary Syndrome) Part 1 Flashcards

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1
Q

acute coronary syndrome is also called

A

unstable angina

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2
Q

coronary artery disease (CAD) presents with ____

A

angina

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3
Q

why does CAD present with angina

A

due to atherosclerosis of the coronary vessels

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4
Q

what are the 3 categories of CAD

A

chronic stable
coronary artery vasospasm
ACS

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5
Q

3 subtypes of ACS

A

NSTEMI
unstable angina
STEMI

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6
Q

differentiate the EKG changes and biomarkers for:
-unstable angina
-NSTEMI
-STEMI

A

unstable angina - nonspecific EKG changes, no positive biomarkers (no myocardial injury)

NSTEMI - nonspecific EKG changes BUT there are positive biomarkers which indicates myocardial injury

STEMI - ST segment elevation on EKG AND positive biomarkers which indicates myocardial NECROSIS

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7
Q

differentiate between the symptoms of unstable angina vs NSTEMI vs STEMI

A

unstable angina and NSTEMI have the same clinical symptoms of angina

STEMI has these symptoms too, but women, elderly, and diabetics have an ATYPICAL REACTION – they dont get the classic gripping chest pain - get atypical symptoms like fatigue, back pain

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8
Q

true or false

in NSTEMI, there is no injury to the heart

A

FALSE- there is
have positive biomarkers

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9
Q

true or false

STEMI will lead to myocardial necrosis because there is TOTAL occlusion of the coronary artery

A

true

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10
Q

3 complications of ACS

A

cardiogenic shock
heart failure
left ventricle thrombus (very dangerous)

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11
Q

what are the 2 key things that we look for to determine the type of ACS?
be specific

A

EKG changes and cardiac biomarkers

cardiac biomarkers - we look to see if troponins and CK-MB (creatinine kinase) are elevated

in ECG, we look to see if ST is elevated specifically

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12
Q

invasive vs noninvasive diagnostic measures of ACS

A

invasive- cardiac catheterization

non-invasive - cardiac stress test

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13
Q

when a patient presents with ACS, what is important to obtain within 10 mins of presentation

A

ECG!!!!
determines STEMI or NSTEMI
risk stratification

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14
Q

true or false

even if a heart attack has resolved, troponins will still be elevated

A

true

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15
Q

cardiac biomarkers are secreted in response to….

A

injury or necrosis of muscle tissue

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16
Q

*target times for reperfusion when dealing with a STEMI patient

A

-give fibrinolytics within 12 hours of symptom onset (if more than 12 hours - DO NOT GIVE)

-do PCI within 120 minutes of symptom onset (door to needle time 30 mins ie - once pt gets to hospital, should get to cath lab within 30 mins)

-length of stay 4-5 days

TOTAL TIME FOR REPERFUSION NO MORE THAN 120 MINS!!! this is highest chance of survival

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17
Q

true or false

if it has been determined through EKG and cardiac biomarkers that the pt has STEMI, no further assessment is needed

A

TRUE - patient must directly go for reperfusion

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18
Q

true or false

fibrinolytics have NO ROLE in NSTEMI patients

A

TRUE

bc for NSTEMI we’re not dealing with a thrombus, but rather a platelet plug

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19
Q

true or false

the GRACE and TIMI scores are used for STEMI patients

A

FALSE

used for NSTEMI

for STEMI we do not stratify the risk - just directly reperfuse the patient

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20
Q

explain what we would do based on TIMI score:

high (5-7)
moderate (3-4)
low risk (0-2)

A

high risk (5-7) - invasive strategy. either PCI or CABG

moderate (3-4) - if they have high risk features, will be invasive (PCI/CABG)
if they do not have high risk features - will be conservative (ie - cardiac stress test)

low risk - will do stress test (noninvasive)

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21
Q

true or false

the longer we wait to reperfuse, the larger the area of injury/necrosis

A

true

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22
Q

what is an “ischemia-guided” strategy

A

AKA conservative strategy. NSTEMI pt has low risk TIMI score

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23
Q

4 words that show the approach to ACS treatment

A

modify (CV risk factors)
slow (progression athero.)
stabilize (plaques)
improve (balance between O2 demand and supply)

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24
Q

there is clinical suspicion of ACS

what 2 things are done STAT

A

LOADING DOSE OF aspirin (162-325mg CHEWED) and EKG within 10 mins of symptoms

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25
patient presents with chest pain (clinical suspicion of ACS) They are immediately given CHEWED 162-325mg of aspirin and an EKG is done EKG shows elevated ST segment and troponins are (+) what is done immediately
MUST REPERFUSE -fibrinolytic (if within 12 hrs symptoms) -PCI within 120mins symptoms (door to needle 30 mins)
26
true or false cardiac biomarkers taken time to be released, so a patient's EKG may show STEMI but biomarkers are (-)
true check biomarkers 2-4 hours later
27
patient presents with clinical suspicion of ACS (chest pain) and is given 162mg-325mg of chewed aspirin, and an EKG is conducted ST comes back depressed, and biomarkers are positive what is done next
have to stratify risk! using GRACE/TIMI have mod - high risk - early invasive approach - either PCI or CABG. however, unlike for STEMI, this does NOT need to be done within 120 minutes of symptom presentation if low risk - "ischemia guided appraoch" - do noninvasive stress test. if stress test (-) - not cardiac origin. if stress test positive, do PCI/CABG typically within 24 hrs
28
patient presents with clinical suspicion of ACS (chest pain) they are given 162mg-325mg of chewed aspirin STAT and an EKG is conducted EKG comes back with ST depression and biomarkers are negative what is done
this is considered unstable angina like for NSTEMI, risk stratification is done. same treatment algorithm-- if low risk, "ischemia-guided approach" - do stress test if stress test negative, the issue was not cardiac related if stress test positive, PCI or CABG (doesnt have to be within 120 mins) if mod-high risk, PCI or CABG typically within 24 hrs
29
acronym to remember the treatment overview for ACS Explain what each letter in the acronym means
THROMBINS2 T - thienopyridines and other P2Y12 antagonists H - heparins (UFH and LMWH) and bivalrudin (direct thrombin inhibitor) R - RAAS antagonsits (ACEI OR ARB) O - oxygen (only if O2 sat less than 90% or hypoxemia) M - morphine B - beta blockers I - interventions (PCI) N - nitroglycerin S - high intensity statins and/or ezetimibe and/or PCSK9 inhibitor S - loading dose aspirin
30
when are the P2Y12 antagonists like thienopyridines given? at what doses?
loading dose upon medical contact
31
true or false RAAS like ACE inhibitors or ARBS must be given immediately
false - within 24-48 hours of index event
32
true or false anyone presenting with ACS symptoms like chest pain gets morphine
FALSE - only if patient is still in a lot of pain depsite giving the max dose of nitroglycerin
33
how soon are beta blockers typically given for ACS patient
typically within 24 hours of index event
34
true or false only SL nitroglycerin can be given to ACS patients for pain
FALSE - can give IV if needed, but it heavily depends on the patients BP if BP less than 90/less than 50, cannot titrate the nitroglycerin anymore and patient may need morphine also, if HR increases over 10 beats/min - cant tolerate anymore (reflex tachycardia)
35
acronym for initial anti ischemic therapy
"MONA +BB" Morphine (if no response/intolerant to high dose NTG) Oxygen (if sat less than 90% or in resp distress or high risk) Nitroglycerin (spray or sublingual - max 3 doses - then move to IV titration) Aspirin - loading dose then maintenance BB within 24 hours -- can give CCB if beta blocker is contraindicated
36
why is oxygen only given to patients whos O2 saturation is less than 90%?
bc too much O2 can actually increase the infarct size
37
for antiplatelet management, EVERY PATIENT gets aspirin and a P2Y12 antagonist explain how the treatment regimen differs: -NSTEMI, ischemia-guided -NSTEMI, invasive -STEMI, PPCI -STEMI + fibrinolytic
NSTEMI, ischemia-guided - ONLY clopidogrel or ticagrelor NSTEMI, invasive - clopidogrel or prasugrel or ticagrelor STEMI, PPCI - clopidogrel or prasugrel or ticagrelor STEMI + fibrinolytic - ONLY CLOPIDOGREL!!!!
38
prasugrel is ONLY indicated if....
patient is getting a PCI
39
patient has STEMI + fibrinolytic what is the only P2Y12 antagonist that can be used? what dose?
clopidogrel - loading dose of 300mg LD 600mg if event was OVER 24 hours ago
40
when is the only time that GPIIb/IIIa inhibitors are used as part of antiplatelet therapt
really only if patient has a thrombus and going for PCI mainly only NSTEMI - not really used a lot
41
true or false when aspirin is being given STAT for ACS, it CANNOT BE ENTERIC COATED
true EC ASPIRIN HAS NO ROLE INITIALLY!!!! must be chewed 162mg-325mg loading dose -- need aspirin to the blood ASAP
42
*maintenance dose of aspirin after ACS
81-325mg (81mg preferred - less bleeding risk and same benefit)
43
what is DAPT
dual antiplatelet therapy 75mg-100mg aspirin given with an oral P2Y12 antagonist
44
true or false in DAPT, aspirin CANNOT BE enteric coated
false - once you get to maintenance dosing it's fine if it's enteric coated
45
loading dose and maintenance dose of clopidogrel
LD - 300mg if on lytics or high risk bleeding - 600mg maintenance dose - 75mg
46
clopidogrel DDI concern
polymorphisms in CYP2C19 AND - DDI with PPIs like omeprazole. PPI's are CYP2C19 inhibitors - efficacy concern pantoprazole is preferred!
47
true or false if a patient is going for surgery, it is unnecessary to hold the plavix
false - hold 5 days before surgery
48
true or false prasugrel is more potent than clopidogrel
TRUE - higher risk of bleeding
49
*concern with prasugrel
HIGH RISK OF BLEEDING!!!! CONTRAINDICATED IF PT HAS HISTORY OF TIA/STROKE
50
how long to hold prasugrel before surgery
7 days - longer than plavix - higher bleed risk
51
*loading dose and maintenance dose of prasugrel
LD - always 60mg maintance dose usually 10mg HOWEVER - need to switch to 5mg if patient is over 75 or under 60kg
52
loading dose and maintenance dose of ticagrelor
LD - 180mg MD- 90mg BID
53
can ticagrelor be crushed
yes
54
major side effect of ticagrelor
dyspnea (SOB - lot of pts experience)
55
between prasugrel, clopidogrel, and ticagrelor, which is the only one taken BID
ticagrelor
56
advantage of ticagrelor over clopidogrel and prasugrel
only one that can be crushed - good for patients with g tube or who cant swallow
57
what must be the aspirin maintenance dose if patient is taking ticagrelot
less than 100mg
58
how long does ticagrelor have to be held before surgery
3 days doesnt hold platelet for entire life
59
what is the only IV P2Y12 antagonist is it ever used?
cangrelor not used too often -- only in 3 scenarios: 1. who cant take oral agents 2. PCI and P2Y12 inhibitor naive. cangrelor may be used to reduce periprocedural ischemia 3. potential bridge in high risk CABG procedures
60
true or false cangrelor cannot be coadministered with prasugrel
TRUE cangrelor CANNOT be given with oral P2Y12 antagonists
61
true or false cangrelor has a short half life
true - very short. around 5 mins
62
true or false GpIIb/IIIa inhibitors are oral anticoagulants
FALSE - IV antiplatelets
63
give example of when GPIIb/IIIa inhibitors are used
in PCI patients with large thrombus for NSETMI patients ofc used with aspirin ie - LV thrombus complication!
64
2 common AE of GpIIb/IIIa antagonists
bleeding, thrombocytopenia
65
which 2 GpIIb/IIIa antagonists need to be dose adjusted for renal issues
eptifibatide tirofiban
66
disadvantage of abciximab (GpIIb/IIIa inhibitor)
it can only be reversed with platelet transfusions
67

Cardio Renal II Midterm (14 decks)

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