PHRM 845: Therapeutics III > ACS > Flashcards

ACS Flashcards

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1
Q

What is Acute Coronary Syndromes?

A
  • It is the IMBALANCE between the myocardial oxygen supply and demand
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2
Q

What is meant by Spontaneous MI?

A
  • The atherosclerotic plaque ruptures
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3
Q

How is the atherosclerotic plaque formed and how does it cause ischemia?

A
  • Atherosclerotic plaque is formed by monocytes entering the cell and becoming macrophages. These macrophages then eat up all the cholesterol becoming a fatty streak. That fatty streak becomes the plaque and when it ruptures is when ischemia occurs.
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4
Q

What is meant by MI secondary to ischemic imbalence?

A
  • The mismatch between the oxygen supply and demand [the heart is wanting my oxygen but cant get it]
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5
Q

What are some risk factors for ACS?

A

Smoking, sedentary lifestyle, improper diet, MALE, family history…

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6
Q

What are some precipitating factors for ACS?

A

Exertion, physical activity, weather [Hot and Cold], sexual activity, shoveling snow, large meals…

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7
Q

What are some signs and symptoms for ACS?

A

Substernal chest pain that then can radiate down the LEFT arm and also up into the lower jaw
- Also some SOB, nausea/vomiting, sweating, dizziness…
- Should go away at rest

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8
Q

How do we diagnose ACS?

A

Give the patient a ECG within 10 minutes of arrival to the ER [look at ST interval[]
- ST Elevation = STEMI [may also have Q wave changes]
- ST Depression = NSTEMI

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9
Q

What is the one Myocardial Injury Biomarkers that test for at the ER?

A

Troponin: sees how much necrotic myocytes are in the blood stream
- High Sensitivity Troponin: PREFERRED - <14 ng/L
- Conventional Troponin: <0.05 ng/mL

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10
Q

What is the difference between Stable & Unstable Angina?

A

Stable Angina:
- Chest pain that occurs during EXERTION; has a fixed stable plaque [relieved at rest and short duration]
Unstable Angina:
- Chest pain that can occur any time really; at REST, SLEEP or with LITTLE EXERTION; has a ruptured plaque [last a longer time, >30 mins]

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11
Q

What is the difference between Unstable Angina & NSTEMI?

A

Both have very similar conditions: Chest pain that can occur any time really; at REST, SLEEP or with LITTLE EXERTION; has a ruptured plaque
Unstable Angina:
- Less Ischemia [not blocked as bad]
- NO troponin
NSTEMI:
- More blocked
- Elevated Troponin

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12
Q

What is the difference between NSTEMI & STEMI?

A

NSTEMI:
- NO elevated ST Interval [ST Depression]
- Elevated Troponin
STEMI:
- ST Elevation
- Possible Q Elevation
- Elevated Troponin

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13
Q

What is a TIMI score?

A
  • Risk of experiencing either death, MI or Urgent need for revascularization within 14 days
    [Low Risk: 0-2, Medium Risk: 3-4, High Risk: 5-7]
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14
Q

How do we determine the TIMI score?

A
  1. AGE >65
  2. > risk factors for CAD [HLD, HTN DM, Smoking, Family history]
  3. Known CAD
  4. Use of Aspirin
  5. ST Depression
  6. Chest Discomfort within 24 hr
  7. Positive Biomarker
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15
Q

Other than the ECG, what is some other early hospital care we should do for ACS patients?

A

MONA

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16
Q

What is MONA?

A

DO IMMEDIATELY
- Morphine 4-8mg IV, then 2-8mg IV q15min
- Oxygen [O2 sat >90%]
- Nitrate Tab 0.3-0.4mg every 5 min x 3
- Aspirin 325mg, then 81mg indefinitely

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17
Q

What is Reperfusion?

A
  • Medical treatment to restore blood flow, either through or around, blocked arteries, typically after a heart attack; either procedural or medical
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18
Q

What are the Procedural reperfusion strategies?

A

PCI [Percutaneous Coronary Intervention] or CABG [Coronary Artery Bypass Graft]

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19
Q

What is a PCI?

A

A PCI is when the cardiologist goes into the arteries of the heart and puts in a stent [something to help hold the arteries open]

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20
Q

What is a CABG?

A

A CABG is basically open heart surgery [they take arteries or veins from either the radial or femoral and “bypass” the blockages in the heart]

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21
Q

What is the Medical reperfusion strategies?

A

Fibrinolytics

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22
Q

What is a Fibrinolytic?

A
  • A way to prevent clots from growing and becoming a problem [the “-plase” & SHOULDN’T be given to patients that are high risk of bleeding]
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23
Q

What is the most appropriate reperfusion strategy for STEMI patients?

A
  • The PCI is PREFERRED over the Fibrinolytic [due to less bleeding, recurrent ischemia and death]
    *Door-to-needle: 30 minutes after getting to hospital [MONA, ECG, Troponin]
    *Door-to-balloon: 90 minutes after getting to hospital [PCI + STENT]
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24
Q

If the patient arrives at a NON-PCI capable hospital, what should happen?

A
  • Transfer then to a PCI capable hospital, as long as its >120 minutes away [If <120 minutes away, then just give fibrinolytic]
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25
What is the most appropriate reperfusion strategy for NSTEMI & Unstable Angina patients?
- NO fibrinolytics - Either Ischemia Guided Strategy or Early Invasive Strategy
26
What is Ischemia Guided Strategy?
- Basically just giving the patients the proper medications to help manage any symptoms or problems [the patient wants a less invasive approach]
27
What is Early Invasive Strategy?
- Giving the patient that is very high risk either a CABG or PCI [patients that have new HF, High Troponin, new ST Depression]
28
What are some the the Antiplatelets that we would use in ACS?
Aspirin, P2Y12 Inhibitors, GPIIb/IIIa Inhibitors
29
How should we appropriately give the patient Aspirin for ACS?
- Want to give 325mg IMMEDIATELY upon arrival [MONA] then give 81mg Once Daily Indefinitely [the higher dose literally doesn't give an advantage]
30
What are the P2Y12 Inhibitors?
Clopidigrel, Ticagrelar, Cangrelor, Prasugrel
31
What are the LOADING dose and MAINTENANCE dose for the P2Y12s?
- Clopidogrel 300-600mg LD* & 75mg daily MD - Ticagrelor 180mg LD & 90 BID MD - Praugrel 60mg LD & 10mg MD - Cangrelor 30mcg/kg LD & no MD
32
What is important to know about Clopidogrel's Loading Dose?
- Should just give the 600mg as LD since there isn't really about benefit about giving the 300mg - DON'T give 600mg during fibrinolytic -- Fibrinolytic + >75yo = NO Loading Dose -- Fibrinolytic + <75yo= 300mg Clopidogrel
33
What is important to know about Prasugrel?
- NOT recommended for Ischemia Guided Therapy - Has greater platelet aggregation - CONTRAINDICATED with stroke - DO NOT give to anyone >75yo, <60kg, or high bleed risk
34
Which P2Y12 Inhibitor should you use in NSTEMI/UA?
Ischemia Gudied Therapy: - Ticagrelor or Clopidogrel Early Invasive Strategy [PCI] - Any; Ticagrelor or Prasugrel are preferred
35
What P2Y12 Inhibitor should you use in STEMI?
Fibrinolytic: - Clopidogrel [HUGE bleeding risk] PCI - Ticagrelor or Prasugrel
36
How should Antiplatelets be handled for someone undergoing a CABG?
- Aspirin; DO NOT HOLD - P2Y12 Inhibitors: HOLD [Ticagrelor - 3d, Clopidogrel - 5d, Prasugrel - 7d]
37
What are the GPIIb/IIIa's?
- Abciximab, Eptifibatide, Tirofiban
38
What is the mechanisam of Action for the GPIIb/IIIa's
- Inhibits the platelet aggregation
39
When should GPIIb/IIIa's be given?
- In ADDITION to Aspirin and P2Y12 Inhibitors [really only used when there is a NEW thrombus that has formed]
40
What is the purpose of Anticoagulation in the therapy of ACS?
- To improve vessel patency and prevent reocclusion
41
What do Unfractionated Heparins [UFH] do?
- Its a penta-saccaride that binds to AT inhibiting its activation, inhibiting thrombin [IIa] and Xa - Risk if HIT - 4T's: Thrombocytopenia, Timing, Thrombosis, oTher
42
What is Enoxaparin?
- A LMWH - Its a smaller penta-saccaride that binds to AT inhibiting its activation, inhibiting thrombin [IIa] and Xa; BUT has a greater effect on Xa
43
What is Bivalirudin?
- A direct thrombin inhibitor [IIa] so it prevents the clotting ability of the blood and help prevents any harmful clots from forming
44
What is Fondaparinux?
- A Xa inhibitor so it helps prevent deep vein thrombosis - DO NOT use in PCI alone
45
When should Anticoagulation be used in patients with UA & NSTEMI?
Ischemia Guided Therapy: - UFH: Yes [48 hr] - Bivalirudin: No - Enoxiparin: Yes [8d in Hospital] - Fondaparinux: Yes [8d in Hospital] Early Invasive Strategy: - UFH: Yes [Until PCI] - Bivalirudin: Yes [Until PCI] - Enoxiparin: Yes [Until PCI] - Fondaparinux: No
46
When should Anticoagulation be used in patients with STEMI?
Fibrinolytics: - UFH: Yes [48 hr] - Bivalirudin: No - Enoxiparin: Yes [8d in Hospital] - Fondaparinux: Yes [8d in Hospital[] PCI: - UFH: Yes [Until PCI] - Bivalirudin: Yes [Until PCI] - Enoxiparin: No - Fondaparinux: No
47
When should the Beta-Blockers be initiates for ACS?
Within 24 hours
48
What would be a reason to not start a Beta-Blocker?
- Bradycardia, AV Block, Asthma
49
Describe the receptor selectivity of the Beta-Blockers?
B1: Metoprolol, Atenolol, Bisoprolol, Nebivolol [Heart] B2: Propranolol, Sotalol, Nadolol [Lungs] Mixed: Carvedilol, Labetolol [B1, B2, Arteries]
50
What are some of the Loading and Maintenance Dosages for Beta-Blockers?
-Metoprolol: 25-50mg q6-12h LD & 100mg BID MD - Carvedilol: 6.25mg BID LD& 25mg BID MD - Propranolol: 40mg BID-TID LD & 80mg QID MD - Atenolol: 25-50mg Daily LD & 100mg Daily MD
51
What is important to know about Beta-Blockers and Cocaine?
- Cocaine is an Alpha and Beta receptor stimulater, so together they can cause chest pain or even MI [since the beta receptor is blocked, it all goes to the alpha receptor causing it]
52
What to counsel the patient on for Beta-Blockers?
- Life long medication - Will lower BP and HR; so it you feel dizzy maybe too low - If you have diabetes, may mask hypoglycemia; NO COLD SWEAT
53
What are the hold parameters for Beta-Blockers? ???
- Holding Parameters: if BP and HR are too low; hold the medication. - TOO LOW? -- <90-120 SBP or < 50-60 BPM * HOLD FOR: ~ SBP < 90 & DBP < 60 ~ SBP < 90 & HR < 60
54
When should Calcium Channels Blockers be used?
- Really should be used when the patient has recurrent ischemia or contraindicated to Beta-Blockers [ONLY the NON DHP: Verapamil or Diltiazem]
55
What is the Mechanism of Action for the Statins?
- Inhibit the conversion of HMG-CoA to Mevalonic Acid; decreasing the formation of Cholesterol and stopping the formation of plaques
56
What are the statins that should be used?
High Intensity Statins: - Atorvastatin: 40-80mg Daily - Rosuvastatin: 20-40mg Daily
57
What is some patient counseling for Statins?
- Life long medication to prevent heart attack - Lower cholesterol; even if normal take it - Most common side effect is MUSCLE PAIN
58
What is the Mechanism of Action for the ACEi?
- Blocks the conversion of Angiotensin I to Angiotensin II
59
What are the ACEi?
- "-pril" - SHOULD be give to all patients as they help decrease mortality
60
When should ACEi not be use?
- During hypotension, renal failure, angioedema
61
What are some monitoring parameters with ACEi?
- Increased Creatinine [decreased pressure in glomerulus] - Increased Potassium [do not give to hyperkalemics] - Decreased BP [Hypotension] - Angioedema [swelling of the face]
62
What is some patient counseling for ACEi?
- Life long medication; helps you live longer - Dizziness from the decreased BP - Dry Cough [Switch to ARBs] - Angioedema [medical emergency]
63
What should we do about Nirtoglyercin?
- SHOULD be given to every patient - 0.3-0.4mg under tongue q5 mins for chest pain [max dose 3, then call 911]
64
What is some counseling for NTG?
- Keep on you - Keep stored in amber glass or airtight container
65
What else should we discuss with the patient about prevention of MI?
- STOP SMOKING, medication adherence, healthier diet
PHRM 845: Therapeutics III
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