ACS- Young

FYI: Acute coronary syndromes (ACS) is a broad term that describes what?

• unstable angina (UA)

• myocardial infarction

  • ST segment elevation MI (STEMI)

  • non-ST segment elevation MI (NSTEMI)

What is the etiology of ACS?

idk how imp

atherosclerosis (cholesterol excess, inflammation, endothelial dysfunction aka stress of blood flow on endothelial lining)

RFs for endothelial dysfunction?

idk how imp

• HTN

• age

• male

• tobacco use

• DM

• obesity

• dyslipidemias

What is the cause of ACS?

erosion, rupture, or fissure of unstable atherosclerotic plaque

What happens after a plaque ruptures?

idk how important

1. thrombogenic parts of plaque exposed

2. causes platelet adhesion to site

3. binding causes changes in platelet shape and platelets active

   • ADP binds to platelet P2Y1 and P2Y12 receptors

     • cross linking of platelets

     • gives the clot a white appearance

Compare a white vs. red clot:

“white clot”	“red clot”
more platelets> fibrin usually causes incomplete blockage of coronary lumen most commonly NSTEMI	more fibrin and RBCs > platelets usually completely blocks vessel most commonly STEMI

What is the patient presentation for ACS?

• what is specific to STEMI?

• what is specific to NSTEMI?

• in general:

  • midline, anterior chest discomfort (at rest, severe new onset, increasing angina at least 20 min in duration)

  • pain may radiate to shoulder, down left arm, to back or jaw

  • may have n/v, sweating, SOB

• STEMI—> unremitting chest discomfort

• NSTEMI—> rest angina OR new angina (<2m) OR angina w/ increased frequency duration or intensity

How is unstable angina diagnosed?

How is MI diagnosed?

• unstable angina: 10-20 min, may or may not be relieved by nitroglycerin (NTG)

• MI: >30 minutes, unrelieved by rest or NTG

What segment is the main area of focus in evaluation of chest pain?

a. PR interval

b. QRS complex

c. PR segment

d. ST segment

e. QT interval

d.

How does the EKG look in NSTEMI vs. STEMI?

idk how imp lowkey

What is the general algorithm to determining whether a STEMI, NSTEMI, or unstable angina occurred?

1. chest discomfort for ≥20 min

2. EKG obtained and interpreted

What are the main markers to differentiate between a NSTEMI and UA?

• UA: normal troponin or CK MB

• NSTEMI: increased troponin, increased CK MB

What is troponin?

What does it reflect?

idk how imp

• troponin—> Components of contractile apparatus of myocardial cells and expressed almost exclusively in the heart

• Reflect injury leading to necrosis, but not the mechanism

PRACTICE:

A pt. presents with crushing chest pain for 40 minutes, his initial EKG reveals ST segment depression, and his troponin is positive, what is his diagnosis?

a. UA

b. NSTEMI

c. STEMI

d. chronic stable angina

b. NSTEMI

What is the acronym for ACS early management?

MONA-B (NOT IN THIS ORDER THO)

• M= morphine

• O= oxygen

• N= nitroglycerin

• A= aspirin

• B= b-blocker

For ACS early management:

What is given to relieve acute chest pain?

How many doses can be given?

After how many doses do you call 911?

• nitroglycerin

• x3 doses to relieve acute CP

• after 1 dose… if pain is unrelieved—> call 911

When should caution be used with nitroglycerin?

What are the C/I to nitroglycerin?

• caution:

  • inferior wall MI

  • RV infarction

• C/I:

  • sildenafil, vardenafil, or avanafil use in past 24 hrs

    • may pos give 12 hrs after avanafil

  • tadalafil use in past 48 hrs

For ACS early management:

• what type of aspirin should be given?

• effect of aspirin?

• what to give in aspirin allergy?

• 1 dose of NON-ENTERIC COATED aspirin

• effect: reduces recurrence of MI and death

• aspirin allergy: use clopidogrel

For ACS early management:

• when is oxygen indicated?

• for oxygen saturation <90%

• respiratory distress

• high risk fts. for hypoxemia

For ACS early management:

• what is given for pain relief?

  • indication?

  • effect?

  • hold for what?

• morphine

  • for unrelieved chest pain despite nitroglycerin and maximally tolerated anti-ischemic medications

  • effect: vasodilation—> hold for hypotension

For ACS early management:

• what is the most widely studied beta-blocker?

• used in what pts.?

• effects of b-blockers?

• C/I to b-blocker use.

• most widely studied—> metoprolol

• used in pts. undergoing primary PCI (percutaneous coronary intervention)

• effects: decreases myocardial ischemia, reinfarction, and frequency of ventricular dyysrhythmias

• C/I: hypotension, low output state, signs of HF, risk factors for cardio shock

PRACTICE:

Which medication should NOT be used with an inferior MI?

a. aspirin

b. clopidogrel

c. nitroglycerin

d. morphine

c.

What are the general management strategies to ACS?

• STEMI

• UA/NSTEMI

just a general overview lowkey

Describe left heart catheterization:

• invasive or noninvasive procedure?

• requires what?

• what is an angiography?

• invasive procedure—> to assess patency of coronary vessels and hemodynamic parameters of cardiac fxn

• requires IV contrast and fluoroscopy

• angiography—> assesses for coronary artery blockages

If appropriate… a percutaneous coronary intervention (PCI) is done during a left heart catheterization. What is a PCI?

• PCI—> procedure to open blocked or narrowed coronary arteries

  • balloon angioplasty ± stent placement

What is a CABG?

• coronary artery bypass grafting

• grafts used as detour around blocked portion of coronary artery

Heparin, enoxaparin, fondaparinux, and bivalirudin are all examples of…

a. antiplatelets

b. fibrinolytics

c. anticoagulants

c. anticoagulants

aspirin, P2Y12 inhibitors, and glycoprotein IIb/IIIa inhibitors are all examples of…

a. antiplatelets

b. fibrinolytics

c. anticoagulants

a. antiplatelets

Match the class to its drugs:

Class	Drug Examples
Unfractionated heparin
LMWH
Direct thrombin inhibitor
Factor Xa inhibitor

drugs: fondaparinux, bivalirudin, enoxaparin, heparin, dalteparin

Class	Drug Examples
Unfractionated heparin	heparin
LMWH	enoxaparin dalteparin
Direct thrombin inhibitor	bivalirudin
Factor Xa inhibitor	fondaparinux

What must be monitored on heparin?

aPTT or ACT

What P2Y12 inhibitors are oral? which are IV?

• oral: clopidogrel (plavix), prasugrel (Effient), ticagrelor (Brillinta)

• IV: cangrelor

MOA of P2Y12 inhibitors:

idk how imp

• block P2Y12 component of ADP receptors on platelet surface—> prevents activation of GPIIb/IIIa receptor complex—> reduces platelet aggregation

Any head trauma needs to go to the ED to be evaluated. Intracranial hemorrhage can be fatal and risk is higher with…

antiplatelet and anticoagulants

When is prasugrel C/I?

Stroke or TIA

tip: praSugrel= C/I in Stroke

When should ticagrelor be avoided?

prior intracranial hemorrhage

FYI comparison of the oral P2Y12 inhibitors:

What drugs are glycoprotein IIb/IIIa inhibitors?

• tirofiban (aggrastat)

• eptifibitide (integrilin)

Monitor what while on Glycoprotein IIb/IIIa inhibitors?

monitor CBC and for s/sx of bleeding (bc of bleeding and thrombocytopenia risk)

What is the “gold standard” for STEMI?

• left heart catheterization (LHC)

  • angiography

  • PCI

    • balloon ± stent

    • PCI recommended triage strategy for STEMI

PCI is preferable to fibrinolytic therapy for a STEMI if done within _____ minutes.

120

When is fibrinolytic therapy preferred over PCI for a STEMI?

• early presentation (if ≤12 hrs from s/sx onset= use fibrinolytics)

• AND

• anticipated first medical contact (FMC)-to-device system time >120 minutes (ex: can’t get to the hospital within 120 minutes to do a PCI)

If fibrinolytics are going to be given for a STEMI, they should be given within ____ minutes of hospital arrival.

30

Examples of fibrinolytics:

• tenecteplase

• reteplase

• alteplase

What are the absolute and relative C/I to fibrinolytic therapy?

i would just focus on the absolute…

absolute:

• any prior ICH (intracerebral hemorrhage)

• known cerebrovascular lesion (these lesions can rupture= bad)

• known malignant intracranial neoplasm (aka bad brain cancer)

• ischemic stroke within 3 months

  • (exception: acute ischemic stroke within 3 hrs)

• suspected aortic dissection

• active bleeding or bleeding diathesis

relative:

• Pregnancy

• History of chronic, severe, poorly controlled hypertension

• Severe uncontrolled hypertension on presentation

• SBP >180 mm Hg or DBP >110 mm Hg

• Traumatic or prolonged (> 10 min) resuscitation or major surgery (within < 3 weeks)

• Recent internal bleeding (within 2 to 4 weeks)

• Current use of anticoagulants

• Higher the INR = Higher risk of bleeding (warfarin)

• Active peptic ulcer

• History of prior ischemic stroke (>3 months), dementia, or known intracranial pathology not covered in absolute CI

• Streptokinase: Exposure (> 5 days) or prior allergic reaction

PRACTICE:

Which of the following is an ABSOLUTE contraindication to using fibrinolytic therapy for STEMI?

a. stroke >3 months ago

b. current anticoagulant use

c. severe uncontrolled HTN

d. suspected aortic dissection

d.

Fibrinolytics are only an option for what ACS?

ONLY FOR STEMI—> NOT FOR UA/NSTEMI

For antithrombic therapy in STEMI pts.

• what is used for primary PCI?

• what is used WITH fibrinolytics?

• what is used for a PCI after fibrinolytics?

• primary PCI

  • aspirin

  • P2Y12 inhibitor

  • anticoagulant (heparin, bivalirudin)

  • glycoprotein IIb/IIIa inhibitors

• with fibrinolytics

  • aspirin

  • clopidogrel

  • anticoagulant (heparin, enoxaparin, fondaparinux)

• PCI after fibrinolytics

  • aspirin

  • clopidogrel

  • anticoagulant (heparin, enoxaparin)

  • glycoprotein IIb/IIIa inhibitors

With Ticagrelor, you CANNOT exceed WHAT dose of aspirin?

• know this.

100 mg

Management strategy for UA/NSTEMI depends on the patient’s risk.

What is done for low risk?

What is done for high risk?

• low risk: ischemia-guided strategy

  • aka medical management—> using meds only

• high risk: early invasive strategy

  • left heart catheterization (LHC)

    • angiography

    • PCI if needed (balloon angioplasty ± stent placement)

What medications can be used for low risk pts. with NSTEMI/UA?

• aspirin

• P2Y12 inhibitor + aspirin

  • clopidogrel or ticagrelor

• anticoagulants

  • UFH

  • enoxaparin

  • fondaparinux

What are the 4 components to the early invasive strategy for high risk pts. with NSTEMI/UA?

anticoagulant (UFH, enoxaparin, bivalirudin)+ aspirin + P2Y12 inhibitor ± GP IIb/IIIa inhibitor

note: cannot given GP IIb/IIIa inhibitor with bivalirudin

After an angiography is done to determine coronary anatomy for the early invasive strategy (aka high risk pts. with NSTEMI/UA)… what 3 pathways can be followed?

1. continue medication management

2. PCI

3. CABG

After the placement of a stent, REGARDLESS of STEMI or NSTEMI, what is required?

• must know the doses

• DUAL ANTIPLATELET THERAPY (DAPT) x 1 year

• aspirin + P2Y12 inhibitor

  • aspirin (continued indefinitely)—> 75-324 mg PO daily

  • P2Y12 inhibitor (usually continued for a year)

    • clopidogrel 75mg PO daily

    • prasugrel 10mg PO daily

    • ticagrelor 90mg PO BID

What is the process for selecting a P2Y12 inhibitor?

FYI

For pts. who undergo PCI with history of AF or VTE who require chronic anticoagulation… what anticoagulants are preferred? what type of therapy is preferred?

• preferred—> DOAC > warfarin

• preferred—> dual antithrombotic therapy (DAT)

  • DOAC+ clopidogrel

What is triple antithrombotic therapy?

• what risks are associated?

• what drugs can’t be given?

triple antithrombotic therapy= anticoagulant + P2Y12 + aspirin

• high bleeding risk

• cannot give ticagrelor or prasugrel (bleed risk)

For ACS, what drug is given regardless of stent or medical therapy and reduces incidence of recurrent MI and death?

aspirin

Are statins given for ACS pts. even if their cholesterol is at goal?

yes

What is the indication for non-DHP CCBs in ACS?

If continuing or frequently recurring ischemia WITH CI to BB therapy OR BB & nitrates used optimally

What’s the acronym for medications at discharge for ACS secondary prevention?

SPABA ± MRA

• S= statins

• P= P2Y12 inhibitor

• A= aspirin

• B= beta-blockers (if c/i= CCB)

• A= ACE inhibitors

• MRA=

  • for pts. post MI with EF <40%, DM, or symptomatic HF