UWorld Chapter 30/32: Acute Coronary Syndromes/ Arrhythmias

Acute Coronary Syndrome (ACS)

What results from plaque build up (atherosclerosis) in the coronary arteries which can rupture, leading to clot formation and sudden, reduced blood flow (ischemia) to the heart?

PCI

What is the coronary revascularization procedure that involves inflating a small balloon inside a coronary artery to widen it and improve blood flow where, typically, a stent is placed to keep the artery open?

NSTEMI

What type of ACS represents a partial blockage with no ECG changes and can be treated with medications alone or with PCI?

STEMI

What type of ACS requires that blocked arteries by opened as quickly as possible with PCI or fibrinolysis?

120 minutes

Within what time frame is PCI preferred for the treatment of STEMI in relation to first medical contact?

30 minutes

Within what time frame should fibrinolytic therapy be initiated in relation to hospital arrival in patients with STEMI if PCI is not possible?

Antianginals

What type of drug treatment is used in addition to PCI or fibrinolytics to Decrease myocardial oxygen demand or increase supply to relieve ischemia?

Antiplatelets

What type of drug treatment is used in addition to PCI or fibrinolytics to inhibit platelet aggregation and prevent clot formation/ growth?

Anticoagulants

What type of drug treatment is used in addition to PCI or fibrinolytics to inhibit clotting factors and prevent clot formation/ growth?

ACS Drug Treatment Options

Remember: "MONA - GAP - BA"

Morphine

Oxygen

Nitrates

Aspirin

GPIIb/IIIa antagonists

Anticoagulants

P2Y12 inhibitors

Beta blockers

ACE inhibitors

Morphine

What medication is utilized for the treatment of ACS in order to provide pain relief and decrease anxiety?

Oxygen

What medication is utilized for the treatment of ACS in patients with arterial oxygen saturation <90% or those with respiratory distress?

Nitrates

What medication is an antiaginal that is used in the treatment of ACS to dilate coronary arteries and improve collateral blood flow, decrease preload and after load, and reduce chest pain?

Aspirin

What medication should be given at a high dose to all patients immediately in the treatment of ACS and continued at a lower, maintenance dose indefinitely?

UFH and bivalirudin

What are the preferred anticoagulants for patients with STEMI to inhibit clotting factors and reduce infarct size?

Beta blockers

What antianginal medication should be given within 24 hours and continued indefinitely as an outpatient to control blood pressure, HR and contractility, decrease ischemia and reinfarction, and increase longterm survival?

ACE inhibitors

What medication should be started within 24 hours and continued indefinitely as an outpatient in all patients with LVEF < 40%, hypertension, diabetes, or stable CKD?

Clopidogrel, Ticagrelor

What are two P2Y12 inhibitors that work by binding to the platelet adenosine diphosphate (ADP) P2Y12 receptor, preventing ADP-mediated activation of the GPIIb/IIIIa receptor complex?

100 mg

What is the maximum dose of aspirin that can be used concomitantly with ticagrelor?

Fibrinolytics

What drug class is used in the treatment of STEMI ONLY to cause fibrinolysis (clot breakdown) by binding to fibrin and converting plasminogen to plasmin?

Alteplase

What treatment is contraindicated in ACS patients with any of the following criteria?

1. active internal bleeding

2. history of recent stroke

3. any prior intracranial hemorrhage

4. recent intracranial or intraspinal surgery or trauma (in the last 2-3 months)

5. intracranial neoplasm, arteriovenous malformation or aneurysm

6. severe, uncontrolled hypertension (unresponsive to emergency therapy)

12 months

How long should DAPT recommended following treatment of ACS for secondary prevention?

3 years

How long should beta blockers be continued in patients with ACS for secondary prevention, except in the case of heart failure or management of hypertension?

High Intensity Statin

What additional, indefinite therapy should be added for secondary prevention following treatment of ACS?

Atrial fibrillation

What is the most common type of arrhythmia?

QTc prolongation

What is defined as a QTc interval > 440 - 460 milliseconds and is a risk factor for Torsades de Pointes, which can cause sudden cardiac death?

Vaughan Williams

What is the classification system that splits antiarrhythmic drugs into categories based on their dominant electrophysiological effect or mechanism of action?

Remember: Double Quarter Pounder, Lettuce, Mayo, Fries, Please! Because Dieting During Stress is Always Very Difficult

Class I Antiarrythmics

A: Disopyramide, Quinidine, Procainamide

B: Lidocaine, Mexiletine

C: Flecainide, Propafenone

"Double Quarter Pounder, Lettuce, Mayo, Fries Please!"

Class II Antiarrythmics

Beta Blockers

"Because"

Class III Antiarrythmics

Dronedarone

Dofetilide

Sotalol

Ibutilide

Amiodarone

"Dieting During Stress Is Always"

Class IV Antiarrythmics

Verapamil

Diltiazem

"Very Difficult"

Amiodarone

With which antiarrhythmic medication should the "FTs" be monitored?

Pulmonary FTs

Liver FTs

Thyroid FTs

Cardiac FTs

Ventricular

In what type of arrhthmias are the Class IIb medications lidocaine and mexiletine used due to having no efficacy in atrial fibrillation?

Dofetilide

Which antiarrythmic is preferred in heart failure?

Ibutilide

Which antiarrhythmis is indicated only for pharmacologic cardioversion?

Rate Control

What AFib management strategy allows the patient to remain in AFib and take medications to control the ventricular rate (HR) with beta blockers or non-DHP CCBs?

80 BPM, 110 BPM

In patients with AFib managed with rate control, the goal resting HR is less than _____ in patients with symptomatic AFib, but a more lenient goal of less than _____ may be reasonable in patients who are Asymptomatic and have preserved left ventricular function.

Rhythm Control

What AFib management strategy has a goal of restoring and maintaining normal sinus rhythm by administering Class 1a, 1c, or III antiarrythmic drugs or electrical cardioversion?

Permanent AFib

In what type of atrial fibrillation should the rhythm control strategy with antiarrhythmic drugs be AVOIDED?

Digoxin

What medication inhibits the Na-K-ATPase pump, causing a positive inotropic effect and exerts a parasympathetic effect, which enhances vagal tone to slow conduction through the AV node, resulting in reduced HR?