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114 Cards in this Set

  • Front
  • Back
Higher hospital death rates: STE ACS or NSTE ACS?
Factors that contribute to the evolution of endothelial dysfunction and formation of fatty streaks that lead to atherosclerotic plaques?
HTN, age, male gender, tobacco use, DM, obesity, dyslipidemias
Difference between STEMI, NSTEMI, and unstable angina (all ACS)?
unstable angina does not produce detectable biochemical marker levels
ECG changes in NSTEMI?
st segment depression, t wave inversion, or no changes
ECG changes in STEMI?
ST segment elevation
What percentage of ACS are caused by rupture or erosion of an atherosclerotic plaque?
What kinds of plaques are likely to rupture?
plaques that are occluded <50% of lumen, eccentric shape (plaque on one side of vessel), thin fibrous cap with large fatty core
What occurs after plaque rupture?
clots form on top of the plaque rupture and partially or fully occlude the artery lumen; exposure of collagen and tissue factor from the plaque leads to platelet adhesion and activation
White clots are associated with what acs?
Red clots are associated with what acs?
Complications of ACS?
heart failure, valve dysfunction, arrythmias, heart block, pericarditis, stroke, venous thromboembolism, LV free-wall rupture
ACS symptoms?
severe new-onset angina >=20 min, pain may radiate to left arm or jaw or back, N/V, diaphoresis, SOB
Who has atypical ACS symptoms?
women, diabetics, elderly may have atypical or no symptoms
When should ECG be done in ACS?
within 10 mins of ED arrival
What biomarkers should be taken in ACS?
troponin and CK MB; 3 over 1st 12-24h: MI diag'd by 1 troponin > MI decision limit OR 2 CK MB > MI decision limit
MI treatment goals?
-Restore blood flow to prevent infarct expansion and MI
-prevent complications and death
-prevent coronary artery reocclusion
-relieve ischemic chest discomfort
-maintain normoglycemia
NSTEMI risk categories?
high (5-7pts), medium (3-4pts), low (0-2pts) (based of TIMI score: Thrombolysis in MI)
Calculation of timi score?
1 pt for:
- age >=65
- >= 3 risk factors for CAD (HTN,DM,smoker, fam hx of early CHD, hypercholesterolemia)
-50% stenosis of coronary artery
-use of aspirin within past 7 days
- ST segment depression (>0.5mm)
- >=2 episodes of chest discomfort in past 24h
-positive biochemical marker for infarction
High risk NSTEMI patients should receive what therapy?
Low risk or moderate risk NSTEMI pts should receive what therapy?
stress test to evaluate likelihood of CAD
If a positive stress test, what tx for NSTEMI pt?
What medications should an ACS pt receive on admission?
MONA B (morphine, oxygen, nitroglycerin, beta blocker, ASA)
In stemi pt, what should door to balloon time be?
< 90 min
If greater than 90 min door to balloon time in STEMI pt, what therapy?
thrombolytic therapy
Better outcomes: PCI or fibrinolysis?
Best predictor of mortality after MI?
LV function (LVEF <40% = higher risk of death)
When should fasting lipid panel be drawn in MI patient?
within 1st 24h
When should ACEi be started for MI pt?
within 24h of presentation
When should a statin be started for MI pt?
prior to discharge in pts with LDL >100mg/dl
When should fibrinolytic therapy be done in STEMI pts?
within 12h of symptoms (can be done in select pts after 12h)
clopidogrel or prasugrel for PCI pts?
clopidogrel or prasugrel for fibrinolytic pts?
only able to use clopidogrel
All STE ACS pts should receive what therapy at discharge?
ASA, BB, statin, ace/arb; selected pts should also have aldosterone antagonist, clopidogrel or prasugrel, or warfarin
Therapy for NSTEMI pts?
fibrinolytic therapy contraindicated, GP IIb/IIIa for high risk pts
Fibrinolytic indication in acs?
for STEMI pts who present wihtin 12 h of symptoms and have >1mm STE on EKG; contraindicated in pts with high bleeding risk (NOT indicated in NSTEMI)
Absolute contraindications for fibrinolysis?
-active internal bleeding
-previous intracranial hemorrhage at any time
-ischemic stroke within 3 months
-head or facial trauma within 3 months
-intracranial neoplasm
-structural vascular lesion
-suspected aortic dissection
Relative contraindications for fibrinolysis?
-BP > 180/110, ischemic stroke < 3months, dementia, intracranial pathology, current anticoag use, bleeding diathesis, traumatic or prolonged CPR (>10min), major surgery in last 3 wks, noncompressible vascular puncture, recent internal bleeding (2-4wks), pregnancy, active peptic ulcer, hx of really bad HTN ;P
All ACS hospital day 1 ASA dosing?
162-325 x1
All ACS hospital day 2 if no stents ASA dosing?
75-162 continued indefinitely
PCI in ACS, pre-pci ASA dosing?
325 before PCI
PCI in ACS, bare metal stent ASA dosing?
325mg daily x 1 month
PCI in ACS, sirolimus stent ASA dosing?
325mg daily x 3 months
PCI in ACS, paclitaxel stent ASA dosing?
325mg x 6 months
ASA dosing following stent dosing regimen?
75mg indefinitely
irreversible cycloxygenase inhibitor
Contraindications to ASA?
hypersensitivity, active bleed, severe bleed risk (do not admin with other NSAIDS)
Maintenance indication for clopidogrel in post MI patients?
given to patients unable to take ASA due to hypersensitive or major GI intolerance
Dosing of clopidogrel for STE ACS?
75mg qd added to aspirin in all pts and continued x 1 month (ideally 1 yr)
If CABG is planned, what to do with clopidogrel?
D/c at least 5 days prior
Dosing clopidogrel for NSTE ACS?
75mg daily added to aspirin x 1 month (ideally 1 year)
All ACS Clopidogrel dosing hospital day 1 ?
300mg x 1
All ACS Clopidogrel dosing hospital day 2 if no stent?
75mg qd x 1month (ideally 1 yr)
In PCI, Clopidogrel dosing pre-pci?
300mg at least 6h prior
In PCI, Clopidogrel dosing for bare metal stent?
75mg qd x 1 month (ideally 1 year)
In PCI, Clopidogrel dosing for drug eluting stents?
75mg qd x 1 year
MOA of clopidogrel?
irreversibly blocks P2Y12 ADP receptors on platelets preventing fibrin binding
Contraindications to clopidogrel?
hypersensitive, active bleed, severe bleed risk
Adverse effects of clopidogrel?
bleeding, N/V, diarrhea
Benefits of prasugrel compared to clopidogrel?
-quicker acting and more potent antiplatelet agent with improved efficacy
-not affected by PPI
(negative is prasugrel increased CAGB bleeding in clinical trials)
Prasugrel dosing in ACS pts with PCI?
60mg loading dose followed by 10mg qd (5mg qd in pts <60kg) x 12-15 months (pts should continue to take aspirin)
MOA of prasugrel?
irreversibly blocks P2Y12 ADp on platelets
Contraindications for prasugrel?
active bleed or prior TIA or stroke
precautions for prasugrel?
age >=75, bw <60kg
adverse effects of prasugrel?
bleeding, thrombotic thrombocytopenia purpura (TTP)
indication for ticagrelor (brilinta)?
reduce rate of CV thrombotic events in pts with ACS
dosing for ticagrelor?
180mg loading dose followed by a maintenance dose of 90mg po bid
MOA of ticagrelor?
binds reversibly to the same P2Y12 ADP receptor as the thienopyridines (clopidogrel, prasugrel)
Contraindications/precautions for ticagrelor?
severe hepatic impairment, hx of intracranial hemorrhage, active bleeding, PUD
ASA dosage with ticagrelor?
ASA <100mg is needed as greater decreases effects of ticagrelor
adverse effects of ticagrelor?
bleeding, dyspnea, bradyarrthmias, elevated uric acid and Scr
Abciximab (reopro) indication?
STEMI with PCI, NSTEMI with PCI, no renal adjustment
Eptifibatide (integrelin) indication?
stemi with pci, nstemi with or without PCI, CrCl < 50 reduce infusion by 50%
Tirofiban (aggrastat) indication?
nstemi not undergoing Pci, crcl < 30 reduce infusion by 50%
MOA of abciximab?
prevents cross linking of platelets through inhibition of gp IIb/IIIa receptros
MOA of eptifibatide?
prevents cross linking of platelets through inhibition of gp IIb/IIIa receptros
MOA of tirofiban?
prevents cross linking of platelets through inhibition of gp IIb/IIIa receptros
Contraindications for gp IIb/IIIa receptor inhibitors?
active bleeding, thrombocytopenia, hx of stroke
Adverse effects with gp IIb/IIIb receptor inhibitors?
bleeding, immune mediated thrombocytopenia
Class for enoxaparin?
Class for dalteparin?
class for fondaparinux?
factor Xa inhibitor
Class for bivalirudin?
direct thrombin inhibitor (reversible)
Class for lepirudin?
direct thrombin inhibitor (irreversible)
Class for argatroban?
direct thrombin inhibitor (reversible)
Anticoag therapy in STEMI for no reperfusion or reperfusion with fibrinolytics?
1st line: enoxaparin or fondaparinux (alt UFH) x 48 h minimum but preferably x hospital stay (max 8 days)
Anticoagulants therapy in STEMI with pci after receiving an anticoagulant?
UFH bolus to support procedure (alt bivalirudin), enoxaparin (last dose <8h = no additional dose, last dose 8-12h =give 0.3mg/kg iv), or fondaparinux (should be used with UFH, not alone)
When to add antiplatelet therapy in NSTEMI?
as soon as possible after presentation
Invasive NSTEMI anticoag strategy?
1st line: enoxaprin or UFH
Alt: bivalirudin or fondaparinux
x8 days
Conservative NSTEMI anticoag strategy?
1st line: enoxaparin or fondaparinux
Alt: UFH (use if CABG planned in 24h)
Increased risk of bleeding = use fondaparinux
any therapies x up to 8 days
binds antithrombin and inhibits clotting factors Xa and IIa
Duration of UFH after PCI?
x48h for pts who will be on warfarin, otherwise d/c immediately
Contraindication for UFH?
hx of HIT, active bleed, severe bleed risk, recent stroke
Adverse effects with UFH?
bleeding, hit
MOA of enoxaparin?
binds antithrombin, inhibits Xa and IIa
Contraindications for enoxaparin?
active bleeding, severe bleed risk, hx of hit, recent stroke, avoid in CABG pts
Adverse effects of enoxaparin?
bleeding and hit (less extent than UFH)
When to renally adj enoxaparin?
crcl <30
MOA of fondaparinux (arixta)?
inhibit Xa
Contraindications for fondaparinux?
crcl <30ml
adverse effects with fondaparinux?
bleeding, catheter thrombosis when used in PCI
ACUITY trial?
-bivalirudin vs bivalirudin+GP IIb/IIIa inhibitor vs heparin/enoxaparin+GP IIb/IIIa inhibitor
-no mortaility difference but bivalirudin monotherapy had less bleeding
Nitrate dosing?
0.4mg sl q 5 min x3
MOA of nitrates?
promotes release of nitric oxide producing vasodilation and myocardial ischemia relief through vasodilation lowering 02 demand and preload
contraindication of nitrates?
Adverse effects of nitrates?
HA, flushing, hypotension, tachycardia
Cardioselective BB?
acebutolol, atenolol, betaxolol, bisoprolol,esmolol, metoprolol, nebivolol
Nonselective BB?
nadolol, propranolol, timolol
Mixed a and BB?
carvedilol and labetolol
indication for IV BB in ACS pts?
only given to hemodynamically stable pts who present with persistent ischemi, HTN, or tachycardia as can lead to cardiogenic shock
Adverse effects of BB?
hypotension, acute HF, bradycardia, heart block, mask hypoglycemia, bronchospasms
Non-dihydropyridine CCB?
verapamil and diltiazem
indications for CCB in STE and NSTE ACS?
pts with contraindications to BB
inhibit Ca influx to myocardial and vascular smooth muscle
Secondary prevention goals in MI?
control modifiable CHD risk factors, prevent developement of systolic HF, prevent recurrent MI or stroke, prevent death