Therapeutics Iii Exam 6- Acute Coronary Syndrome Ii

Front 1

tecagrilor MoA

Back 1

reversible, non thienopyridine P2Y12 antagonist

Front 2

ticagrelor metabolism and activation

Back 2

CYP3A4

but NO hepatic activation (not prodrug?)

Front 3

ticagrelor contraindications (3)

Back 3

hx of intracranial bleeds
severe hepatic dysfunction?
CYP3A4 inhibitors or inducers

Front 4

ticagrelor AE (2)

Back 4

bleeds (more than other thienopyridines)
dyspnea

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goal of glycoprotein IIb/IIIa inhibitors

Back 5

prevent total occlusion of infarct related artery

Front 6

indication of glycoprotein IIb/IIIa inhibitors (2)

Back 6

to prevent ischemic complications FOLLOWING PCI

considered in pt with NSTE-ACS undergoing EI strategy (planned PCI)

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usage of glycoprotein IIb/IIIa inhibitors- do you use it alone or in combo?

Back 7

DO NOT REPLACE anticoag- alsways use with LMWH/UFW otherwise you will increase mortality

Front 8

GP IIb/IIIa receptor function

Back 8

IIb/IIIa is for the actual clots- cross linking of fibrinogen

Front 9

how/when/duration to administer GP IIb/IIIa inhibitor after event

Back 9

continued 48-72 h after event or until PCI
if plavix loading (300 mg) was giving more than 6 h earlier you don't need to give GP inhibitors

Front 10

3 GP IIb/IIIa inhibitors

Back 10

abciximab
tirofibane
eptifibatide

Front 11

difference in GP IIb/IIIa inhibitor usage in EI (2)

Back 11

abciximab or accelerated dose? epitifibatide if PCI is within 4h of presentation (or can get pt there in 4 h)

tirofiban or eptifibatide regular if treated medically for first 48 h

Front 12

usage of GP IIb/IIIa inhibitors in EC: what patient population (type)

not beneficial where?

Back 12

use limited to those at high risk for future cardiac events (+troponin)

not really beneficial in EC strategy- particularly, abciximab is NOT USED in EC at all

Front 13

ONLY use GP IIb/IIIa in EC if what 3 properties? (3)

Back 13

ONLY if continuing ischemia, +troponins, or TIMI risk >=4

Front 14

dosing (route)/2 drugs for GP IIb/IIIa inhibitors used in EC

Back 14

continuing infusion of tirofiban or eptifibatide

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abciximab- type of inhibitor
indication

Back 15

irreversible
PCI ONLY

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abciximab- CL

Back 16

monoclonal...RES? (phagocytic cells?)

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eptifibitide- type of inhibitor
indication (2)

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reversible
UA/NSTEMI EC and ELECTIVE PCI

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eptifibitide CL

Back 18

renal

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tirofiban CL

Back 19

renal

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tirofiban type of inhibitor
indication

Back 20

reversible
UA/NSTEMI EC

Front 21

HR goal of BBs

Back 21

goal of BBs: slow heart rate to 55-60 BPM

Front 22

beta blocker- immediate treatment

then afterwards dosing

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metoprolol 5 mg IV q5min for 3 doses (immediate) IVP

then 25-50 mg po bid and increase as tolerated FOREVER. IS THIS TARTRATE? YES. OK.

Front 23

benefits of BB in ACS (2)

Back 23

decreases risk of progression to AMI in pt with UA
reduces frequency of recurrent MI

Front 24

mortality benefit with immediate IV therapy of BB
mostly used for hwat (2)

Back 24

no mortality benefit in NSTE-ACS with immediate iV therapy- mostly used for pt who are hypertensive or in afib with RVR

Front 25

BBs to avoid

Back 25

ones with ISA like acetobutolol

Front 26

absolute CI for BBs (7)

Back 26

HR < 55-60
SBP < 90-100
mod to severe LVF with decompensation
peripheral hypoperfusion (shock)
AV conduction abnormalities (2nd/3rd degree heart block)
SEVERE COPD/asthma...eh...maybe, if they have dyspnea upon admin
cocaine use

Front 27

5 relative CIs for BBs

Back 27

hx of asthmar
already using BB
already using non DHP CCB
severe PVD (can decrease perfusion)
uncontrolled/brittle insulin dependent diabetes

Front 28

ACEI- whom to give to (2)

Back 28

ACEI- everyone gets if NSTEMI- may be beneficial (guidelines) in all pt after MI
High risk NSTEMI/UA needs one

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ACEI evidence(3)

Back 29

no placebo controlled trials in NSTE-ACS
20% RRR in combined endpoint of CV death, MI, stroke, cardiac arrest in HIGH RISK pt
no benefit in low risk but how many low risk pt are you going to see with MI

Front 30

ACEI absolutely should be given in what 3 pt pops (3)

Back 30

use in pt with diabetes
LVEF <40% (HF)
hypertension

Front 31

3 As of ABCDEs of treatment : think through when you would give each of these

Back 31

A: antiplatelet- asa, plavix, GP IIb/III a inhibitors

anticoagulation-UFH/LMWH

ACEI/ARB

Front 32

when NOT to give LMWH (2)

Back 32

24h prior to CABG
CrCl < 60 unless monitoring anti Xa

Front 33

2 Bs of ABCDEs of treatmetn
goal BP

Back 33

Beta blockade
BP control (ACEI and BBs firstline)- (<130/85 or 80 if diabetes

Front 34

2 Cs of ABCDEs

Back 34

cholesterol treatment (goal < 70 mg/dL) ALL should be on potent, HD statin

cig smoking cessation

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2 Ds of ABCDEs

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diabetes managemnet (<7% A1C)
Diet

Front 36

Exercise for NSTEMI/UA pt recommendation

Back 36

aerobic/weight bearing exercise 4-5 times per week for > 30 min

Front 37

aldosterone blockade- effect on all cause mortality
when to start?

what type of pt? (2)

Back 37

aldosterone blockade- improved mortality in eplenerone/spironolactone if started 3-14 days post MI with ACEI/BB at optimal doses

pt had SYMPTOMATIC HF and EF <40%

Front 38

UHHH GP inhibitors...when do you even give these

Back 38

---look up

Front 39

PT WITH STEMI- OH NO what do you do (2)

Back 39

MONA
beta blockade- oral within first 24 h- mortality benefit in both early and late phases of STEMI- treat fo lyfe

Front 40

ok pt is on EMS after 911 call- what do you want them to do on the way to hospital? (2)

Back 40

encourage 12 lead ECG
consider prehospital fibrinolytic if capable and EMS to needle within 30 min (goal)

Front 41

door to needle time goal

EMS to balloon time goal

Back 41

door to needle (ER door-->fibrinolytic) time goal- 30 min

EMS to balloon time goal- within 90 min of arriving at hospital (>95% efficacy at restoring flow)- if you can't do this (not at a good hospital) give the fibrinolytic

Front 42

goal total ischemic time

Back 42

120 min

Front 43

when is primary PCI indicated (give PCI first)

meds given at this time?

Back 43

preferred if in hospitals with cath lab and surgical back up

abciximab rec'd ASAP before PCI

Front 44

primary PCI preferred if...(4)

Back 44

high risk pt (cardio shock)

CI to fibrinolysis (ICH, bleeds)
late presentation (>3h from sx onset- maybe person just sat there)
dx of STEMI in doubt (like a really young person that is thin)

Front 45

pt who recieve fibrinolysis- what do we need to do with them after?

Back 45

pt receiving fibrinolysis should be risk stratified to ID need for further revascularization with PCI or CABG

Front 46

in addition to PCI (primary or secondary) in STEMI, all pt should receive what? (2)

Back 46

all pt should receive late hospital care and secondary prevention of STEMI

Front 47

what is MoA of thrombolytis

Back 47

exogenous plasminogen activators -
plasmonigen is proenzyme converted to plasmin by plasminogen activators (which then digests fibrin)

Front 48

thrombolytic administration timing for STEMI- max, preferable time, ideal time

Back 48

administer within 12h of symptom onset
prefer within 6 h
IDEALLY within 30 min of arrival to hospital (door to needle)

Front 49

3 non selective thrombolytics

what does non selective entail

Back 49

streptokinase
anistreplase
urokinase

nonselective means they bind CIRCULATING AND BOUND plasminogen (more bleeds)

Front 50

3 selective thrombolytics
what does selective entail

Back 50

alteplase (tPA)
reteplase (rPA)
tenecteplase

more selective for bound plasminogen (already formed clots)

Front 51

most selective thrombolytic

Back 51

tenecteplase

Front 52

STK 2 properties (2)

Back 52

STK antigenic- can occur when given SECOND time (challenge etc) so not really given anymore since it also has low efficacy

Front 53

Tenecteplase dosing frequency

Back 53

once

Front 54

alteplase (TPA) dosing

Back 54

IVP, then 0.75 mg/kg over 30 min, then 0.5 mg/kg over 60 min

Front 55

reteplase dosing

Back 55

IVP q30 min x2

Front 56

stent vs thrombolytics- mortality effect, other effects (4)

Back 56

stent > thrombolytics for mortality rate decreases

also smaller infarct size, less reinfarcation
less medical cost, less CV event readmission for HF/ischemia

Front 57

8 absolute CIs for thrombolytics

Back 57

-ANY prior hemorrhagic CVA
-ischemic CVA within 3 months?? Why? Transformation into hemorrhagic stroke
intracranial neoplasma or AVM ( bulge in artery at risk of rupture)
internal bleeds
aortic dissection (more bleed risk)
-facial/closed head trauma- increase risk of hemorrhage
-same with diabetic retinopathy
-malignant BP (>200/120)- also increases risk of brain hemorrhage

Front 58

relative CIs for thrombolytics- look at list

Back 58

age >75
active peptic ulcer
pregnancy (more abortions)
Hx TIA/ischmemia GREATER than 3 months ago

ANYTHING BLEED RELATED THAT ISN"T IN ABSOLUTE CI LIST

Front 59

monitoring for efficacy after thrombolytic (2)

Back 59

monitor ST elevation (EKG)
monitor sx for 60-180 min after initiation of fibrinolytic

Front 60

3 noninvasive findings that indicate reperfusion (after thrombolytic)

Back 60

relief of symptoms
maintenance and restoration of hemodynamic/electrical stability
reduction of >=50% of initial ST segment elevation pattern on f/u ECG 60-90 min after initiation of therapy

Front 61

after giving thrombolytic- 6 conditions where you could do rescue PCI/CABG

Back 61

cardiogenic shock
severe CHF/pulmonary edema
ventricular arrhythmias
hemodynamic/electrical instability
persistent ischemic symptoms
reduction of >=50% of initial ST segment elevation not achieved 60-90 min after giving drug

Front 62

thrombolytic + GPIIb/IIIa inhibitor effects

Back 62

increases bleeds, not much diff in mortality (30 day)

Front 63

anticoag for STEMI- when to stop (2) in PCI vs. thrombolytics

Back 63

anticoag d/ced immediately after PCI/CABG


if combining with thrombolysis, use concurrently for >=48 h, until discharge preferably

Front 64

3 anticoags for STEMI use

Back 64

IV UFH
enoxaparin
fondaparinux
(no bivalirudin)

Front 65

7 things to monitor with anticoag in STEMI
3 for drug, 3 for efficacy, 1 for...idk

Back 65

troponin
aPTT with heparin
H/H q6h
platelets
sx
SCr
telemetry (EKG)

Front 66

age > 75 dosing for enoxaparin (2)

Back 66

no bolus (usually 30 mg IV-->then SQ)
reduce dose to 0.75 mg/kg SQ BID

Front 67

contraindication for fondaparinux

Back 67

SCr > 3 mg/dL

Front 68

thienopyridine use in STEMI
not studied in what?
how is dosing different, or is it the same?

Back 68

if stented, use plavix the same as you would in UA/NSTEMI regardless of if they got thrombolytic
no bolus

primary PCI was exluded from study

Front 69

duration of thienopyridine with ASA in STEMI (2)

Back 69

at least 14 days
reasonable up to 1 year

Front 70

plavix and CABG

Back 70

hold >= 5 days before

Front 71

prasugel vs plavix in STEMI efficacy

Back 71

better outcomes with prasugel but more risk in bleeds

Front 72

prasugel- NOT studied in what STEMI population

Back 72

med managmenet (thrombolytic monotherapy)

Front 73

when to start ACEI in STEMI (2)

Back 73

start after SL nitro and BB

usually start within first 24 h for pt

Front 74

patient pop that receives ACEI for STEMI (4)

Back 74

anterior STEMI if they have HF signs (congestion), LVEF <40%, and EVERYONE WITH STEMI UHH OK if their BP allows

Front 75

lifelong therapy with ACEI for STEMI pt if what? (3)

Back 75

lifelong therapy if pt has LV dysfunction, CHF, anterior MI

Front 76

2 relative contraindications for ACEI

Back 76

hypotension, chronic renal failure

Front 77

2 absolute CI for ACEI

Back 77

acute renal failure, bilateral RAS

Front 78

bad ACEI- why?

Back 78

enalaprilat (IV form- increase MORTALITY due to fast onset, makes ppl hypotensive)
avoid- increases mortality

Front 79

lisinopril dosing for STEMI

Back 79

5-10 mg po qd

Front 80

ACEI dosing duration

Back 80

forever

Front 81

4 important monitoring things forr ACEs

Back 81

SBP > 90-100
renal fxn (<30 % increase from baseline)
HF sx
K+<=5

Front 82

5 ADR for ACEI

Back 82

cough
angioedema (can occur even if on med for long time)
diarrhea
taste alteration
dizzy

Front 83

aldosterone antagonist in STEMI

Back 83

same criteria as in NSTEMI

Front 84

goal LDL for STEMI pt (2 options)

Back 84

goal LDL < 100 mg/dL??? i thought it was 70 for the NSTEMI...check. option <70 if very high risk (has additional risk factor- diabetes, smoker, recurrent)

Front 85

AMI effect on LDL

what this means for measuring LDL in STEMI/NSTEMI pt

Back 85

AMI artificially depresses cholesterol by 1/3 to 1/2 so you MUST measure within 24h of presentation or else wait 6-12 weeks

Front 86

first 24 h of STEMI- what to do (7)

Back 86

1) asa within 1st 24 hr- chewed
2) fibrinolytic if not primary PCI
3) UFH/LMWH
4) plavix load
5) metoprolol 5 mg IV, then po
6) ACEI/ARB
7) check lipids- statin

Front 87

7 things to do to pt after first 24h, during hospitalization for STEMI

Back 87

1) asa- maybe with plavix
2) UFH/LMWH (d/c once PCI/CABG is done, if it is done)
3) plavix 75 mg qd
4) titrate up orally until HR 55-60
5) titrate ACEI as tolerated to doses in clinical trials
6) keep on statin
7) consider aldosterone blocker if meets requirements

Front 88

6 long term things to keep pt on for STEMI

Back 88

ASA (1-2 baby asa)
plavix
BB
ACEI
maybe spirono
statin