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114 Cards in this Set
- Front
- Back
Higher hospital death rates: STE ACS or NSTE ACS?
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STE ACS
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Factors that contribute to the evolution of endothelial dysfunction and formation of fatty streaks that lead to atherosclerotic plaques?
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HTN, age, male gender, tobacco use, DM, obesity, dyslipidemias
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Difference between STEMI, NSTEMI, and unstable angina (all ACS)?
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unstable angina does not produce detectable biochemical marker levels
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ECG changes in NSTEMI?
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st segment depression, t wave inversion, or no changes
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ECG changes in STEMI?
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ST segment elevation
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What percentage of ACS are caused by rupture or erosion of an atherosclerotic plaque?
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>90%
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What kinds of plaques are likely to rupture?
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plaques that are occluded <50% of lumen, eccentric shape (plaque on one side of vessel), thin fibrous cap with large fatty core
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What occurs after plaque rupture?
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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
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White clots are associated with what acs?
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NSTE ACS
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Red clots are associated with what acs?
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STE ACS
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Complications of ACS?
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heart failure, valve dysfunction, arrythmias, heart block, pericarditis, stroke, venous thromboembolism, LV free-wall rupture
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ACS symptoms?
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severe new-onset angina >=20 min, pain may radiate to left arm or jaw or back, N/V, diaphoresis, SOB
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Who has atypical ACS symptoms?
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women, diabetics, elderly may have atypical or no symptoms
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When should ECG be done in ACS?
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within 10 mins of ED arrival
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What biomarkers should be taken in ACS?
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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
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MI treatment goals?
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-Restore blood flow to prevent infarct expansion and MI
-prevent complications and death -prevent coronary artery reocclusion -relieve ischemic chest discomfort -maintain normoglycemia |
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NSTEMI risk categories?
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high (5-7pts), medium (3-4pts), low (0-2pts) (based of TIMI score: Thrombolysis in MI)
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Calculation of timi score?
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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 |
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High risk NSTEMI patients should receive what therapy?
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PCI or CABG
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Low risk or moderate risk NSTEMI pts should receive what therapy?
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stress test to evaluate likelihood of CAD
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If a positive stress test, what tx for NSTEMI pt?
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PCI or CABG
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What medications should an ACS pt receive on admission?
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MONA B (morphine, oxygen, nitroglycerin, beta blocker, ASA)
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In stemi pt, what should door to balloon time be?
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< 90 min
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If greater than 90 min door to balloon time in STEMI pt, what therapy?
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thrombolytic therapy
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Better outcomes: PCI or fibrinolysis?
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PCI
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Best predictor of mortality after MI?
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LV function (LVEF <40% = higher risk of death)
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When should fasting lipid panel be drawn in MI patient?
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within 1st 24h
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When should ACEi be started for MI pt?
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within 24h of presentation
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When should a statin be started for MI pt?
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prior to discharge in pts with LDL >100mg/dl
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When should fibrinolytic therapy be done in STEMI pts?
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within 12h of symptoms (can be done in select pts after 12h)
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clopidogrel or prasugrel for PCI pts?
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either
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clopidogrel or prasugrel for fibrinolytic pts?
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only able to use clopidogrel
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All STE ACS pts should receive what therapy at discharge?
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ASA, BB, statin, ace/arb; selected pts should also have aldosterone antagonist, clopidogrel or prasugrel, or warfarin
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Therapy for NSTEMI pts?
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fibrinolytic therapy contraindicated, GP IIb/IIIa for high risk pts
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Fibrinolytic indication in acs?
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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)
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Absolute contraindications for fibrinolysis?
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-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 |
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Relative contraindications for fibrinolysis?
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-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
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All ACS hospital day 1 ASA dosing?
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162-325 x1
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All ACS hospital day 2 if no stents ASA dosing?
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75-162 continued indefinitely
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PCI in ACS, pre-pci ASA dosing?
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325 before PCI
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PCI in ACS, bare metal stent ASA dosing?
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325mg daily x 1 month
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PCI in ACS, sirolimus stent ASA dosing?
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325mg daily x 3 months
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PCI in ACS, paclitaxel stent ASA dosing?
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325mg x 6 months
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ASA dosing following stent dosing regimen?
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75mg indefinitely
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MOA of ASA?
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irreversible cycloxygenase inhibitor
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Contraindications to ASA?
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hypersensitivity, active bleed, severe bleed risk (do not admin with other NSAIDS)
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Maintenance indication for clopidogrel in post MI patients?
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given to patients unable to take ASA due to hypersensitive or major GI intolerance
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Dosing of clopidogrel for STE ACS?
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75mg qd added to aspirin in all pts and continued x 1 month (ideally 1 yr)
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If CABG is planned, what to do with clopidogrel?
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D/c at least 5 days prior
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Dosing clopidogrel for NSTE ACS?
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75mg daily added to aspirin x 1 month (ideally 1 year)
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All ACS Clopidogrel dosing hospital day 1 ?
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300mg x 1
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All ACS Clopidogrel dosing hospital day 2 if no stent?
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75mg qd x 1month (ideally 1 yr)
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In PCI, Clopidogrel dosing pre-pci?
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300mg at least 6h prior
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In PCI, Clopidogrel dosing for bare metal stent?
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75mg qd x 1 month (ideally 1 year)
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In PCI, Clopidogrel dosing for drug eluting stents?
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75mg qd x 1 year
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MOA of clopidogrel?
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irreversibly blocks P2Y12 ADP receptors on platelets preventing fibrin binding
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Contraindications to clopidogrel?
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hypersensitive, active bleed, severe bleed risk
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Adverse effects of clopidogrel?
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bleeding, N/V, diarrhea
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Benefits of prasugrel compared to clopidogrel?
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-quicker acting and more potent antiplatelet agent with improved efficacy
-not affected by PPI (negative is prasugrel increased CAGB bleeding in clinical trials) |
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Prasugrel dosing in ACS pts with PCI?
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60mg loading dose followed by 10mg qd (5mg qd in pts <60kg) x 12-15 months (pts should continue to take aspirin)
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MOA of prasugrel?
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irreversibly blocks P2Y12 ADp on platelets
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Contraindications for prasugrel?
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active bleed or prior TIA or stroke
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precautions for prasugrel?
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age >=75, bw <60kg
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adverse effects of prasugrel?
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bleeding, thrombotic thrombocytopenia purpura (TTP)
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indication for ticagrelor (brilinta)?
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reduce rate of CV thrombotic events in pts with ACS
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dosing for ticagrelor?
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180mg loading dose followed by a maintenance dose of 90mg po bid
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MOA of ticagrelor?
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binds reversibly to the same P2Y12 ADP receptor as the thienopyridines (clopidogrel, prasugrel)
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Contraindications/precautions for ticagrelor?
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severe hepatic impairment, hx of intracranial hemorrhage, active bleeding, PUD
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ASA dosage with ticagrelor?
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ASA <100mg is needed as greater decreases effects of ticagrelor
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adverse effects of ticagrelor?
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bleeding, dyspnea, bradyarrthmias, elevated uric acid and Scr
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Abciximab (reopro) indication?
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STEMI with PCI, NSTEMI with PCI, no renal adjustment
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Eptifibatide (integrelin) indication?
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stemi with pci, nstemi with or without PCI, CrCl < 50 reduce infusion by 50%
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Tirofiban (aggrastat) indication?
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nstemi not undergoing Pci, crcl < 30 reduce infusion by 50%
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MOA of abciximab?
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prevents cross linking of platelets through inhibition of gp IIb/IIIa receptros
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MOA of eptifibatide?
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prevents cross linking of platelets through inhibition of gp IIb/IIIa receptros
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MOA of tirofiban?
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prevents cross linking of platelets through inhibition of gp IIb/IIIa receptros
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Contraindications for gp IIb/IIIa receptor inhibitors?
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active bleeding, thrombocytopenia, hx of stroke
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Adverse effects with gp IIb/IIIb receptor inhibitors?
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bleeding, immune mediated thrombocytopenia
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Class for enoxaparin?
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LMWH
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Class for dalteparin?
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LMWH
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class for fondaparinux?
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factor Xa inhibitor
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Class for bivalirudin?
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direct thrombin inhibitor (reversible)
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Class for lepirudin?
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direct thrombin inhibitor (irreversible)
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Class for argatroban?
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direct thrombin inhibitor (reversible)
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Anticoag therapy in STEMI for no reperfusion or reperfusion with fibrinolytics?
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1st line: enoxaparin or fondaparinux (alt UFH) x 48 h minimum but preferably x hospital stay (max 8 days)
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Anticoagulants therapy in STEMI with pci after receiving an anticoagulant?
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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)
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When to add antiplatelet therapy in NSTEMI?
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as soon as possible after presentation
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Invasive NSTEMI anticoag strategy?
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1st line: enoxaprin or UFH
Alt: bivalirudin or fondaparinux x8 days |
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Conservative NSTEMI anticoag strategy?
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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 |
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MOA of UFH?
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binds antithrombin and inhibits clotting factors Xa and IIa
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Duration of UFH after PCI?
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x48h for pts who will be on warfarin, otherwise d/c immediately
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Contraindication for UFH?
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hx of HIT, active bleed, severe bleed risk, recent stroke
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Adverse effects with UFH?
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bleeding, hit
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MOA of enoxaparin?
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binds antithrombin, inhibits Xa and IIa
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Contraindications for enoxaparin?
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active bleeding, severe bleed risk, hx of hit, recent stroke, avoid in CABG pts
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Adverse effects of enoxaparin?
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bleeding and hit (less extent than UFH)
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When to renally adj enoxaparin?
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crcl <30
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MOA of fondaparinux (arixta)?
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inhibit Xa
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Contraindications for fondaparinux?
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crcl <30ml
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adverse effects with fondaparinux?
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bleeding, catheter thrombosis when used in PCI
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ACUITY trial?
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-bivalirudin vs bivalirudin+GP IIb/IIIa inhibitor vs heparin/enoxaparin+GP IIb/IIIa inhibitor
-no mortaility difference but bivalirudin monotherapy had less bleeding |
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Nitrate dosing?
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0.4mg sl q 5 min x3
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MOA of nitrates?
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promotes release of nitric oxide producing vasodilation and myocardial ischemia relief through vasodilation lowering 02 demand and preload
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contraindication of nitrates?
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PDE5
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Adverse effects of nitrates?
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HA, flushing, hypotension, tachycardia
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Cardioselective BB?
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acebutolol, atenolol, betaxolol, bisoprolol,esmolol, metoprolol, nebivolol
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Nonselective BB?
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nadolol, propranolol, timolol
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Mixed a and BB?
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carvedilol and labetolol
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indication for IV BB in ACS pts?
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only given to hemodynamically stable pts who present with persistent ischemi, HTN, or tachycardia as can lead to cardiogenic shock
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Adverse effects of BB?
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hypotension, acute HF, bradycardia, heart block, mask hypoglycemia, bronchospasms
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Non-dihydropyridine CCB?
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verapamil and diltiazem
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indications for CCB in STE and NSTE ACS?
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pts with contraindications to BB
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MOA of CCB?
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inhibit Ca influx to myocardial and vascular smooth muscle
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Secondary prevention goals in MI?
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control modifiable CHD risk factors, prevent developement of systolic HF, prevent recurrent MI or stroke, prevent death
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