ALL ACS Recommendations
How fast does the ACS guidelines recommend obtaining an ECG upon suspected ACS?
Within 10 minutes
T or F: each 30 minute delay for PCI is associated with a 7.5% increase in 1 year mortality
TRUE
What is the typical loading dose of aspirin with ACS?
162-325mg
What is the loading dose of ticagrelor used in STEMI?
180mg
T or F: In patients with ACS without contraindications, early (<24 hours) initiation of beta blocker therapy is recomended to reduce risk of reinfarction and ventricular arrhythmias
TRUE
*REDUCE-AMI trial showed long-term beta-blocker treatment did not significantly reduce the risk of death or new myocardial infarction in patients who experienced an acute myocardial infarction (MI) and had preserved left ventricular ejection fraction (LVEF). However, currently no recommendation in guidelines.
Name 1 validated risk score used in STEMI and NSTEMI to guide therapeutic decisions?
GRACE & TIMI risk scores
T of F: In a patient with suspected ACS and an initial troponin that is non-diagnostic of STEMI or NSTEMI. It is recommended to draw a repeat troponin 6 hours from initial?
FALSE
*Recommended 1-2 hours later
In patients with NSTEMI/STEMI planned for an invasive PCI, which P2Y12 are preferred per guidelines?
Preferred: Ticagrelor & Prasugrel
Alternatives: Clopidogrel
*Triton-TIMI(prasugrel) and Plato(ticagrelor) showed a 16-20% reduction in CV death, MI or stroke as well as a reduced risk of stent thrombosis when compared to clopidogrel.
Which statins should be added to all STEMI patients post PCI?
High intensity statin (rosuvastatin(20-40mg) or atorvastatin(40-80mg))
T or F: ACEi and ARBs have shown reduced MACE events following ACS
TRUE
*Recommended to give in high risk patients, and reasonable to start in those not considered high risk due to reduced MACE in studies
What is the first medical contact (FMC) assessment to first device time goal for a patient with a STEMI going for PCI?
Less than 90 minutes
T or F: An ACS patient with an oxygen saturation of 92% should receive oxygen
FALSE
*less than 90%. May increase myocardial injury by increasing vasoconstriction and increasing oxidative stress*
Name 2 dosing adjustments for prasugrel with the indication of ACS following PCI?
1) Body weight less than 60kg
2) Age greater than or equal to 75 years old
*Adjustment goes from a MD of 10mg daily to 5mg daily
When do the guidelines recommend gycoprotein 2b/3A inhibitors in ACS?
With STEMI patients with large thrombus burden
T orF: Per guidelines, patients with ACS who have tolerated DAPT with clopidogrel, transition to clopidogrel greater than or equal to 1 month post PCI is useful to reduce bleeding risk
FALSE
*This recommendation is with ticagrelor only
Which P2Y12 inhibitors are prodrugs?
Prodrugs: clopidogrel & prasugrel
Active drugs: ticagrelor
T or F: According to guidelines, the use of opiates may delay gastric and intestinal absorption of oral P2Y12 inhibitors
TRUE
*examples: morphine and fentanyl*
What do you give a patients with a STEMI who has an allergy to aspirin?
Loading dose of P2Y12 initially. After PCI, it is recommended to undergo aspirin desensitization for continuation of DAPT thereafter
What is the dose of enoxaparin given following fibrinolytic therapy for a STEMI in a 70yof?
30mg IV bolus, followed in 15 minutes by 1mg/kg SQ Q12H(Max 100mg/dose)
*If greater than 75yo, would dose 0.75mg/kg Q12H
In patients on triple therapy (DAPT + OAC) with a recent stent, what medications should be used per the guidelines?
Aspirin: 1-4 weeks post PCI discontinue
Plavix + OAC therafter
What is the biggest reason for discontinuation of ticagrelor occuring in 10-15% of patients?
Transient dyspnea
*MOA: increased levels of adenosine in the bloodstream, caused by ticagrelor's inhibition of adenosine uptake, leading to stimulation of adenosine receptors in the lungs, which can trigger the sensation of dyspnea
T or F: continuation of high dose aspirin 325mg daily following PCI was found to be superior to low dose aspirin (75-100mg) for reduction of MACE
FALSE
*found to be not superior with an increased risk of minor GI bleeding*
What is the loading dose and maintenance dose of clopidogrel following fibrinolytic therapy for a STEMI in a 78 year old male?
Loading dose is 75mg and maintenance dose is also 75mg daily.
*If less than 75 years old, you would load with 300mg and follow with a maintenance dose of 75mg daily
In patients with STEMI, what is the dose of fondaparinux used to support PCI?
Trick Question: Fondaparinux should not be used d/t increased risk of stent thrombosis
What is the dose of alteplase in STEMI?
Infuse 15 mg IV bolus over 1 to 2 minutes, followed by infusions of 0.75 mg/kg (not to exceed 50 mg) over 30 minutes, then 0.5 mg/kg (not to exceed 35 mg) over 1 hour; maximum total dose: 100 mg.