Module 3: Overview Of Acs

Front 1

T/F patients suspected of having ACS are medical emergencies

Back 1

T

Front 2

ACS is characterized by __________________

Back 2

myocardial ischemia

Front 3

________________ occurs when an acute thrombus forms in an atherosclerotic coronary artery, immediately disrupting blood flow to parts of the myocardium.

Back 3

ACS

Front 4

The initial consequences of ACS depend on ______________, _________________, and ___________________.

Back 4

size, location, and duration of the obstruction

Front 5

ACS range from ____________________ through to _________________.

Back 5

transient ischemia to infarction

Front 6

ECG and cardiac enzyme tests are very important because treatment with clot busters (fibrinolytics) because why?

Back 6

Treatment with fibrinolytics that benefit patients with STEMI may increase risk for those with NSTEMI. That is why ECG and cardiac enzyme measurement is important to determine which one it is.

Front 7

ECG is used to determine if patients with definite ACS have _______________, __________________, or ________________.

Back 7

UA, NSTEMI, or STEMI

Front 8

If diagnosed with STEMI, the patient is immediately evaluated for ___________________.

Back 8

reperfusion therapy

Front 9

If the patient is diagnosed with UA or NSTEMI and is experiencing ongoing pain, elevated cardiac markers, and hemodynamic abnormalities, the patient is admitted to ______________ for further management

Back 9

coronary care unit (CCU)

Front 10

ACS usually occurs when an acute thrombus forms in n atherosclerotic coronary artery immediately disrupting _________________ to parts of the myocardium

A) blood flow
B) electrical signal transmission
C) carbon dioxide delivery
D) A & C

Back 10

A

Front 11

If a patient presenting to the ED is diagnosed with STEMI, the patient should be:
A) transferred to the CCU
B) given more tests to determine the best course of action
C) evaluated for immediate reperfusion therapy
D) discharged with 2 doses of nitroglycerin if the patient has already been prescribed nitroglycerin for UA

Back 11

C

Front 12

Total ischemic time is ___________ from _____________ to _____________________.

Back 12

less than 120 minutes from onset of symptoms to reperfusion

Front 13

"the golden hour"

Back 13

the first 60 minutes after the onset of symptoms

Front 14

What is the ideal time for Fibrinolytic therapy or PCI? Why?

Back 14

during " the golden hour" because the greatest reduction in mortality is observed when reperfusion is achieved within 60-90 minutes of the onset of symptoms.

Front 15

PCI is the treatment of choice in most ____________ cases

Back 15

STEMI

Front 16

If a patient is experiencing STEMI, the next step is to determine the optimal strategy for repercussion. The choice is between _______________ and _______________.

Back 16

pharmacologic or invasive strategy (PCI)

Front 17

skilled PCI laboratory

Back 17

PCI lab team that performs at least 36 PCIs/year, or the IC who performs the procedure does at least 75 PCIs each year

Front 18

Fibrinolytics generally preferred if: _________________, ______________________, or _________________.

Back 18

1) early presentation </= 3hrs since symptom onset but will be a delay to PCI
2) PCI not avail bc cath lab not avail or occupied
3) Delay to PCI because door-to-needle or door-to-balloon time is greater than 1 hr. Door -to-balloon time is >90 minutes

Front 19

PCI preferred if : ________________, __________________, _______________________, ___________________, or ________________________.

Back 19

1) skilled PCI cath lab is ope and door-to-needle and door t-to-balloon time is <90 minutes. door-to-balloon time is < 90 minutes
2) high risk STEMI
3) Contrindication to fibrinolytics
4) Late presentation- symptom onset was >/= 3 hours ago
5) STEMI diagnosis is in doubt

Front 20

For every 30 minute in delay from symptom onset to primary PCI, there is an _______________ increase in the relative risk of dying within _____________.

Back 20

8%. 1 year

Front 21

Three typical drugs used during PCI:

Back 21

1) heparin
2) thienopyradine
3) GPIIb/IIIa

Front 22

Due to reduction in mortality seen when reperfusion is rapidly achieved, what concept has emerged?
A) "PCI for all"
B) "through the door in 4"
C) "the golden hour"
D) all of the above

Back 22

C

Front 23

Which of the following is not a factor that would lead to a decision to perform PCI over fibrinolysis?
A) High risk
B)Late presentation-symptom onset > 3 hrs ago
C) STEMI diagnosis in doubt
D) Early presentation but a delay in treatment of greater than 90 min

Back 23

D

Front 24

What are 2 major differences of UA/NSTEMI and STEMI?

Back 24

1) primary PCI is not routinely indicated for UA/NSTEMI
2) Fibrinolytics should not be administered to UA/NSTEMI patients

Front 25

UA/NSTEMI risk factors:

Back 25

-Age
-CAD
-CAD stenosis
-ST-segment deviation on ECG
-previous chronic use of ASA
-2 episodes of resting angina in the last 24 hrs
-Elevated cardiac markers

Front 26

TIMI risk scores range between ___________ and ___________, with the higher score indicating a greater risk of developing an adverse cardiovascular outcome.

Back 26

0, 7

Front 27

TIMI risk score of 1-2 =_______________, 3-4=__________________, and 5-7=__________________?

Back 27

low risk, intermediate risk, and high risk

Front 28

Patients at high risk of adverse events (TIMI 5-7) are recommended to do what?

Back 28

undergo early angiography and PCI with in 72 hrs of presentation -especially if they are hemodynamically unstable and/or have elevated cardiac markers, or have symptoms despite maximal drug therapy

Front 29

What is the common link with all ACS?

Back 29

atherothrombosis

Front 30

atherothrombosis

Back 30

when an atherosclerotic plaque ruptures in the coronary artery and a cascade of events leads to the formation of a thrombus with intermittent or stable obstruction to blood flow to the myocardium

Front 31

Dissolution

Back 31

mechanical destruction of a thrombus to re-establish blood flow

Front 32

ACS results from....

Back 32

an acute obstruction of a coronary artery

Front 33

The majority of patients with ST-elevation ultimately develop what?

Back 33

Q-wave MI

Front 34

A minority of patients with ST-elevation develop what?

Back 34

non-Q-wave MI

Front 35

An MI that is involved with the whole thickness of the myocardium is usually characterized by what on ECG? How about ones that do not involve the whole thickness?

Back 35

abnormal Q- waves, NQ-wave MI

Front 36

Patients who present without ST-segment elevation have what?

Back 36

either UA or NSTEMI. the distinction being made on the basis of cardio markers in the blood.

Front 37

The majority of patients with NSTEMI go on to develop what? How about the minority?

Back 37

NQMI, Q-wave MI

Front 38

Which classification of ACS is characterized by complete occlusion of a coronary vessel by a thrombus?
A) UA
B) NSTEMI
C) STEMI
D) DES

Back 38

C

Front 39

The majority of patients with a STEMI ultimately develop a:
A) QwMI
B) NQMI

Back 39

A

Front 40

UA/NSTEMI is characterized by myocardial ischemia that results in the typical symptoms that result with __________?

Back 40

angina pectoris

Front 41

Patients with NSTEMI have __________________ indicating myocardial cell death, which is often reflected in ECG.

Back 41

elevated cardiac enzymes

Front 42

UA has at least one of what features?

Back 42

-chest pain occurring at rest (or with minimal exertion) and lasting more than 20 mins
-often more severe than previous symptoms and new onset within the past month
-occurring with a crescendo pattern at rest

Front 43

NSTEMI

Back 43

-the ischemic discomfort of UA but with myocardial necrosis (evidenced by cardiac markers in the blood) without ST-segment elevation or new Q-waves

Front 44

_______________ is recommended for patients with high-risk UA/NSTEMI. ______________ is recommended for lower-risk patients.

Back 44

PCI, medical management

Front 45

Which ethnicity tends to present at a slightly younger age with ACS than the overall presenting population?

A) Hispanics
B) African Americans
C) Asian Americans
D) Caucasians

Back 45

B

Front 46

Which of the following describes a clinical feature of UA/NSTEMI?
A) aching of lower back, jaw, neck, or shoulder
B) burning of the chest
C) flu-like symptoms
D) all of the above

Back 46

D

Front 47

Reperfusion can be obtained by what ways?

Back 47

via fibrinolytics or PCI

Front 48

Approximately how many cases of MI are there every year in the US?

A) 1.5 million
B) 250,000
C) 600,000
D) nearly 1 billion

Back 48

A

Front 49

Which of the following is the most important treatment goal for STEMI patient?

A) relieve pain
B) reperfusion
C) prevent/treat complications
D) reduce cardiac workload

Back 49

B

Front 50

What is the first goal of STEMI?
A) smoking cessation
B) adequate exercise and proper nutrition
C) normotension and normoglycemia
D) prevention of a future thrombotic event (secondary prevention)

Back 50

D

Front 51

What is the average number of years of life lost due to a heart attack?
A) 5
B) 10
C) 15
D) 20

Back 51

C

Front 52

Following an ACS event, ________________ is almost universal at some stage during the recovery process
A) urinary incontinence
B) development of phobias
C) depression
D) recurrent hospitalizations

Back 52

C

Front 53

The prevalence of which condition (also a risk factor for CHD) is increasing?
A) type 2 diabetes
B) obesity
C) hypercholesterolemia
D) all of the above

Back 53

D

Front 54

What are 6 unresolved issues in the management of ACS?

Back 54

1) Anti-platelet resistance
2) Timing and dosing of Plavix
3) Premature D/C of ASA + thienopyradines after PCI esp with DES
4) Use and duration of DATin pts with DES to prevent late stent thrombosis
5) lack of reliable criteria to identify pts at presentation who will require CABG, and who should not receive thienopyradines bc of bleeding risks
6) reluctance to treat STEMI pts aggressively

Front 55

Resistance def

Back 55

variable metabolism of the anti platelet drug in the liver to its active metabolite

Front 56

There is conflicting data regarding optimal time of clopidogrel LD prior to PCI and whether a higher LD may provide additional benefit. What does the AHA Guidelines suggest?

Back 56

Clopidogrel be administered at least 6hrs prior to PCI in pts with ACS at 300mg. They also note that >300mg is reasonable to achieve higher levels of antiplatelet activity more rapidly

Front 57

CURRENT/OASIS-7

Back 57

Determine whether there are additional benefits in pts w ACS who receive 600mg LD clopidogrel followed by 150mg MD compared to standard 300mg LD, 75mg MD. Trial also evaluates whether higher doses of clopidogrel are assocoiated with higher risk of major bleeding

Front 58

DAT reduces cardiac events after PCI compared with ___________ alone or _______________and ______________ . This is why DAT is recommended by ACC/AHA as preventative therapy for __________________ in pts with stents.

Back 58

ASA, ASA and warfarin
12 months

Front 59

ACC/AHA recommends DAT for up to ____________ after NSTEMI events in pts with PCI or managed conservatively.

Back 59

1 year

Front 60

D/C of DAT in pts with DES increases RR of stent thrombosis in the first 30 days _____________ -fold and increases the RR of late thrombosis (>30 days) by _______-fold.

Back 60

161, 57

Front 61

very late stent thrombosis

Back 61

>12 months after stent placement

Front 62

Risk of very late stent thrombosis may be higher with ____________ than with ___________ .

Back 62

DES, BMS

Front 63

Following BMS, stent thrombosis is __________ after ________ wks, and DAT is usually Rx'd for _____________ wks.

Back 63

rare, 2 wks, 3-6 wks

Front 64

FDA recommends DAT for ________ months after DES in pts not at high risk for bleeding.

Back 64

12

Front 65

In patients who are at high risk for bleeding, DAT should be continued for _____________ months following sirolimus DES and ____________ months following paclitaxel DES.

Back 65

3, 6

Front 66

Until the issue of very late DES stent thrombosis is evaluated further, SCAI recommends that pts at higher risk for stent thrombosis continue DAT for longer than _________ months.

Back 66

12

Front 67

Use of ASA and clopidogrel has shown to reduce mortality in ACS when initiated early, within ____________ of symptoms.

Back 67

24hrs

Front 68

_____________ may be a preferred revascularization strategy for patients with LV systolic dysfunction, diabetes, and those with multi-coronary vessel disease

Back 68

CABG

Front 69

Hospitals with high patient volumes and high rate of invasive procedures have ______________________ for STEMI than those hospitals that take a more conservative approach or treat fewer patients.

Back 69

lower mortality rates

Front 70

Which group of patients is most likely to demonstrate a variable response to clopidogrel?
A) elderly patients >75yrs
B) patients with underlying diabetes
C) patients who have undergone CABG in the previous 12 months
D) younger women (<55 yrs)

Back 70

B

Front 71

What is the approved LD of clopidogrel?
A) 75mg
B) 300mg
C) 600mg
D) 900 mg

Back 71

B

Front 72

The FDA recommednds DAT after implementation of a DES in pts not at high risk for bleeding
A) 1 month
B) 2 months
C) 12 months
D) indefinitely

Back 72

C