Acute Coronary Syndrome

Front 1

Two groups of IHD

Back 1

Chronic CAD (stable angina: increased demand)
ACS: decreased supply

Front 2

Stable angina

Back 2

Chest pain reproducible
Relieved by rest/NG
Of typical duration/quality
Associated with exertion

Front 3

UA

Back 3

Ischemic discomfort of new onset, occurs at rest, severe and in crescendo pattern (more severe, prolonged, frequent)

Front 4

NSTEMI

Back 4

UA criteria + evidence of myocardial necrosis

Front 5

White thrombi

Back 5

Platelet rich

Front 6

Red thrombi

Back 6

Fibrin/cell rich

Front 7

Anti-ischemic therapy options

Back 7

Nitrates, morphine, BB, CCB

Front 8

Nitrates MOA

Back 8

No released from endothelium
Venous (Arterial at higher doses)
Venous: lowers preload/MVO2
Arterial: lowers BP/AL/relieves coronary artery vasospasm (improves O2 flow)

Front 9

Nitrates dosing

Back 9

SL: 0.4mg Q5min X 3 doses
IV: 5mcg/min --> increase by 5mcg/min Q3-5 mins up to 20mcg/min then increase by 10mcg/min up to 200mcg/min (400 max)

Front 10

Nitro tolerance

Back 10

Develops in 24-48 hours: make sure to have nitrate-free interval (10-12 hours/day)
Titrate down to avoid withdrawal

Front 11

Nitrate benefit groups

Back 11

HF, persistent ischemia, no C/I, uncontrolled high BP

Front 12

AE Nitro

Back 12

headache, flushing, hypotension, tachycardia

Front 13

When to D/C Nitro

Back 13

post PCI/CABG

Front 14

Beta blockers MOA

Back 14

Block B1 (reducing HR, contractility, and O2 demand: improve filling time)

Front 15

BB Benefits

Back 15

Reduce re-infarction, infarct size, arrhythmias

Front 16

BB benefit groups

Back 16

HD stable + no signs ADHF

Front 17

AE BB

Back 17

hypotension, bradycardia, acute HF, AV block

Front 18

CCB MOA

Back 18

Inhibit influx of Ca in myocardial/vascualr SM cells: vasodilation

Front 19

When to use CCB

Back 19

Only if C/I to BB --> start BB is CCB is being used for HTN
(data shows little benefit other than for Sx control)

Front 20

AE CCB

Back 20

Acute HF, LVSD
C/I: WPW, SBP <90, Systolic HF

Front 21

Benefit groups: CCB

Back 21

Coronary vasopasm/cocaine-induced (Printzmetal): can also use NTG
BB will worsen through unnopposed B2

Front 22

Aspirin dose

Back 22

Initial: 325mg/maintain 81mg/<100mg with ticagrelor

Front 23

OASIS-7 Tiral

Back 23

High vs. low dose ASA

Front 24

Platelet 3 Step

Back 24

1. Adhere: via GP1b and vWF
2. Activation: release ADP, 5HT, TXA2 and expression GP2a/3b receptor
3. Adhere: fibringoen/VWF to GP2a/3b receptors

Front 25

ASA dosing CABG

Back 25

Continue through CABG

Front 26

CREDO trial

Back 26

long-term use clopidogrel had lower risk of death, MI, stroke vs. placebo

Front 27

Prasurgerl benefits over plavix

Back 27

Faster onset, stronger action, less DDI
Trition-timi 38: lower MI, stroke, death but more bleeding

Front 28

Prasurgerl c/I

Back 28

stroke, >75y/o, <60kg

Front 29

Ticagrelor benefits over plavix

Back 29

Not a prodrug, reversible, PLATO: lower MI, stroke, death but more bleeding

Front 30

Benefits of G2b/3a inhibitors

Back 30

reduce risk of re-infarction and need for repeat PCI when added to therapy

Front 31

High risk patients who benefit from G2b/3a

Back 31

DM, elevated troponin, ST seg elevation (meta-analysis showed lower death/MI)

Front 32

Two uses of G2b/3a

Back 32

1. High risk patients undergoing PCI
2. Low risk patients with unremitting ischemia who will eventually undergo PCI/angiography

Front 33

Primary PCI G2b/3a

Back 33

In combo with UHF + ASA
A E or T is fine

Front 34

Recurrent ischemia G2b/3a

Back 34

Despite ASA, clopidogrel, ACoag
E or T (A only for PCI)

Front 35

Anticoag choices early invasive

Back 35

UFH, LMWH, FX, Bivali

Front 36

Anticoag for CABG

Back 36

UFH (shorter duration of action)

Front 37

Preference for fondaparinux

Back 37

High bleeding risk
OASIS-5: non-inferior to enoxaparin with less bleeding
Must be given with UFH due to lack of 2 blocking

Front 38

ACUITY trial

Back 38

Bivali superior to heparin/G2b + less bleeding

Front 39

Warfarin for ACS patients (4 patient groups)

Back 39

Triple therapy INR: 2-2.5
Patients with LV thrombus, extensive ventricular wall motion abnoramities, history of TE disease/A-fib

Front 40

Eptifibatide (integrilin) Indication

Back 40

1. ACS (UA/NSTEMI): medically managed + PCI
2. PCI support (STEMI)

Front 41

Dose Eptifibatide ACS

Back 41

ACS: Bolus 180mcg/kg (max 22.6mg) over 1-2 mins  CI 2mcg/kg/min (max: 15mg/hr) until discharge or CABG (hold 4 hours prior) up to 72 hours
*PCI w/in 72hrs: CI at time of PCI up to 18-24 hours or discharge (</96 hours total)
WITH UFH + ASA

Front 42

Eptifibatide dosing PCI

Back 42

PCI: Bolus 180mcg/kg (max 22.6mg) over 1-2 mins right before PCI  CI 2mcg/kg/min (max: 15mg/hr)  2nd bolus 10 mins after 1st  CI 18-24 hours or discharge
*D/C heparin post PCI

Front 43

Renal/hepatic Eptifibatide

Back 43

ACS: <50: 180mcg/kg bolus (max 22.6mg)  1mcg/kg/min (max: 7.5mg/hr)

PCI: <50: 180mcg/kg bolus (max: 22.6mg) right before PCI then CI of 1mcg/kg/min (max: 7.5mg/hr) + 2nd bolus 180mcg/kg (max 22.6mg) 10 mins after 1st
No liver

Front 44

Eptifibatide DDI

Back 44

Antiplatelets, anticoagulants, NSAIDs, etc.

Front 45

Eptifibatide MOA

Back 45

*Glycoprotein 2a/3b inhibitor (blocks binding of VWF and fibrinogen)
*Reversibly blocks platelet aggregation + prevents thrombosis
*Effects persist over infused and are reversed when infusion ends

Front 46

Eptifibatide PK

Back 46

Onset: 1 hour
½ life (E): 2.5 hours
Duration: platelet function restored in 4 hours
E: Urine

Front 47

Eptifibatide AE

Back 47

Bleeding, hypotension, thrombocytopenia, injection site reaction

Front 48

Eptifibatide monitoring

Back 48

Renal function, PT, aPPT

Front 49

Abciximab Indication

Back 49

1 ACS (UA/NSTEMI) not responsive to med therapy with planned PCI <24 hours
2 PCI
3 STEMI undergoing PCI

*With ASA and UFH (min)

Front 50

Abciximab dose PCI

Back 50

PCI: 0.25mg/kg bolus 10-60 mins prior to PCI  CI 0.125mcg/kg/min (max 10mcg/min) for 12 hours

Front 51

Abciximab dose ACS unresponsive to med therapy

Back 51

0.25mg/kg bolus then 18-24 hour CI of 10mcg/min (stop 1 hour post PCI)

Front 52

Abciximab STEMI

Back 52

0.25mg/kg bolus at time of PCI  CI 0.125mcg/kg/min (max: 10mcg/min) up to 12 hours

Front 53

Abciximab renal/hepatic

Back 53

None: metabolized by proteases

Front 54

Abciximab interactions

Back 54

Dextran, antiplatelets, NSAIDs, etc

Front 55

Abciximab MOA

Back 55

*Fab antibody fragment
*Glycoprotein 2a/3b inhibitor (inhibits platelet aggregation)

Front 56

Abciximab PK

Back 56

Onset: rapid
½ life (E): 30 mins (platelet function may remain abnormal for up to 7 days post infusion)
M: proteases
TTP: 30 mins to platelet inhibition

Front 57

Abciximab AE/monitoring

Back 57

Bleeding, hypotension, chest pain, nausea
thrombo, AB development

Monitor: aPPT, H/H

Front 58

Tirofiban Indications

Back 58

1 ACS (UA/NSTEMI)
2 PCI (unlabeled)

*With heparin

Front 59

Tirofiban dosing ACS

Back 59

ACS: 0.4mcg/kg/min for 30 mins then 0.1mcg/kg/min: continue through and post angiography (12-24 hours)

Front 60

Tirofiban dosing PCI

Back 60

PCI: 25mcg/kg over 3 mins at time of PCI  CI 0.15mcg/kg/min up to 18-24 hours

Front 61

Tirofiban renal/hepatic

Back 61

<30: reduce by 50%
No hepatic

Front 62

Tirofiban MOA

Back 62

*Reversible antagonist of fibrinogen binding to GP 2b/3a receptor

Front 63

Tirofiban PK

Back 63

1/2: 2 hours
E: urine

Front 64

Tirofiban AE/monitoring

Back 64

Bleeding, bradycardia, nausea

Monitor: CBC, aPTT (heparin)

Front 65

Bivalirudin Indications

Back 65

1 PCI +/- HIT/HITTS*
2 UA/NSTEMI early invasive (UL)
3 STEMI primary PCI (UL)
4 HIT (UL)

*With ASA and provisional GP 2b/3a

Front 66

Bivalirudin dosing PCI +/- HIT

Back 66

PCI +/- HIT: 0.75mg/kg bolus right before PCI  1.75mg/kg/hr CI (up to 4 hours post)  CI of 0.2mg/kg/hr up to 20 hours if needed after

Front 67

Bivalirudin dosing UA/NSTEMI

Back 67

0.1mg/kg bolus  0.25mg/kg hour CI  bolus 0.5mg/kg at time of PCI + CI 1.75mg/kg/hr up to 4 hours post PCI
*CABG: D/C 3 hours prior and dose with UFH
*Med management: 0.25mg/kg/hr up to 72hrs

Front 68

Bivalirudin renal/hepatic

Back 68

PCI: 10-29: 1mg/kg/hr; dialysis (0.25mg/kg/hr)
Cardiac surgery/HIT: no adjustment per manufacturer

Front 69

Bivalirduin MOA

Back 69

Specific and reversible DTI: binds both circulating and clot-bound thrombin
*Prevents fibrinogen to fibrin, activation of V, VIII, XIII

Front 70

Bivalirudin PK

Back 70

Onset: immediate
Duration: baseline coagulation times 1 hr post-DC
½ life (E): 25 mins (1 hr <30)

Front 71

Bivalirudin AE

Back 71

Bleeding, hypotension, pain, headache, nausea, back pain

Front 72

ARA indications post-MI

Back 72

Already on ACE and BB

LVEF <40, and either Sx HF or DM unless CI!

Front 73

Anticoag initial conservative

Back 73

LMWH/fonda > UFH 2a recommendation

Front 74

STEMI lytic therapy: anticoag

Back 74

After fibrinolysis for at least 48 hours with IV UFH or SC LWMH (preferred) or FX for up to 8 days

Front 75

In high risk patients, cardic ath is looking for what?

Back 75

1. whether occluded or partially occluded epicardial arteries exist

2. which ones cna be intevened on

3. whether to make an intervention, stent or PTCA

Front 76

UFH vs. enxoparain with tenecteplase

Back 76

Clearance of UFH is not as altered (preferred choice)

Tenec also has shorter 1/2 life than alteplase