CC January 2015 Non-ST Elevation-Acute Coronary Syndrome

echoecho's version from 2016-01-01 17:07


Question Answer
The American College of Cardiology / American Heart Association (ACC/AHA) now refers to acute coronary syndrome (ACS) as what?a spectrum of conditions due to an abrupt reduction in coronary blood flow
List the 3 conditions that are related to acute coronary syndrome (ACS)?1) ST elevation MI (STEMI) 2) non-ST elevation MI (NSTEMI) 3) unstable angina (UA)
In 2014, the term "non-ST-elevation-acute coronary syndrome (NSTE-ACS) was introduced and encompasses what two conditions? And recognizes the two as part of a what?1) NSTEMI 2) UA (unstable angina) 3) continuum
The symptoms of ACS may be similar across all three conditions (STEMI, NSTEMI, UA). List the shared symptoms?1) substernal chest pain OR 2) pressure ACCOMPANIED by 3) radiation typically to the jaw, neck, back or left arm and ASSOCIATED with 4) diaphoresis, nausea, vomiting and/or shortness of breath
What procedure can be done to help differentiate STEMI from NSTEMI?EKG
What labs could help differentiate NSTEMI from UA? What would be the results?1) cardiac biomarkers (usually troponin) 2) levels of troponin are elevated in NSTEMI but not in UA
Withe increasing sensitivity of newer generations of cardiac biomarkers, why has the incidence of UA actually decreased?because more patients have been classified as having NSTEMI
One entity included in ACS and potentially confused with NSTEMI is what, in which the ST changes may only be seen the posterior leads (V 7-9)?true posterior MI
Since Q waves may represent what injury, they are not useful in the diagnostic criteria for ACS?new or prior myocardial injury
*** The most recent guideline concerning NSTE-ACS from ACC/AHA was released in 2014. The authors recommend what for all patients presenting with possible NSTE-ACS? Is there a separate TIMI risk score for patients with STEMI?1) be evaluated with a risk assessment score (such as the TIMI or thrombolysis in MI risk score). 2) yes
*** Regarding the TIMI Risk Score for NSTE-ACS, one point is assigned for each of the conditions, list the 7 conditions receiving one point each?1) age > 65 y.o. 2) ASA use within the last 7 days 3) at least 2 episodes of chest pain in the previous 24 hours 4) ST changes of at least 0.5 mm in contiguous leads 5) elevated serum cardiac biomarkers 6) known coronary artery disease (CAD) 7) at least 3 risk factors for CAD such as A) hypertension or on medications for hypertension or B) current cigarette smoker or C) HDL level < 40 mg/dL or D) family hx of premature CAD in a male < 55 years old or female < 65 years old
*** The risk of all-cause mortality, new or recurrent MI or severe recurrent ischemia requiring urgent revascularization at 14 days, is based on the total number of points, list the points and the % of all-cause mortality?0-1 points = 4.7%; 2 points = 8.3 %; 3 points = 13.2%; 4 points = 19.9%; 5 points = 26.2%; 6-7 points = 40.9%
Within ____ minutes of presentation, what should be performed and reviewed?EKG
If the initial EKG is nondiagnostic but the patient still has symptoms or is at high risk for ACS, what may be considered?serial EKGs (every 15 to 30 minutes for an hour)
Are non-specific ST segment changes (such as elevations < 5mm and T-wave inversion, are diagnostically helpful?no
What do Q waves (although they do not indicate current ischemia), do demonstrate a high likelihood of significant what?CAD
Up to 4% of chest pain patients with completely normal EKGs have what?UA (unstable angina)
What is the physical exam in patients with NSTE-ACS?normal exam
If there are signs of decompensated heart failure or cardiogenic shock are present, what is unlikely to be the cause and the patient requires urgent treatment?NSTE-ACS
*** Patients with suspected NSTE-ACS should have what done?cardiac-specific troponin levels drawn at initial presentation and AFTER 3-6 hours dot assess for an evolving pattern of myocardial damage
Troponin levels in NSTEMI and STEMI typically increase after ___ hours of myocardial damage and may remain elevated for as long as ___ days?6; 14
List diseases and conditions that may cause elevated levels of troponin in patients WITHOUT ACS?1) chronic renal disease 2) tachyarrhythmias 3) acute heart failure 4) sepsis 5) burns 6) respiratory failure 7) acute neurological disease (subarachnoid hemorrhage and stroke)
To differentiate between diseases and conditions that may cause elevated levels of troponin in patients WITHOUT ACS and one that has ACS, what lab can be useful?CK-MB (creatinine kinase-myocardial band)
By definition, cardiac biomarkers are NORMAL in patients with what?UA (unstable angina)
List the initial medical management of patients WITH suspected NSTE-ACS?1) supplemental oxygen for patients with oxygen saturations of < 90%, respiratory distress of features of hypoxia 2) sublingual NTG is administered for pain relief (unless the patient has recently taken a phosphodisterase inhibitor, such as sildenafil (Viagra) or has hypotension 3) IV NTG is indicated if the chest pain persists despite 3 doses of sublingual NTG 4) Morphine sulfate is used if the pain persists despite the administration of NTG OR if contraindications to the use of NTG exist.
What medication should be given to all patients with NSTE-ACS upon presentation as long as no contraindication exist (such as allergy or active bleeding ulcer)?NON-ENTERIC coated, chewable ASA (162 to 325 mg)
Maintenance ASA should be continued for how long at a dose of 81 to 325 mg daily?indefinitely (there are no recommendations to alter the dose after 1 year)
What medication can be given upon presentation if the patient has contraindications to aspirin administration?Clopidogrel (Plavix) at a loading dose of 300-600
In a NSTE-ACS patient, what medications should be co-administered with indefinite ASA for up to one year?a P2Y-12 inhibitor as EITHER 1) clopidogrel 75 mg daily OR 2) ticagrelor (Brillinta) 90 mg daily after loading doses
Why should updated guidelines be consulted?because initial doses and choice of antiplatelet agent may vary depending on initial treatment choices (invasive or non-invasive)
In addition to antiplatelet therapy, the ACC/AHA recommends for NSTE-ACS patients what?1) use of anticoagulation as part of initial treatment of patients 2) use of low-molecular-weight heparin (enoxaparin (Lovenox)), fondaparinux (Arixtra), bivalirudin (Angiomax) or unfractionated heparin. 3) duration of therapy is during hospitalization ONLY or until PCI is performed
*** Is fibrinolytic therapy indicated for patients with UA (unstable angina)? no
*** What medication should be started within the first 24 hours of presentation for patients with NSTE-ACS because long-term morality is decreased in patients on this medication?beta-blockers
*** What are the contraindications to starting beta-blockers in the above NSTE-ACS patient?1) decompensated heart failure 2) evidence of low output state 3) increased risk of cardiogenic shock 4) severe heart block 5) severe pulmonary disease
*** In patients with NSTE-ACS and stabilized heart failure, beta blockers WITHOUT intrinsic sympathomimetic activity such as what medications is preferred?beta blockers WITHOUT intrinsic sympathomimetic activity such as sustained-release metoprolol succinate (Toprol XL), bisoprolol (Zebeta) or carvedilol (Coreg)
What medication is recommended for patients with a left-ventricular ejection fraction < 40% and in patients with CKD or DM unless contraindications exist?ACEI
What is a reasonable choice if patients are intolerant ACEI?ARBs (angiotensin-receptor blockers)
What other medication should patients be started on if they are not on them and there are no contraindications for this NSTE-ACS patient?HMG-Co-A reductase inhibitors (statins)
List the 2 major management strategies that exist for patients with NSTE-ACS?1) early invasive 2) ischemia-guided
Patients undergoing the early invasive strategy have the potential for what?1) a rapid and definitive evaluation of their symptoms 2) earlier intervention (and therefore reduction in recurrence of symptoms and complications) and earlier hospital discharge
Intervention with what procedure and at the discretion of the interventional cardiologist, what medication may be added in the early invasive strategy?1) angiography and percutaneous coronary intervention (PCI) with stenting may be done within 24 hours of presentation OR delayed to within 72 hours after all medical therapy as detailed above is used 2) a glycoprotein IIa / IIIb inhibitor may be added
Patients undergoing the ischemia-guided strategy may avoid what?costly and invasive interventions should their symptoms resolve with medical therapy
Patients undergoing the ischemia-guided strategy, if their symptoms persist or worsen despite medical therapy, what should be done?invasive intervention (PCI and stenting) or revascularization with CABG
*** The ACC/AHA guideline offers recommendations for the appropriate management strategy to use in patients with NSTE-ACS, what are the 5 indications for immediate invasive (< 2 hours) therapy?1) refractory angina 2) heart failure or worsening mitral valve regurgitation 3) hemodynamic instability 4) recurrent angina or ischemia at rest or with low-level activities 5) sustained ventricular tachycardia or ventricular fibrillation
*** The ACC/AHA guideline offers recommendations for the appropriate management strategy to use in patients with NSTE-ACS, what are the 3 indications for ischemia guided therapy?1) low risk TIMI score (0-1) 2) low-risk, troponin negative female patients 3) patient or physician preference in the absence of high-risk features
*** The ACC/AHA guideline offers recommendations for the appropriate management strategy to use in patients with NSTE-ACS, what are the 3 indications for early invasive (< 24 hours)?1) none of the < 2 hour (immediate invasive) criteria 2) increasing troponin levels 3) new ST-segment depression
*** The ACC/AHA guideline offers recommendations for the appropriate management strategy to use in patients with NSTE-ACS, what are the 7 indications for delayed invasive (< 72 hours)? : 1) none of the prior criteria 2) DM 3) renal insufficiency 4) reduced left ventricular function 5) early postinfarction angina 6) percutaneous coronary intervention < 6 months ago 7) prior coronary artery bypass graft surgery 8) TIMI score > 2
Question Answer
If an ischemia-guided management strategy is used, it may be beneficial to use what test to help with risk stratification?noninvasive test
Give an example of a noninvasive test that is preferred?treadmill testing
Treadmill testing is preferred under what conditions for these NSTE-ACS patients?1) capable of exercising 2) low to intermediate risk for coronary disease 3) have been pain free with minimal activity for at least 12 hours
What may be added to stress testing if a patient has EKG changes that make interpretation difficult?imaging
Why is imaging be useful in women?it improves the diagnostic accuracy of noninvasive testing in women
What stress testing is reserved for patients who cannot exercise?pharmacological stress testing
Following a dx of NSTE-ACS, a number of secondary prevention recommendations were made in the guideline, list these?1) while antiplatelet treatment with ASA and a P2Y12 agent (clopidogrel or ticagrelor) are standard therapy, most patients do NOT require long term anticoagulation 2) under unusual circumstances, the addition of what to antiplatelet therapy is necessary but requires cautious monitoring and a lower prothrombin time (PT) targets?warfarin (Coumadin)
Comment on use of NSAIDs?should be avoided but if they cannot avoid, use Naproxen (Naprosyn) over other agents
Are hormonal therapy with estrogen and/or progesterone recommended?no
Are there any benefits seen with antioxidants or folate supplementation?no
Patients should be instructed in what with coordinated care between cardiology and the PCP?1) proper diet 2) supervised exercise program 3) tobacco cessation
*** SUMMARY = The latest AHA/ACC guideline on acute coronary syndrome (2014) combines what two entities in one entity called non-ST-elevation-acute coronary syndrome (NSTE-ACS)?1) UA (unstable angina) 2) non-ST elevation myocardial infarction
*** SUMMARY = All adult patients presenting with chest pain should have urgent evaluation for what?1) a cardiac cause with clinical evaluation 2) risk assessment (TIMI risk score) 3) serial EKGs 4) cardiac biomarkers
*** SUMMARY = Based on presentation and risk assessment, patients with NSTE-ACS should be stratified to what treatments?1) ischemia-based treatment 2) early percutaneous intervention (PCI) with stenting OR 3) surgical revascularization