ACS

Acute Coronary Syndrome (ACS)

Classified by causative event → total of 5 diff types

1. Most common ~90% →

2. Arterial occlusion primarily driven by _____________ → MI

3. VTE driven by ________

4. Post MI pathophysiology → activates ____ and ______

5. ^ can create ________ leading to HF

1. type 1 → acute plaque rupture

2. platelet aggregation

3. clotting cascade

4. +SNS, RAAS

5. ventricular hypertrophy

COMPLICATIONS FROM MI

1. construction issues → 3

2. cardiac function → 3

3. structural issues → 3

1. bradycardia, heart block, vent arrhythmia

2. cardiogenic shock, HF, TE (thromboembolism)

3. papillary muscle rupture, free wall rupture, pericarditis

Patient presentation MI (diff from angina)

1. ________ chest pain

2. Squeezing, heaviness, or tightness of chest lasting ______

3. Pain may radiate to …

4. -

5. -

6. -

7. ATYPICAL PRESENTATION IN … (5)

1. crushing

2. >10 min

3. arms, shoulder, back, abdomen, jaw

4. NV

5. diaphoresis (sweating)

6. SOB

7. >75, women, diabetes, impaired renal, dementia

SIGNS

1. ADHF with _______ distention

2. ___________

3. _____ on auscultation

4. New ________ or mitral regurgitation

5. New _________

6. Hemodynamic abnormalities ranging from …

1. jugular venous

2. pulm edema

3. S3

4. murmur

5. arrhythmias

6. HTN to hypotension w/shock

ACS WORK UP (in order)

1. ________ + goal time

2. -

3. -

4. -

5. -

6. -

1. EKG <10 min

2. cardiac troponin (cytoplasm troponin is BAD)

3. chem panel K, Mg, SCr

4. CBC

5. coagulation tests → aPTT, anti Xa

6. lipid panel

1. P =

2. QRS =

3. T =

4. ____ tells us whether the patient is having an MI

1. atria

2. vent contracting

3. vent resetting

4. ST

1. ST elevation →

2. no ST elevation →

1. STEMI

2. normal troponin → unstable angina; +troponin → NSTEMI

GREEN BOX → placed on every patient

1. *MONA-B =

2. Morphine (analgesia/anxiolytic) → place in therapy → CI?

3. ^ alternative?

4. O2 indicated in patients with O2 saturation _____

5. NTG → initially given … → CI?

6. Aspirin → place in therapy → initial dose → when to use?

7. Beta blocker → when to use?

8. ^ alternative? (CI to BB)

1. morphine, O2, NTG, ASA, BB

2. 2nd line pain after NTG → CI hypersens, hypotens, brady/lethargy

3. fentanyl

4. <90%

5. SL then IV if anginal symptoms persist → CI SBP<90 or >30 below baseline, PDE5i

6. all → 162-324 mg CHEWED → IMMEDIATELY

7. for all → use any EXCEPT ISA → within 24h

8. CCB

Do NOT use beta blockers in patients with ACS due to ___________ use → potential of unopposed alpha stimulation & coronary vasospasm

cocaine → use CCB

WHAT TESTS OR LABWORK WOULD BE THE MOST APPROPRIATE TO OBTAIN ON OUR PATIENTS?

A. CBC, BMP, Coagulation tests

B. EKG, Troponin, BMP

C. Troponin, BMP, CBC

D. EKG, Coagulation tests, CBC

B

What is a situation that a beta blocker would be CI in but a CCB would not?

A. Hypotension

B. Acute decompensated heart failure

C. Cocaine use

D. Third degree heart block

C

What would be the most appropriate treatment to initiate in FC?

A. Morphine, Oxygen, Metoprolol

B. Metoprolol, Diltiazem, Nitro

C. Aspirin, Morphine, Carvedilol

D. Aspirin, Oxygen, Nitro

D

(always give ASA immediately, O2 89% so give, can give some more nitro too)

Would you give him?

1. M

2. O

3. N

4. A

5. B

1. no (NTG not given yet + substance use disorder)

2. no (97%)

3. yes

4. yes

5. no → CCB

1. NSTEMI: Used in LOWER risk patients that do not require urgent PCI → ___________ approach

2. Risk assessment by _______ or _______ score

1. selective invasive

2. TIMI, GRACE

1. NSTEMI: Used in INTERMEDIATE - HIGH risk patients → ____________ approach

2. Also beneficial for (6)

1. routine invasive

2. 70+, prev MI, ST changes, HF, +troponin, diabetes

What treatment path is best for Alex?

A. selective invasive

B. routine invasive

C. STEMI

B

(age 70, +troponin, symptoms → routine invasive)

What treatment path is best for Antonio?

A. selective invasive

B. routine invasive

C. STEMI

A

NSTEMI TREATMENT

1. Initial treatment during workup (both)→

2. Additional tx aimed at keeping vasculature patent (both) → 2

3. final step: Selective invasive →

4. final step: Routine invasive →

1. ASA, O2 if <90%, BB in first 24h, NTG/morphine

2. antiplatelets (P2Y12), anticoagulants (heparin)

3. continued workup

4. angiography

P2Y12 INHIBITORS:

1. antiplatelet through ____ pathway

   *4 agents, can NOT use them interchangeably for all ACS tx regimens!!!

2. Irreversible binding →

3. Reversible binding →

4. Prodrugs →

5. Clopidogrel (______) → metab by multiple CYPs but mainly 50% _____ → may be used in … → Platelets require ____ to recover after stopping → monitor …

6. Prasugrel (______) → metab by .. → _________ platelet inhibitor compared to clopidogrel → CI? → Platelets require ____ to recover after stopping → monitor …

7. Ticagrelor (_______) → metab by … → CI? → monitor …

8. Cangrelor (_______) → the only inhibitor admin ____

1. ADP

2. clopidogrel, prasugrel

3. ticagrelor, cangrelor

4. clopidogrel, prasugrel

5. Plavix → CYP2C19 → ALL → ~5d → s/s bleeding

6. Effient → 1 CYP → more potent → CI hx stroke/TIA → ~7d → s/s bleeding

7. Brilinta → CYP3A4 → CI in ASA>100 mg/day → s/s bleeding, dyspnea

8. Kengreal → IV

P2Y12 Overview

1. Planned PCI → use …

2. NO planned PCI → use …

1. ticagrelor or prasugrel, clopidogrel

2. ticagrelor, clopidogrel

ANTICOAGULATION:

1. Tx is __________ and NOT continued after discharge

2. Unfractionated Heparin UFH → Large interpatient variability require monitoring every _______ (aPTT, AXA) → place in therapy? → monitoring?

3. Enoxaparin (Lovenox, LMWH) → smaller fragments which create a more _____ effect than UFH, anticoagulation monitoring NOT required → place in therapy? → CI?

4. Agent can be used in HIT + lower risk patients? → risk?

5. Agent can be used in HIT + PCI ONLY (not fibrinolysis)? + monitoring

1. short term

2. 6h → ALL → s/s bleeding, HIT

3. predictive → ALL → CI hx HIT

4. fondaparinux/Arixtra → catheter thrombosis

5. Bivalirudin/Angiomax → s/s bleeding, ACT (activated clotting time)

What medications should be AVOIDED in Alex due to his history?

A. NTG infusion

B. Aspirin

C. Bivalirudin infusion

D. Prasugrel

D

What presenting factor immediately decides Saul’s treatment arm?

A. Initial troponin of 1.0 ng/ml

B. His current cocaine use and chest pain

C. His EKG reading

D. The severity of his chest pain symptoms

C (ST elevation → treat on STEMI pathway)

STEMI TREATMENT: (+ST)

1. All STEMI patients should have _________ rapidly pursed → _________

2. PCI compared to fibrinolysis (3)

3. 2 types of PCI →

4. CABG (harvested vein) may be necessary in patients w ___________

1. reperfusion therapy → PCI, fibrinolytic

2. +survival, -risk stroke/IC hemorrhage, -reinfarction/ischemia

3. DES (drug eluting stent), BMS (bare metal stent)

4. severe/multivessel CAD

FIBRINOLYSIS

1. Primarily favored in patients with DELAY to cath lab ________

   fibrinolytic initiated than patient transferred to PCI capable hospital

2. ABSOLUTE CONTRAINDICATIONS → 2

3. 3 agents →

1. >120 min

2. hx stroke, severe HTN

3. alteplase, reteplase, tenecteplase

STEMI TREATMENT step wise

1. Initial during workup

2. Revascularization

3. additional concurrent tx

4. POST STENTING →

1. MONAB

2. PCI, fibrinolysis

3. antiplatelets, anticoagulants

4. DAPT for 12 months → shorten for +risk bleeding

UNDER WHICH SITUATION SHOULD SAUL RECEIVE FIBRINOLYTICS?

A. He is two and a half hours from a cath lab

B. The doctor anticipates he will need a CABG

C. If he is being taken immediately to the cath lab

D. He experiences cardiac arrest

A

HIGH BLEED RISK MANAGEMENT:

1. Patients stable on _________ and ______ from event can stop ASA

2. Patients can de-escalate from higher bleed risk P2Y12s (prasugrel and ticagrelor) to _______

3. Patients w GI bleeding as concern can be safely initiated on ______

4. Patients who require therapeutic anticoagulation with their DAPT (apixaban, etc) should ___________________

1. ticagrelor >1 month → stop ASA

2. clopidogrel

3. GI bleed → start omeprazole

4. DC ASA 1-4 weeks post event

Important STEMI METRICS

Door to EKG!!!

<10 min

When to pick ticagrelor over clopidogrel?

ACS or MI

ACS DISCHARGE → THROMBINS2

When are each used?

1. Thienopyridine (clopidogrel, prasugrel)

2. Heparin

3. RAAS

4. Oxygen

5. Morphine

6. Beta blocker

7. Intervention (PCI)

8. NTG

9. Statin

10. Salicylate

1. during + discharge

2. during

3. started during admiss/discharge

4. during if O2 sat <90%

5. 2nd line pain

6. during first 24h + prn discharge

7. during

8. during + prn discharge

9. start at discharge

10. during + discharge

SECONDARY PREVENTION: CHOLESTEROL MANAGEMENT

1. Patient not on statin or on low/moderate → initiate ________

2. Consider _______ add on

3. Reassess lipid profile in ______

4. Patient on max tolerated statin →

5. →

6. →

1. high-intensity statin

2. ezetimibe

3. 4-8 weeks

4. LDL<55 continue+reassess

5. LDL 55-69 consider add nonstatin+reassess

6. LDL>70 add nonstatin+reassess

ACS SECONDARY PREVENTION

1. all patients without CI →

2. all patients without CI →

3. DAPT

4. Beta blockers → all without CI →

5. ACEi → all without CI →

6. MRA →

1. SL NTG prn (CI PDE5i)

2. daily baby ASA (75-162mg) → watch for ticagrelor (<100mg daily)

3. PDY12 for 12 months

4. use HF BBs (metoprolol succ, bisoprolol, carvedilol) for CHF

5. ARNI if CHF or intolerant to ACEi cough

6. all w HFrEF + diabetes/CHF

SH IS BEING DISCHARGED. WHEN REVIEWING HIS MEDICATION LIST, WHICH MEDICATION HAS A CONTRAINDICATION PRESENT?

PTA Med List:

• Aspirin 81mg daily

• Citalopram 10mg daily

• Pantoprazole 20mg daily

• Tadalafil 5mg daily

• Metformin 500mg twice daily

Medications added at discharge:

• Lisinopril 10mg daily

• Metoprolol succinate 50mg daily

• Ticagrelor 90mg BID

• Nitro 0.4mg prn

A. Aspirin

B. Ticagrelor

C. Nitro

D. Lisinopril

C

(CI w tadalafil)

What medication class to use for stenting?

GIIb/IIIa

What medications to add/adjustments for ACS discharge?

1. +atorvastatin (to high intensity)

2. BB

3. -ASA to 81 mg daily

(no NTG bc he is on tadalafil)

What changes should be made based on his current therapy regimen? What other medication issues should be investigated at this appointment?

DC ASA for 1-4 weeks (since he is on ticagrelor + apixaban)