Therapeutics - ACS Part 2

Question 1

true or false

anticoagulant therapy should be given to ALL ACS patients

Answer 1

TRUE

to decrease intracoronary and catheter thrombosis

Question 2

which anticoagulants are preferred in a patient getting a PCI

Answer 2

unfractionated heparin (UFH) or bivalrudin

Question 3

state which anticoagulant the patient should get:
NSTEMI:
-Ischemia guided
-invasive

Answer 3

ischemia guided - UFH, lovenox, or fondaparinux

invasive - UFH, lovenox, bivalrudin

Question 4

which anticoagulant(s) can be given to a patient who is given a fibrinolytic for STEMI

Answer 4

UFH, lovenox, fondaparinux

Question 5

true or false

bivalrudin can be given with a fibrinolytic

Answer 5

NO – INCREASED RISK OF BLEEDING

Question 6

When is anticoagulant therapy discontinued?

Answer 6

usually after the PCI

Question 7

only time bivalrudin can be given as an anticoagulant

Answer 7

when pt is getting PCI (invasive)

NOT WHEN GETTING FIBRINOLYTIC!!!!!

Question 8

bivalrudin class

Answer 8

direct thrombin inhibitor

Question 9

UFH concerns

Answer 9

bleeding (monitor Hgb and hematocrit), aPTT/active clotting time, HIT (platelets

Question 10

how long is UFH used

Answer 10

up to 48 hours

or after PCI is done

Question 11

true or false

anti-Xa does NOT need to be monitored for enoxaparin

Answer 11

true

Question 12

is dose adjustment needed ever for enoxaparin?

Answer 12

yes - if CrCl less than 30

Question 13

how long to use enoxaparin

Answer 13

until the PCI or until out of hosptial (up to 8 days)

Question 14

true or false

bivalrudin does not need a dose adjustment in renal failure

Answer 14

fals e- it does

Question 15

can bivalrudin be given if pt has history of HIT?

Answer 15

YES - it’s a direct thrombin inhibitor!

Question 16

how long to give bivalrudin

Answer 16

until PCI - up to 4 hours post PCI

Question 17

monitoring paramters for fondaparinux

does anti Xa need to be monitored?

Answer 17

bleeding, spinal or epidural hematoma, platelets

dose adjust CRCL less than 30

no anti xa

Question 18

true or false

fondaparinux needs renal dose adjustment in CrCl less than 30

Answer 18

FALSE - IT’S CONTRAINDICATED! NO DOSE ADJUSTMENT JUST CANT USE

Question 19

can fondaparinux be given if the patient had a history of HIT

Answer 19

yes

Question 20

when to d/c fondaparinux

Answer 20

until PCI or until out of hospital

Question 21

true or false

fondaparinux is not used alone in PCI

Answer 21

true

Question 22

true or false

fondaparinux is a 1st line anticoagulant if pt is going for a PCI

Answer 22

FALSE

1ST line is UFH or bivalrudin

Question 23

****very important - in which STEMI patients can fibrinolytics not be given

Answer 23

IF SYMPTOM ONSET HAS BEEN LONGER THAN 12 HOURS - NE BENEFIT ONLY BLEEDING RISK

Question 24

explain in which scenario fibrinolytics would be given

Answer 24

only in STEMI patients whose symptoms started less than 12 hours ago, and their PCI cant be performed within 120 mins of symptom onset

imp to note that fibrinolytics dont open the artery all the way - just buys time to get to cath lab

Question 25

true or false when fibrinolytics are used, they are used alone

Answer 25

FALSE - used with other anticoagulant like UFH, enoxaparin, or fondaparinux

Question 26

as mentioned, fibrinolytics are combined with another anticoagulant like UFH, enoxaparin, or fondaparinux how long is this anticoagulant continued

Answer 26

for at least 48 hours whole hospitalization (up to 8 days) or up until the pt gets revascularized

Question 27

4 things to monitor in a patient getting a fibrinolytic

Answer 27

bleeding ECG chest pain releif allergies ( for older ones like strptokinase)

Question 28

**preferred reperfusion strategy

Answer 28

PCI

Question 29

if it has been less than 12 hours since symptom onset, what are the reperfusion options what about over 12 hours?

Answer 29

less than 12 hours - PCI or fibrinolytics more than 12 hours - PCI/CABG ONLY - cannot use lytics

Question 30

name some post PCI complications

Answer 30

bleeding rupture stent thrombosis (clot) arrrhythmia mechanical complications CIN (contast induced nephropathy)

Question 31

as mentioned, stent thrombosis is a PCI complication what can be done to prevent

Answer 31

caused by premature discontinuation - counsel!!!!! increase DAPT duration (MD aspirin + MD P2Y12 antagonist) for at least 12 months

Question 32

**duration of DAPT as medical therapy with NO intervention being scheduled

Answer 32

at least 12 months

Question 33

**duration of DAPT if pt got lytics

Answer 33

at least 14 days - up to 12 months

Question 34

**duration of DAPT if pt got PCI

Answer 34

at least 12 months

Question 35

**duration of DAPT if pt got CABG

Answer 35

1 year

Question 36

is DAPT ever continued for longer than 12 months?

Answer 36

yes - can find DAPT score if 2 or more - prolong dap for around 15 months if less than 2 - do not continue beyond 12 months. at 12 months, stop P2Y12 and ccontinue aspirin indefinitely

Question 37

true or false women have higher rates of in-hospital and long-term complications

Answer 37

true

Question 38

Name 4 classes of drugs that are for secondary prevention and DISCHARGE MEDS --- that the pt actually goes home with

Answer 38

beta blocker (or CCB if BB C/I) renin antagonist (if Hfref - aldosterone antagonist) DAPT (duration varies) high intensity statin

Question 39

what med may be beneficial to a discharged patient

Answer 39

PPI - decreased risk of stomach ulcers

Question 40

true or false pts being discharged from ACS should avoid NSAIDS

Answer 40

true - can prevent normal scars from forming

Question 41

pt has STEMI and needs emergency reperfusion what is initial therapy?

Answer 41

MONA morphine (if needed) oxygen (if needed) aspirin 162-325mg chewed STAT + oral P2Y12 clopidogrel 300-600mg (if lytic given - only 300mg) or ticagrelor 180mg nitroglycerin

Question 42

3 options for fibrinolytics what must they be given with and for how long

Answer 42

alteplase reteplase tenectaplase with UFH or LMWH for 48 hours

Question 43

true or false lytic can be given with bivalrudin

Answer 43

FALSE

Question 44

pt is NSTEMI what therapy is given initially (risk assessment not made yet)

Answer 44

MONA aspirin LD chewed + P2Y12 (ticagrelor 180mg or clopidogrel 300-600mg) morphine maybe o2 maybe nitroglycerin

Question 45

pt has UA what is initial therapy given (risk assessment not made yet)

Answer 45

MONA

Question 46

pt has UA or NSTEMI and determined to follow ischemia-guided approach name 5 therapies to start stat

Answer 46

1. chewed aspirin LD (if not started yet) 2. oral P2Y12 (clopidogrel or ticagrelor - if not given yet) 3. anticoagulant (UFH FOR 48 HRS, LOVENOX 7 days or d/c , OR FONDAPARINUX 7 days or d/c) 4. atorvastatin 40-80mg 5. depending on BP and stability - BB and ace inhibitor potentially

Question 47

name the 6 potential CHRONIC discharge meds for secondary prevention

Answer 47

low dose aspirin P2Y12 antagonist high potency statin REGARDLESS LDL b blocker low dose ACEI/ARB aldisterone antagonist if EF less than 40%

Question 48

if patient is in respiratory distress and O2 sat is normal - do we give O2?

Answer 48

yes - bc in respiratory distress

Question 49

*loading dose clopidogrel if getting fibrinolytic

Answer 49

300mg

Question 50

when may the efficacy of ticagrelor be decreased

Answer 50

in patients getting aspirin doses over 300mg only give less than 100mg!

Question 51

true or false a loading dose of a P2Y12 receptor antagonist should be given before a PCI

Answer 51

true

Question 52

interaction between cangrelor and the oral P2Y12 inhibitors

Answer 52

onset of action of clopidogrel and prasugrel is delayed with cangrelor coadmin. therefore, clopidogrel and prasugral shold not be started until cangrelor infucion is done no interaction with ticagrelor tho!!!!!!!!

Question 53

true or false eptifibatide and tirofiban are preferred GpIIb/IIIa antagonists

Answer 53

true - just have to d/c to reverse the effect abciximab needs platelet transfusions to reverse