ACS

Question 1

ACUTE CORONARY SYNDROME

Answer 1

UA: PAIN NOT RELIEVED BY NTG OR REST

PRINZMETAL ANGINA: CORONARY ARTERY SPASM. TX WITH NON DHP CCB AND NITRATES

AMI: ACUTE MYOCARDIAL INFARCTION
-STEMI: ST ELEVATION

-MNSTEM: NON ST ELEVATION

Question 2

ACS SYMPTOMS

Answer 2

diaphoresis, n/v, sob, anxiety, pain

Question 3

UA

NSTEMI

STEMI

Answer 3

UA: ( - )CARDIAC ENZYME

NSTMEI: (+) cardiac enzyme + trp but no ST elevation on ECG

STEMi: + cardiac enz, + trp plus ST elevation on ECG

trp measeured in 3hr & 6hr

Question 4

**UA/NSTEMI

STEMI

Answer 4

tx with antiplatelt anticoag plus possibly PCI stent
***Never THROMBOLYTICS

UA/NSTEMI: Artheroscleroi plaque rupture. rupture plaque is magnet for pt aggregation and clot formation . Antiplatelt and anticoagulat used to prevent new clot formation

STEMI

**TX WITH
-PCI STENT,
-ANTIPLATELET
- PARENTERAL ANTICOAG
- OR CABG OR
-THROMBOLYTICS **

a sudden thrombi clot blocking the flow therefore tx with PCI stent to open blocakge. Thrombolytic used

Question 5

ACS inital measure

Answer 5

MONA BAS
- morphine
- oxygen sat <90%
- Nitrate : SLG NTG upto 3x
- Aspirin : DATP (use clopidogrel or triacagelor if ASA allergy)

BB: Metoprolol IV if hypertensive; oral if not hypertensive

STating: High intesnity Lipitor 40-80mg and crestor 20-40mg

serial ECG( detect abnormalities in electrical impulse of heart)

Serial troponin

Question 6

morphine

Answer 6

• dec BP—o2 demmand
• AVoid morphine if SBP <90 mmHG
• If allergy to morphine use meperidien (demerol)

Question 7

NTG

Answer 7

• vasodilation of coronary arteries and peripheal arteries
• Do not use if SBP <90 mmHg
• Do not use with PDE-5 Inhibitor within 24-36 hrs —severe hypotension

sildenafil - viagra
vardenafil- levitra
tadalfil - cialis

Question 8

ASA

Answer 8

• admin to all emergecy pt unless CI
• chewed 160-325mg abs more quickly
• ASA supp recomm with N/V
• CI: PUD, bleeding disorder, ASA allergy
• maintenance dose 81mg daily

Question 9

BB in AMI

Answer 9

• red o2 demand
• red arrythmia and afib
• dec rate of infarction and mortilty
• Metoprolol commonly used

Question 10

ACE inhib and MI

Answer 10

• ACEI prevent ventricular remodeling
• decrease sudden death and recurrent MI
• started within 24 hrs but after 6hr when BP has stabilized
• Inital dose should be low
• Iv therapy not recomm
• ACEI inhib use in MI are LISIONPRIL AND CAPTOPRIL
• IF ACE NOT TOLERATED USE ARB

Question 11

AFTER THE EXACT DIAGNOSIS IS MADED WITH ECG AND TROPONIN

Answer 11

• IF stemi: reperfusion therapy with PCI stent (pref) or CABG or Fibrinolytics

**thrombolytics: if hosp is not PCI -capable and >120 min delay

**IF >120 min delay in PCI fibrinolytic therapy must be started with 30 min of arriving at hosp

IF UA/NSTEM: DAPT and antiplatelet for all
- may receive PCI stent but no fibrinolytics

PCI: accompanied by DAPT and parenteral anticoag

Question 12

Bare metal stent

Answer 12

re-stenosis

Question 13

drug eluting stent

Answer 13

coated with med such as tacrolimus, paclitaxel- interfere with cell prolif/ re-stenosis

chance of thrombosis is high for 1 year

Question 14

DAPT

Answer 14

ASpirin
- 162-325 mg loading before PCI +
- 81mg lifetime

PLUS

P2y12 inhibior
- clopidogrel 300-600mg loading then 75mg QD
- Prasugrel : 60mg load then 10mg QD
- triacagelor: 180mg load then 90mg BID

Question 15

DAPT after PCI stent

Answer 15

BMS: DAPT for atleast 1 month upto 1 year

Drug eluting stent
- avg pt: 6-12 month DAPT then ASA monotherapy
- high bleeidng risk: 1-3 months DAPT
- high ischemic risk: INC DAPT dur accord

DAPT should not be interrupted for Surgery

Question 16

p2y12 inhibitor

Answer 16

Prasugrel (effient)
- do not use if hx of stroke/TIA and warning agaisnt use in >75y/o patient

Tricagelor (Brilinta)
- use if <100 mg of Aspirin

Clopidogrel (Plavix)
- prodrug and need CYP2c19 to convert to activate form
- safer for high bleeding risk

Both clopidogrel and Prasugrel are pro-drug and require cyp2c19 to convert to active form

CYP2c19 inhibitor : omeprazole (prilosec) and esomeprazol (Nexium)

Question 17

*

CYP2c19 inhibitor :

Answer 17

omeprazole (prilosec) and esomeprazol (Nexium)

Question 18

THROMBOLYTICS IN STEMI

Answer 18

check for following
- BP MUST BE <180/110 mmHg
- no hx of ischemic stroke for last 3 months
- no hx of hemmorhagic stroke
- No known bleeding disorder

Question 19

DAPT AFTER THROMBOLYTICS

Answer 19

ASA and Plavix after thrombolytics Loading dose
- ASA 162-325mg LD &
- Clopidogrel load 300mg <75 y/o and 75mg for > 75 y/0o

ASA and Plavix after thrombolytics MD dose
- ASA 81mg and
- Clopidogrel 75mg for atleast 14 days

Question 20

UA/NSTMI managment

Answer 20

1. DAPT
2. Parenteral anticoagulant ( UFH, Bivalruding, Enoxaparin, Fondaparinux)
3. PCI
4. Possible GPIIa/b (Tirofiban-aggrastat, Eptifibatide- Integrilin)

Question 21

Before discharge acronmy

Answer 21

NAABAS
N: NTG
A: DAPT
B: BB
A: ACEI
S: STATIN (HIGH)

AFTER AMI: check EF wtih ECHO. If HFrEF<40% add MRA aldosterone and consdier Entresto instead of ACEI

if pt develop Afib: Add PO anticaogulant
DOAC or warfarin plus P2y12 inhib (W/o ASA) triple therapy

Question 22

Initial ACS managment

Answer 22

Mona Bas
morphine
oxygen if o2 sat < 90%
Ntg 0.4mg q5min
ASA: 325mg Po chew or rectal

BB: metorpol 25mg Po or IV if hypertensive
ACEI : low dose after 6 hrs within 24 hr
Statin: high dose

Lipitor 40-80mg
Crestor 20-40mg