Term
| When should we shoot for that 30-40% reduction in LDL? |
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Definition
| Patients with high risk diagnosed w/ LDL goals of <100mg/dL should also shoot for a 30-40% reduction, whichever results in a greater reduction in LDL |
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Term
| How does a patient with chronic stable angina experience ACS? |
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Definition
| When atherosclerotic plaque ruptures and a thrombus forms (the body activates platelets and the clotting system). The body's reaction can either partially or completely occlude a coronary artery |
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Term
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Definition
| ACS is an umbrella term that includes UA, NSTEMI, and STEMI |
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Term
| What is the physiological difference between a patient with chronic stable angina and a patient with ACS |
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Definition
| A patient with chronic stable angina has an unruptured plaque while a patient experiencing ACS has a ruptured plaque that leads to platelet activation and thrombus formation |
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Term
| How are patients with STEMI and NSTEMI managed differently? |
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Definition
STEMI: patients are managed with fibrinolytics to break up the fully occluded thrombus
NSTEMI: Prevent thrombus from partially occluding to fully occluding the coronary artery, so use antiplatelets and PCI (dont use fibrinolytics bc of high risk of bleeding) |
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Term
| How do you differentiate between UA, NSTEMI, and STEMI based on ECG & labs? |
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Definition
UA: No ST elevation, no abnormal [TN] & [CK-MB]
NSTEMI: no ST elevation, abnormal [TN] & [CK-MB]
STEMI: ST elevation, abnormal [TN] & [CK=MB] |
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Term
| When is the only time a thrombolytic is an option? |
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Definition
STEMI and not going for PCI/CABG
Risk of bleeding is too high in any other patients |
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Term
| When is NTG contraindicated in? |
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Definition
| When SBP < 90 or Sildenafil within 24 hrs (longer with tadalafil or vardenafil) |
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Term
| When a patient comes into the ER with angina, what do we do for the angina? |
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Definition
1. SL NTG (unless CI: SBP < 90, use of sildenafil within 24 hrs)
2. IV BB (unless CI, give NDHPCCB if patient has RAD)
3. NTG drip/ointment applied q6hrs to chest wall
4. Morphine 2-8 mg q5-15 min prn CP w/ NTG + BB
DO NOT SEND PATIENT HOME! |
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Term
| If patient comes into ER with angina, how do we address the thrombus? |
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Definition
- Can do either PCI or CABG.
- If unsure whether patient will be doing PCI or CABG, use UFH drip until a decision is made (don't want to give anti-platelets if patient is doing CABG bc of high risk of bleed)
1. Oral anti-platelet:
- ASA 160-325mg
- Clopidogrel 300-600mg LD, then 75mg QD (unless patient going to CABG)
2. Anticoagulants
- LMWH (enoxaparin), UFH (CABG), Xa Inhibitor (Fondaparinux), Direct Thrombin inhibitor (Bivalirudin)
3. IV anti-platelets (GP 2b-3a inhibitors: Eptifibatide or Tirofiban)
- esp in PCI bc PCI disrupts endothelial lining of the coronary artery so platelet activation is likely |
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Term
| Would you need to give BB to a patient who was discharged with UA? |
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Definition
| No bc the patient did not have an MI so you will not see elevated troponin o rCK MB and you do not need to treat them as if they are post-MI at discharge |
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Term
| If a STEMI patient chooses thrombolytic therapy, what would you need to give? |
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Definition
1. Fibrinolytic
2. ASA + Clopidogrel
3. "heparin-like" |
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Term
| Is a STEMI/NSTEMI patient needs to do a PCI, what would you give them? |
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Definition
1. ASA + Clopidogrel
2. "heparin-like" or bivalirubin-based combo
3. IV GP 2b 3a inhibitor |
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Term
| If you gave Clopidogrel/Prasugrel, what procedure can you NOT do? |
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Definition
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Term
| When will a physician be inclined to do CABG? |
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Definition
Mainly determined by cardiac catheterization:
1. CAD with left main disease --> CABG!
2. 3 vessel disease or 2 vessel disease w/ proximal LAD involvement AND left ventricular dysfunction or treated DM? CABG! |
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Term
| What determines whether a patient should do BMS or DES? |
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Definition
1. Can patients go on DAT for long time?
- Yes AND low risk of bleeding: DES
- No: BMS |
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Term
| What determines how long patient will be on DAT? |
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Definition
| Type of stent: BMS or DES |
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Term
| What is the difference between DES and BMS? |
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Definition
BMS:
1. risk of re-occlusion is highest during the 1st 30 days due to platelet activity
DES:
1. has drug fully embedded into the scaffolding/mesh which goes away in 3-6 months
2. After drug has gone away, DES now acts like BMS
3. After 6 months, there is a sudden risk of re-occlusion |
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Term
| How would you dose Enoxaparin in a NSTE-ACS patient? |
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Definition
1. Weight based dosing
2. May give 30mg IV bolus
3. 1mg/kg SQ q12hr, if CrCl < 30mL/min, then 1mg/kg q24 hrs |
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Term
| How would you dose UFH in a NSTE-ACS patient? |
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Definition
1. Weight based dosing
2. Preferred when CABG is planned within 24 hrs
3. Bolus: Dose of UFH 60-70U/kg (max 5000U) IV
3. Infusion: 12-15U/kg/hr (max 1000U/hr)
4. Monitor aPTT (how thin is the blood)
5. Titrate rate of heparin based on aPTT (desired 1.5-2.5 times control) |
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Term
| Why is dosing for ACS lower than for patients with PE or DVT? |
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Definition
| ACS patients are on many other drugs that increase the risk of bleeding while patients with PE or DVT do not have as many DDIs so can use higher doses |
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Term
| If patient has CrCl < 50, what is dosing for patient on Eptifibatide? |
|
Definition
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|
Term
| If patient has CrCl < 30, what is the dosing for Tirofiban? |
|
Definition
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|
Term
| If patient has CrCl < 30, what is the dosing for Enoxaparin? |
|
Definition
1 mg/kg SQ q24 hrs
- Capped at 100mg
- May have an initial 30 mg IV dose |
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Term
| What should be monitored for Enoxaparin? |
|
Definition
- Must renally dose
- Thombocytopenia (too few platelets)
- Stop if platelets decr. by 50% or below 100,000/mm3 |
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Term
| What are the SE of GP 2b/3a inhibitors? |
|
Definition
1. Bleeding (monitor aPTT)
2. Nausea
3. Hypotension
4. Thrombocytopenia (multiple drugs given to ACS patient can cause it) |
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Term
| What are the CI of GP 2b/3a inhibitors? |
|
Definition
1. Active or recent bleeding (4-6 weeks)
2. Severe HTN (SBP>180-200, DBP>110)
3. Any hemorrhagive CVA (+/- intracranial neoplasm, AVM, or aneurysm)
4. Any CVA within 30 days-2 years
5. Major surgery or trauma within 4-6 weeks
6. Thrombocytopenia (<100,000/mm3)
7. Bleeding diathesis/warfarin w/ elevated INR |
|
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Term
| What should be monitored in GP 2b/3a inhibitor? |
|
Definition
1. aPTT
2. Platelet counts |
|
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Term
| When is Fondaparinux CI in? |
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Definition
|
|
Term
If patient is going for CABG, what should you keep in mind about:
1. clopidogrel
2. GP 2b/3a inhibitors
3. Enoxaparin
4. Fondaparinux |
|
Definition
1. D/C Clopidogrel 5-7 days before elective CABG procedure
- Error if Clopidogrel is given right before CABG
2. Stop any GP 2b/3a inhibitor 4 hrs before CABG
3. Exoxaparin must be stopped 12-24 hrs
4. Fondaparinux must be stopped at least 24 hrs prior |
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Term
| What is the difference between DTI and heparin complexes? |
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Definition
Heparin complexes do not work on thrombin bound to clots
DTIs can work on bound and unbound thrombin AND does not cause HIT |
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Term
| What did the REPLACE-2 and ACUITY PCI show? |
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Definition
If using Bivalirubin, don't need to use GP 2b/3a inhibitors
Bivalirubin show similar efficacy and less bleeding than heparin + GP 2b/3a inhibitors |
|
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Term
| Do you need to monitor aPTT in Enoxaparin? |
|
Definition
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|
Term
| If you need an anticoagulant but patient has low renal function, which drug will you choose? |
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Definition
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Term
| When might a physician not consider doing the 30mg IV bolus of exoxaparin? |
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Definition
| If patient > 75 yo bc 30 mg IV bolus may increase chances of bleeding complications |
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Term
| For UFH, what do you need to monitor for? |
|
Definition
|
|
Term
| If patient's CrCl < 30mL/min, what anticoagulant should you avoid? |
|
Definition
|
|
Term
| When would you give Bivalirudin? |
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Definition
| If patient has HIT and needs anticoagulant (may not need GP 2b/3a inhibitors) |
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Term
| If patient develops HIT while on UFH, which other anticoagulant should not be used? |
|
Definition
1. Fondaparinux
2. Enoxaparin |
|
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Term
| What is the preferred treatment for STEMI patient (PCI or thrombolytic)? |
|
Definition
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Term
| If thrombolytic was given, but patient only shows partial or not showing improvements, then what should you do? And what could be a potential problem? |
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Definition
| Send patient off to do PCI/CABG. Problem is that the patient may already be given clopidogrel (at least we bought time for the patient with drug) |
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Term
| What are the 5 types of thrombolytics? |
|
Definition
1. Streptokinase
2. Anistreplase
3. Alteplase
4. Reteplase
5. Tenectaplase (TNK-tPA) |
|
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Term
| What should we be aware of when using Streptokinase or Anistreplase? |
|
Definition
- Strep means immunogenecity
- Streptokinase is a product made by streptococcal bacteria and if patient has strept infection and has developed strept antibodies, these drugs will be less effective
- once we give that drug and we have to give it again later, the body has already created antibodies to it so remember next time they come in, dont give strep products bc not as efficient |
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Term
| Which thrombolytics do not need additional heparin bolus? |
|
Definition
| Streptokinase and Anistreplase (the more specific a drug is for a target of action, the more likely you are to give a bolus of heparin) |
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Term
| What is an advantage to using TNK-tPA? |
|
Definition
|
|
Term
| Which thrombolytic is used for acute stroke? |
|
Definition
|
|
Term
| Which thrombolytic is used for MI/ACS? |
|
Definition
|
|
Term
| When is thrombolytics best administered? |
|
Definition
| Best if administered within 12 hrs of onset of symptoms |
|
|
Term
| What are CI of thrombolytics? |
|
Definition
1. Hemorrhagic stroke history
2. IC neoplasm
3. Active bleed
4. Aortic dissection
Relative CI:
1. BP > 180/110
2. INR > 2.0
3. Recent trauma/surg
4. Active PUD
5. Strep exposure |
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Term
| What event should you expect after giving thrombolytic? |
|
Definition
Re-profusion arrhythmias
When you fix the clot and enable blood to flow into areas of the heart muscle where it was previously ischemic, the cells start working again, but may not be working normally and may result in arrhythmia. |
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Term
| Which thrombolytic is weight based? |
|
Definition
|
|
Term
| When giving TNK-tPA, what must you also give? |
|
Definition
Enoxaparin or Heparin
Enoxaparin:
1. 30mg IVB (not likely to be given to those > 75yo)
2. 1mg/kg SQ q 12 hrs (max 100mg/dose)
Heparin
1. 60-70U/kg LD (max 5000U)
2. Infusion: 12-15U/kg/hr (max 1000U/hr)
Look at renal function! If there is renal impairment, use heparin instead of Enoxaparin! |
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Term
| What does non-primary PCI mean? |
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Definition
| It means that patient had thrombolytic but did not completely improve |
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Term
| What thienopyridine choice would you choose if patient has received fibrinolytic therapy and needs non-primary PCI? |
|
Definition
1. If patient was already given clopidogrel, continue with clopidogrel as thienopyridine of choice
2. If clopidogrel has not been given, give 300-600 LD of clopidogrel |
|
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Term
| Which thienopyridine would you choose if patient needs non-primary PCI and did not receive fibrinolytic therapy? |
|
Definition
1. 300-600mg LD of clopidogrel
2. 60 mg LD of Prasugrel (no later than 1 hr after PCI) |
|
|
Term
| When is Prasugrel not recommended as part of a DAT regimen when PCI is planned? |
|
Definition
| In STEMI patients with prior history of stroke and transient ischemic attack |
|
|
Term
| Once a patient has had an MI, what are they at high risk for? |
|
Definition
They are at high risk for:
1. Another MI
2. sudden cardiac death (probably from arrhythmia)
3. HF (parts of the heart can no longer conduct pulses) - worst prognosis in 5 years than cancer
4. Other vascular events |
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|
Term
| What was the PROVE-IT trial about? |
|
Definition
For patients with ACS, more aggressive goals offer greater benefits (lower incidence of death or major CV events)
Atovastatin 80mg > Pravastatin 40mg |
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|
Term
| What did SAVE, AIRE, and TRACE trials show? |
|
Definition
Cumulative data that showed ACEI have lower probability of events including death, hospitalization, or acute decompensated HF
SAVE: Captopril
AIRE: Ramipril
TRACE: Trandolapril |
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Term
| What did the EPHESUS:All-Cause Mortality trial show? |
|
Definition
Showed that Aldosterone Antagonists (Eplerenone) added to therapy (ACEI/ARB + BB) seemed to decrease myocardial fibrosis, so patients with MI might still have areas of ischemia around and by using aldosterone antagonists, we can control amount of fibrosis as heart tries to heal and potentially save more myocardium
- DO NOT start in patients with poor renal function or have hyperkalemia |
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|
Term
| Which patient population is Epelerone indicated for? |
|
Definition
| Patients with MI, LVEF < 40% and either DM or HF |
|
|
Term
| What d/c medications do you give a patient with angina? |
|
Definition
1. ASA
2. Lipid lowering agent
3. ACEI/ARB
4. BB/NDHPCCB
5. SL NTG |
|
|
Term
| What d/c medications do you give a patinet with NSTEMI/STEMI? |
|
Definition
1. ASA + Clopidogrel
2. Lipid lowering agent
3. ACEI/ARB
4. BB
5. Eplerenone
6. SL NTG |
|
|
Term
| If patient has ACS with HTN crisis, what form of NTG should you give them? |
|
Definition
| NTG IV drip so you can titrate (goal is to reduce BP by 20%) |
|
|
Term
| If patient only has ACS (no HTN crisis), what form of NTG should you give them? |
|
Definition
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