Term
What does the term ACS include?
What should lab tests include ?
What is TIMI and how is it used? |
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Definition
ACS includes myocardial ischemia, ST elevation, MI, unstable angina etc.
Lab tests cbc, ecg, glucose, creatinine, lipids, troponin***
*** Highly accurate, sensitive indicator of myocardial injury.
TIMI is the Thrombolysis in MI risk score, it is a risk calculation tool for patients with NSTEMI or unstable angina. Predicts death and early ischemic events. |
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Term
| When should coronary angiography and revascularization be used? |
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Definition
| Use in patients high risk patients (TIMI score > or equal to 3), recurrent ischemic symptoms, HF, V-tach |
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Term
| How should patients be treated (nonpharm) when they are admitted with NSTEMI or unstable angina? |
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Definition
| BEDREST while ongoing, until symptoms stablize. Use supplemental O2. Continuous ECG monitoring for potentially threatening arrhythmias. |
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Term
Management of ischemic symptoms with ACS & NSTEMI?
Continues past 30 min?
High risk ?
REFER TO TC pg. 492
High Risk ? |
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Definition
Management NSTEMI:
ASA & NTG stat, if prolongs > 30 minutes
NTG IV, BB (CCB if BB are contraindicated), Heparin
If high risk, revascularization with GP inhibitors
If not high risk: initiate Clopidogrel, no need for invasive treatment
After all that ACE inhibitors |
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Term
Nitrates:
When are they used in UA/ischemic events?
contraindications |
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Definition
Nitrates:
First: NTG sl
Second: if symptoms persist after 15 minutes IV NTG
Contraindications: ED meds 24 hours after use. |
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Term
Use of BB in UA/ischemic symptoms ?
Contraindications |
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Definition
BBs - use in both NSTEMI and STEMI with UA. Unless contraindicated
Contraindications: 2nd or 3rd degree heartblock without pacemaker, HF, COPD, asthma, HoTN (<100 mm Hg), bradycardia<50 beats per minute. |
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Term
| ACEIs when are they used in patients with UA/ STEMI/ NSTEMI ? |
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Definition
| All of them, unless contraindicated. |
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Term
| When to use ACEIs in UA/NSTEMI/STEMI |
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Definition
Always use in ALL patients who have HF, diabetes, left ventricular dysfunction, high risk chronic CAD.
Use in patients who cannot control HTN with BBs nitrates. |
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Term
| When should CCBs be used in UA/NSTEMI/STEMI ischemia |
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Definition
When BBs are contraindicated, and *coronary SPASMS*
Coronary spasms occur in prinzmetal angina, for which BBs are contraindicated. |
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Term
ASA
When should it be used in ACS?
What is the standard dose ?
Standard dose in patients taking clopidogrel? |
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Definition
ALWAYS use it in ASA in patients with ACS
Standard dose - 325 mg
Dose with clopidogrel |
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Term
Thienopyridines
Ticlopidine, Clopidogrel & Prasugrel
Agent of choice? |
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Definition
Thienopyridines
Clopidogrel is the agent of choice
Hold for 5 days before bypass or revasularization. |
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Term
Heparins:
Types & drugs?
When is it used in UA/NSTEMI or STEMI?
What is the preferred agent in NSTEMI?
When is the use of LMWH not prefered? What should be used? in this case |
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Definition
Heparin
UFH, LMWH - enoxaprin, dalteparin, nadroparin, tinzaparin.
Always used in UA/NSTEMI, and in STEMI used if not taking PCI.
Preferred agent in NSTEMI is enoxaparin
LMWH is not preferred in patients with renal dysfunction <30ml/min. Use UFH in this case. |
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Term
Factor Xa inhibitor - name it
Efficacy vs. enoxaparin ?
Incidence of bleeding vs enoxaparin? |
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Definition
Factor Xa inhibitor - fondaparinux
Enoxaparin similar efficacy
Lower incidence of bleeding than enoxaparin. |
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Term
Glycoprotein IIb/IIIa inhibitors
What are the drugs?
which is expensive, and limits its use to cardiac catheterization?
When are they to be used ?
What must be monitored for in these patients?
Is it safe to use these with heparins? |
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Definition
Glycoprotein IIb/IIIa inhibitors
Eptifibatide, tirofiban, abciximab
Abciximab is expensive and so its use is limited to cardiac catheterization.
Are to be used at immediately before PCI
Monitor patients for bleeding
NOT SAFE to use glycoprotein 11b/IIIa inhibitors with heparin |
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Term
Direct thrombin inhibitors:
name it
What is it used for? |
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Definition
Direct thrombin inhibitors:
Bivalirudin
Used in combination with thienopyridine and/or glycoprotein IIb/IIIa inhibitor in patients undergoing PCI with ACS. |
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Term
When should clopidogrel be discontinued ? (how many days before surgery)
How long should heparin therapy continue? |
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Definition
Clopidogrel d/c 5 days before surgery
Heparins should last 48 hours or more for high risk |
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Term
Aldosterone Antagonists.
Drugs?
When are they beneficial in ACS? |
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Definition
Aldosterone Antagonists
Spironolactone and Eplerenone.
Reduced morbidity/mortality in HF associated STEMI. |
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Term
Complications of STEMI
How can pericarditis be treated ? |
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Definition
HF, Arrhythmias, Pericarditis, mechanical complications 650mg daily), or NSAIDS if that is ineffective.
Pericarditis can be treated with ASA o(6 |
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Term
Selective BB with ISA
name it
Adverse effects
Interactions
Comments |
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Definition
Selective BB with ISA
name it - Acebutalol
Adverse effects - Depression, bradycardia (less than non ISAs), bronchospasm (less with selective), impotence,
Interactions
Comments |
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Term
B1 selective BBs without ISA
name some
Adverse effects
Being selective has what affect on adverse effects ?
Interactions
Comments |
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Definition
name some - BAM! Bisoprolol, Atenolol, Metoprolol
Adverse effects - bradycardia, HA, impotence, * NO hyperglycemia (only for nonselective), depression, HF, heartblock --> LESS non-cardio effects.
Interactions - Digoxin, nonDHP CCBs(bradycardia) & amiodarone.
Comments - BB should not be used in patients over 60, avoid in patients with asthma |
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Term
non selective BBs without ISA
name some, which has ISA?
Adverse effects
Interactions
Comments |
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Definition
non selective BBs
name some - timolol, propranolol, nadolol
Adverse effects - bradycardia, HA, impotence, rare: *hyperglycemia (only for nonselective), depression, HF, heartblock
Interactions - Digoxin, nonDHP CCBs(bradycardia) & amiodarone.
Comments - BB should not be used in patients over 60, avoid in patients with asthma, |
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Term
nonDHP CCBs
AEs:
Interactions:
Comments/contraindications- |
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Definition
nonDHP CCBs
Diltiazem, verapamil,
AEs: bradycardia, exacerbate HF,
Interactions: 3A4 substrate, BBs and digoxin
Comments/contraindications- contraindicated in 2nd/3rd degree heartblock. HF contraindicated |
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Term
DHP CCBs:
AEs:
Interactions:
Comments/contraindications-
Which is intermediate acting? when should it be used? |
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Definition
DHP CCBs: Filodipine, amlodipine, nifedipine
AEs: Ankle edema, palpitations, flushing
Interactions: 3A4
Which intermediate acting - filodipine, should be used emergency situations. |
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Term
ACEIs
AEs
Interactions
Comments/contraindications |
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Definition
ACEIs: -prils
AEs: Hyperkalemia, *DRY COUGH, can precipitate renal failure, rarely angioedema
Interactions- K+ sparing diuretics, lithium, NSAIDS can worsen renal function in combination.
Comments/contraindications- *PREGNANCY CONTRAINDICATION with RAAS. Arterial stenosis, history of angioedema contraindicated. Monitor SCr, Potassium |
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Term
Aldosterone Antagonist - name them
AE's
Interactions |
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Definition
Aldosterone Antagonist - spironolactone, epleronone
AE's - Rash, Urticaria, gynecomastia, hyperkalemia, SLE.
Interactions - hyperkalemia w NSAIDS, ACEI, digoxin |
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Term
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Definition
ASA -
AE's - NSAID GI upset, tinnitus, hypersensitivity. Decrease renal function.
DIs - Heparin, warfarin, other NSAIDs |
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Term
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Definition
Clopidogrel
AEs - Bleeding, rash, purpura, GI upset,
DIs - PPIs reduce level 50%, caution with NSAIDS, metabolized by 2C19 --> some patients cannot metabolize it therefore must test for it |
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Term
Prasugrel
AEs -
DIs -
Contraindications |
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Definition
Prasugrel
AEs - Risk of bleeding, caution patients >75, or body weight below 60kg,
Contraindications - Hx ISCHEMIC STROKE
DIs - |
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Term
UFH
AEs -
DIs -
When are UFH's preferred? |
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Definition
UFH
AEs - Bleeding, thrombocytopenia
DIs - ASA, warfarin
When CrCl lower than 30ml/min patients cannot use enoxaparin and should use UFH |
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Term
LMWH - name them
AEs -
DIs -
When is their use not recommended ? |
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Definition
LMWH - enoxaparin, dalteparin
AEs - Hematoma at injection site, bleeding
DIs - Warfarin & ASA, |
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Term
Specific Xa inhibitor - name it
AEs -
DIs - |
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Definition
Specific Xa inhibitor - fondaparinux
AEs - Bleeding, allergic reactions
DIs - Other drugs that affect hemostasis |
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Term
Direct thrombin inhibitor - name it
AEs -
DIs - |
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Definition
Direct thrombin inhibitor - Bivalrudin
AEs - Bleeding, allergic rxns
DIs - Caution with other drugs in hemostasis. |
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Term
Glycoprotein IIb/IIIa inhibitors - Name them
AEs -
DIs - |
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Definition
Glycoprotein IIb/IIIa inhibitors - Eptifibatide, Tirofiban
AEs - bleeding, primarily at puncture sites.
DIs - Other drugs that effect hemostasis. |
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