Acute Coronary Syndrome (Acs)

Front 1

Higher hospital death rates: STE ACS or NSTE ACS?

Back 1

STE ACS

Front 2

Factors that contribute to the evolution of endothelial dysfunction and formation of fatty streaks that lead to atherosclerotic plaques?

Back 2

HTN, age, male gender, tobacco use, DM, obesity, dyslipidemias

Front 3

Difference between STEMI, NSTEMI, and unstable angina (all ACS)?

Back 3

unstable angina does not produce detectable biochemical marker levels

Front 4

ECG changes in NSTEMI?

Back 4

st segment depression, t wave inversion, or no changes

Front 5

ECG changes in STEMI?

Back 5

ST segment elevation

Front 6

What percentage of ACS are caused by rupture or erosion of an atherosclerotic plaque?

Back 6

>90%

Front 7

What kinds of plaques are likely to rupture?

Back 7

plaques that are occluded <50% of lumen, eccentric shape (plaque on one side of vessel), thin fibrous cap with large fatty core

Front 8

What occurs after plaque rupture?

Back 8

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

Front 9

White clots are associated with what acs?

Back 9

NSTE ACS

Front 10

Red clots are associated with what acs?

Back 10

STE ACS

Front 11

Complications of ACS?

Back 11

heart failure, valve dysfunction, arrythmias, heart block, pericarditis, stroke, venous thromboembolism, LV free-wall rupture

Front 12

ACS symptoms?

Back 12

severe new-onset angina >=20 min, pain may radiate to left arm or jaw or back, N/V, diaphoresis, SOB

Front 13

Who has atypical ACS symptoms?

Back 13

women, diabetics, elderly may have atypical or no symptoms

Front 14

When should ECG be done in ACS?

Back 14

within 10 mins of ED arrival

Front 15

What biomarkers should be taken in ACS?

Back 15

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

Front 16

MI treatment goals?

Back 16

-Restore blood flow to prevent infarct expansion and MI
-prevent complications and death
-prevent coronary artery reocclusion
-relieve ischemic chest discomfort
-maintain normoglycemia

Front 17

NSTEMI risk categories?

Back 17

high (5-7pts), medium (3-4pts), low (0-2pts) (based of TIMI score: Thrombolysis in MI)

Front 18

Calculation of timi score?

Back 18

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

Front 19

High risk NSTEMI patients should receive what therapy?

Back 19

PCI or CABG

Front 20

Low risk or moderate risk NSTEMI pts should receive what therapy?

Back 20

stress test to evaluate likelihood of CAD

Front 21

If a positive stress test, what tx for NSTEMI pt?

Back 21

PCI or CABG

Front 22

What medications should an ACS pt receive on admission?

Back 22

MONA B (morphine, oxygen, nitroglycerin, beta blocker, ASA)

Front 23

In stemi pt, what should door to balloon time be?

Back 23

< 90 min

Front 24

If greater than 90 min door to balloon time in STEMI pt, what therapy?

Back 24

thrombolytic therapy

Front 25

Better outcomes: PCI or fibrinolysis?

Back 25

PCI

Front 26

Best predictor of mortality after MI?

Back 26

LV function (LVEF <40% = higher risk of death)

Front 27

When should fasting lipid panel be drawn in MI patient?

Back 27

within 1st 24h

Front 28

When should ACEi be started for MI pt?

Back 28

within 24h of presentation

Front 29

When should a statin be started for MI pt?

Back 29

prior to discharge in pts with LDL >100mg/dl

Front 30

When should fibrinolytic therapy be done in STEMI pts?

Back 30

within 12h of symptoms (can be done in select pts after 12h)

Front 31

clopidogrel or prasugrel for PCI pts?

Back 31

either

Front 32

clopidogrel or prasugrel for fibrinolytic pts?

Back 32

only able to use clopidogrel

Front 33

All STE ACS pts should receive what therapy at discharge?

Back 33

ASA, BB, statin, ace/arb; selected pts should also have aldosterone antagonist, clopidogrel or prasugrel, or warfarin

Front 34

Therapy for NSTEMI pts?

Back 34

fibrinolytic therapy contraindicated, GP IIb/IIIa for high risk pts

Front 35

Fibrinolytic indication in acs?

Back 35

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)

Front 36

Absolute contraindications for fibrinolysis?

Back 36

-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

Front 37

Relative contraindications for fibrinolysis?

Back 37

-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

Front 38

All ACS hospital day 1 ASA dosing?

Back 38

162-325 x1

Front 39

All ACS hospital day 2 if no stents ASA dosing?

Back 39

75-162 continued indefinitely

Front 40

PCI in ACS, pre-pci ASA dosing?

Back 40

325 before PCI

Front 41

PCI in ACS, bare metal stent ASA dosing?

Back 41

325mg daily x 1 month

Front 42

PCI in ACS, sirolimus stent ASA dosing?

Back 42

325mg daily x 3 months

Front 43

PCI in ACS, paclitaxel stent ASA dosing?

Back 43

325mg x 6 months

Front 44

ASA dosing following stent dosing regimen?

Back 44

75mg indefinitely

Front 45

MOA of ASA?

Back 45

irreversible cycloxygenase inhibitor

Front 46

Contraindications to ASA?

Back 46

hypersensitivity, active bleed, severe bleed risk (do not admin with other NSAIDS)

Front 47

Maintenance indication for clopidogrel in post MI patients?

Back 47

given to patients unable to take ASA due to hypersensitive or major GI intolerance

Front 48

Dosing of clopidogrel for STE ACS?

Back 48

75mg qd added to aspirin in all pts and continued x 1 month (ideally 1 yr)

Front 49

If CABG is planned, what to do with clopidogrel?

Back 49

D/c at least 5 days prior

Front 50

Dosing clopidogrel for NSTE ACS?

Back 50

75mg daily added to aspirin x 1 month (ideally 1 year)

Front 51

All ACS Clopidogrel dosing hospital day 1 ?

Back 51

300mg x 1

Front 52

All ACS Clopidogrel dosing hospital day 2 if no stent?

Back 52

75mg qd x 1month (ideally 1 yr)

Front 53

In PCI, Clopidogrel dosing pre-pci?

Back 53

300mg at least 6h prior

Front 54

In PCI, Clopidogrel dosing for bare metal stent?

Back 54

75mg qd x 1 month (ideally 1 year)

Front 55

In PCI, Clopidogrel dosing for drug eluting stents?

Back 55

75mg qd x 1 year

Front 56

MOA of clopidogrel?

Back 56

irreversibly blocks P2Y12 ADP receptors on platelets preventing fibrin binding

Front 57

Contraindications to clopidogrel?

Back 57

hypersensitive, active bleed, severe bleed risk

Front 58

Adverse effects of clopidogrel?

Back 58

bleeding, N/V, diarrhea

Front 59

Benefits of prasugrel compared to clopidogrel?

Back 59

-quicker acting and more potent antiplatelet agent with improved efficacy
-not affected by PPI
(negative is prasugrel increased CAGB bleeding in clinical trials)

Front 60

Prasugrel dosing in ACS pts with PCI?

Back 60

60mg loading dose followed by 10mg qd (5mg qd in pts <60kg) x 12-15 months (pts should continue to take aspirin)

Front 61

MOA of prasugrel?

Back 61

irreversibly blocks P2Y12 ADp on platelets

Front 62

Contraindications for prasugrel?

Back 62

active bleed or prior TIA or stroke

Front 63

precautions for prasugrel?

Back 63

age >=75, bw <60kg

Front 64

adverse effects of prasugrel?

Back 64

bleeding, thrombotic thrombocytopenia purpura (TTP)

Front 65

indication for ticagrelor (brilinta)?

Back 65

reduce rate of CV thrombotic events in pts with ACS

Front 66

dosing for ticagrelor?

Back 66

180mg loading dose followed by a maintenance dose of 90mg po bid

Front 67

MOA of ticagrelor?

Back 67

binds reversibly to the same P2Y12 ADP receptor as the thienopyridines (clopidogrel, prasugrel)

Front 68

Contraindications/precautions for ticagrelor?

Back 68

severe hepatic impairment, hx of intracranial hemorrhage, active bleeding, PUD

Front 69

ASA dosage with ticagrelor?

Back 69

ASA <100mg is needed as greater decreases effects of ticagrelor

Front 70

adverse effects of ticagrelor?

Back 70

bleeding, dyspnea, bradyarrthmias, elevated uric acid and Scr

Front 71

Abciximab (reopro) indication?

Back 71

STEMI with PCI, NSTEMI with PCI, no renal adjustment

Front 72

Eptifibatide (integrelin) indication?

Back 72

stemi with pci, nstemi with or without PCI, CrCl < 50 reduce infusion by 50%

Front 73

Tirofiban (aggrastat) indication?

Back 73

nstemi not undergoing Pci, crcl < 30 reduce infusion by 50%

Front 74

MOA of abciximab?

Back 74

prevents cross linking of platelets through inhibition of gp IIb/IIIa receptros

Front 75

MOA of eptifibatide?

Back 75

prevents cross linking of platelets through inhibition of gp IIb/IIIa receptros

Front 76

MOA of tirofiban?

Back 76

prevents cross linking of platelets through inhibition of gp IIb/IIIa receptros

Front 77

Contraindications for gp IIb/IIIa receptor inhibitors?

Back 77

active bleeding, thrombocytopenia, hx of stroke

Front 78

Adverse effects with gp IIb/IIIb receptor inhibitors?

Back 78

bleeding, immune mediated thrombocytopenia

Front 79

Class for enoxaparin?

Back 79

LMWH

Front 80

Class for dalteparin?

Back 80

LMWH

Front 81

class for fondaparinux?

Back 81

factor Xa inhibitor

Front 82

Class for bivalirudin?

Back 82

direct thrombin inhibitor (reversible)

Front 83

Class for lepirudin?

Back 83

direct thrombin inhibitor (irreversible)

Front 84

Class for argatroban?

Back 84

direct thrombin inhibitor (reversible)

Front 85

Anticoag therapy in STEMI for no reperfusion or reperfusion with fibrinolytics?

Back 85

1st line: enoxaparin or fondaparinux (alt UFH) x 48 h minimum but preferably x hospital stay (max 8 days)

Front 86

Anticoagulants therapy in STEMI with pci after receiving an anticoagulant?

Back 86

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)

Front 87

When to add antiplatelet therapy in NSTEMI?

Back 87

as soon as possible after presentation

Front 88

Invasive NSTEMI anticoag strategy?

Back 88

1st line: enoxaprin or UFH
Alt: bivalirudin or fondaparinux
x8 days

Front 89

Conservative NSTEMI anticoag strategy?

Back 89

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

Front 90

MOA of UFH?

Back 90

binds antithrombin and inhibits clotting factors Xa and IIa

Front 91

Duration of UFH after PCI?

Back 91

x48h for pts who will be on warfarin, otherwise d/c immediately

Front 92

Contraindication for UFH?

Back 92

hx of HIT, active bleed, severe bleed risk, recent stroke

Front 93

Adverse effects with UFH?

Back 93

bleeding, hit

Front 94

MOA of enoxaparin?

Back 94

binds antithrombin, inhibits Xa and IIa

Front 95

Contraindications for enoxaparin?

Back 95

active bleeding, severe bleed risk, hx of hit, recent stroke, avoid in CABG pts

Front 96

Adverse effects of enoxaparin?

Back 96

bleeding and hit (less extent than UFH)

Front 97

When to renally adj enoxaparin?

Back 97

crcl <30

Front 98

MOA of fondaparinux (arixta)?

Back 98

inhibit Xa

Front 99

Contraindications for fondaparinux?

Back 99

crcl <30ml

Front 100

adverse effects with fondaparinux?

Back 100

bleeding, catheter thrombosis when used in PCI

Front 101

ACUITY trial?

Back 101

-bivalirudin vs bivalirudin+GP IIb/IIIa inhibitor vs heparin/enoxaparin+GP IIb/IIIa inhibitor
-no mortaility difference but bivalirudin monotherapy had less bleeding

Front 102

Nitrate dosing?

Back 102

0.4mg sl q 5 min x3

Front 103

MOA of nitrates?

Back 103

promotes release of nitric oxide producing vasodilation and myocardial ischemia relief through vasodilation lowering 02 demand and preload

Front 104

contraindication of nitrates?

Back 104

PDE5

Front 105

Adverse effects of nitrates?

Back 105

HA, flushing, hypotension, tachycardia

Front 106

Cardioselective BB?

Back 106

acebutolol, atenolol, betaxolol, bisoprolol,esmolol, metoprolol, nebivolol

Front 107

Nonselective BB?

Back 107

nadolol, propranolol, timolol

Front 108

Mixed a and BB?

Back 108

carvedilol and labetolol

Front 109

indication for IV BB in ACS pts?

Back 109

only given to hemodynamically stable pts who present with persistent ischemi, HTN, or tachycardia as can lead to cardiogenic shock

Front 110

Adverse effects of BB?

Back 110

hypotension, acute HF, bradycardia, heart block, mask hypoglycemia, bronchospasms

Front 111

Non-dihydropyridine CCB?

Back 111

verapamil and diltiazem

Front 112

indications for CCB in STE and NSTE ACS?

Back 112

pts with contraindications to BB

Front 113

MOA of CCB?

Back 113

inhibit Ca influx to myocardial and vascular smooth muscle

Front 114

Secondary prevention goals in MI?

Back 114

control modifiable CHD risk factors, prevent developement of systolic HF, prevent recurrent MI or stroke, prevent death