T1: ACS Treatment Tutoring By Alaina Darby

Which of the following can be used to differentiate NSTEMI from UA? ST elevation Troponin levels Rapidity of onset EKG B… this is the only thing!

Which of the following best describes the pathophysiology of STEMI? Plaque disruption that partially occludes the vessel and releases troponin Plaque disruption that partially occludes the vessel and does not release troponin Plaque disruption that totally occludes the vessel and releases troponin Plaque disruption that totally occludes the vessel and does not release troponin C

Case: AK is a 43 yo WF who presents to the ED with chest pain. She reports that she has been experiencing chest pain for 1 hour prior to arrival to the ED PMH: diabetes, HTN, TIA PSH: bilateral oophorectomy SH: smokes ½ ppd, denies alcohol use, denies elicit drug use FH: father died of MI at age 60 Vitals/Labs: BMI: 34 HDL: 21 LDL: 100 Troponin: negative EKG: T wave inversion, ST segment elevation, and Q wave normal

How many modifiable risk factors does AK have? 3 4 5 6 AK is a 43 yo WF who presents to the ED with chest pain. She reports that she has been experiencing chest pain for 1 hour prior to arrival to the ED. PMH: diabetes, HTN, TIA PSH: bilateral oophorectomy SH: smokes ½ ppd, denies alcohol use, denies elicit drug use FH: father died of MI at age 60 Vitals/Labs: BMI: 34, HDL: 21, LDL: 100, Troponin: negative, EKG: T wave inversion, ST segment elevation, and Q wave normal How many modifiable risk factors does AK have? 3 4 5 6 C… DM, HTN, smoking, obesity, HDL

How many non-modifiable risk factors does AK have? 1 2 3 AK is a 43 yo WF who presents to the ED with chest pain. She reports that she has been experiencing chest pain for 1 hour prior to arrival to the ED. PMH: diabetes, HTN, TIA PSH: bilateral oophorectomy SH: smokes ½ ppd, denies alcohol use, denies elicit drug use FH: father died of MI at age 60 Vitals/Labs: BMI: 34, HDL: 21, LDL: 100, Troponin: negative, EKG: T wave inversion, ST segment elevation, and Q wave normal How many non-modifiable risk factors does AK have? 1 2 3 A

AK should be diagnosed with what? NSTEMI UA STEMI Cannot be determined AK is a 43 yo WF who presents to the ED with chest pain. She reports that she has been experiencing chest pain for 1 hour prior to arrival to the ED. PMH: diabetes, HTN, TIA PSH: bilateral oophorectomy SH: smokes ½ ppd, denies alcohol use, denies elicit drug use FH: father died of MI at age 60 Vitals/Labs: BMI: 34, HDL: 21, LDL: 100, Troponin: negative, EKG: T wave inversion, ST segment elevation, and Q wave normal AK should be diagnosed with what? NSTEMI UA STEMI Cannot be determined C

Which of the following occurs first on the EKG? ST segment elevation T wave inversion Pathological Q waves B

Which is not indicative of myocardial injury? ST segment elevation T wave inversion Pathological Q waves B

AK is a 43 yo WF who presents to the ED with chest pain AK is a 43 yo WF who presents to the ED with chest pain. She reports that she has been experiencing chest pain for 1 hour prior to arrival to the ED. PMH: diabetes, HTN, TIA PSH: bilateral oophorectomy SH: smokes ½ ppd, denies alcohol use, denies elicit drug use FH: father died of MI at age 60 Vitals/Labs: BMI: 34, HDL: 21, LDL: 100, Troponin: negative, EKG: T wave inversion, ST segment elevation, and Q wave normal Should her ST segment not be elevated, AK should be diagnosed with what? NSTEMI UA STEMI Cannot be determined D

Which medications should be administered within the first 24-48 hours? AK is a 43 yo WF who presents to the ED with chest pain. She reports that she has been experiencing chest pain for 1 hour prior to arrival to the ED. PMH: diabetes, HTN, TIA PSH: bilateral oophorectomy SH: smokes ½ ppd, denies alcohol use, denies elicit drug use FH: father died of MI at age 60 Vitals/Labs: BMI: 34, HDL: 21, LDL: 100, Troponin: negative, EKG: T wave inversion, ST segment elevation, and Q wave normal Which medications should be administered within the first 24-48 hours? ASA 81 mg, Clopidogrel 600 mg, UFH 60 units/kg ASA 162 mg, Clopidogrel 300 mg, UFH 60 units/kg ASA 325 mg, Clopidogrel 300 mg, UFH 12 units/kg ASA 325 mg, Clopidogrel 75 mg, UFH 60 units/kg B

Which medication regimen would be appropriate if AK will undergo PCI? AK is a 43 yo WF who presents to the ED with chest pain. She reports that she has been experiencing chest pain for 1 hour prior to arrival to the ED. PMH: diabetes, HTN, TIA PSH: bilateral oophorectomy SH: smokes ½ ppd, denies alcohol use, denies elicit drug use FH: father died of MI at age 60 Vitals/Labs: BMI: 34, HDL: 21, LDL: 100, Troponin: negative, EKG: T wave inversion, ST segment elevation, and Q wave normal Which medication regimen would be appropriate if AK will undergo PCI? ASA 81 mg, Clopidogrel 600 mg, UFH 12 units/kg ASA 162 mg, Ticagrelor 180 mg, UFH 60 units/kg ASA 325 mg, Clopidogrel 75 mg, Bivalirudin ASA 325 mg, Ticagrelor 90 mg, Bivalirudin B

ASA/ticagrelor/eptifibatide ASA/clopidogrel/heparin AK is a 43 yo WF who presents to the ED with chest pain. She reports that she has been experiencing chest pain for 1 hour prior to arrival to the ED. PMH: diabetes, HTN, TIA PSH: bilateral oophorectomy SH: smokes ½ ppd, denies alcohol use, denies elicit drug use FH: father died of MI at age 60 Vitals/Labs: BMI: 34, HDL: 21, LDL: 100, Troponin: negative, EKG: T wave inversion, ST segment elevation, and Q wave normal Which medication regimen would be appropriate if AK is undergoing a thrombolytic approach (in addition to tPA)? ASA/ticagrelor/eptifibatide ASA/clopidogrel/heparin ASA/heparin/eptifibatide ASA/ticagrelor/bivaliruden B

Clopidogrel/ Ticagrelor ACS Non-invasive ASA Clopidogrel/ Ticagrelor UFH/ Enoxaparin Reperfusion Thrombolytic Clopidogrel Invasive (PCI) Clopidogrel/ Ticagrelor/ Prasugrel One of the following: UFH/ Enoxaparin and GP IIb/IIIa Bivalirudin

ASA/enoxaparin/ticagrelor ASA/heparin/prasugrel ASA/heparin/ticagrelor AK is a 43 yo WF who presents to the ED with chest pain. She reports that she has been experiencing chest pain for 1 hour prior to arrival to the ED. PMH: diabetes, HTN, TIA PSH: bilateral oophorectomy SH: smokes ½ ppd, denies alcohol use, denies elicit drug use FH: father died of MI at age 60 Vitals/Labs: BMI: 34, HDL: 21, LDL: 100, Troponin: negative, EKG: T wave inversion, ST segment elevation, and Q wave normal Should AK be diagnosed with NSTEMI and undergo PCI, which of the following would not be indicated for her? ASA/enoxaparin/ticagrelor ASA/heparin/prasugrel ASA/heparin/ticagrelor ASA/heparin/clopidogrel B

Which of the following must always be used with bivalirudin? ASA GP IIb/IIIa inhibitor Enoxaparin Heparin A… also thienopyridine

Which of the following can be used as an alternate to ASA if the patient has an allergy? Clopidogrel Prasugrel Ticagrelor A

Which of the following cannot be used in combination with ASA for a patient with UA/NSTEMI? Clopidogrel Prasugrel Ticagrelor B

If a patient undergoes the noninvasive approach, which of the following is an acceptable regimen? ASA continued 1 year afterward + clopidogrel continued 1 year afterward ASA continued 1 year afterward + prasugrel continued 1 year afterward ASA continued indefinitely + clopidogrel continued 1 month afterward ASA continued indefinitely + prasugrel continued 1 year afterward C

If a GK is 65 yo and undergoes thrombolytic therapy due to STEMI, which of the following should be his regimen? Clopidogrel 300 mg loading dose followed by 75 mg/day for 1 year Clopidogrel 300 mg loading dose followed by 75 mg/day for 1 month Clopidogrel 200 mg loading dose followed by 75 mg/day for 1 year Clopidogrel 200 mg loading dose followed by 75 mg/day for 1 month A

Which of the following should be withheld 7 days prior to CABG? Clopidogrel Prasugrel Ticagrelor B

For invasive therapy for UA/NSTEMI, which of the following regimens should be used in a high risk patient? ASA, heparin, GPIIb/IIIa, and prasugrel ASA, heparin, and prasugrel ASA, heparin, GPIIb/IIIa, and clopidogrel ASA, heparin, and clopidogrel A or C B or D C or D C

For invasive therapy for UA/NSTEMI, which of the following regimens should be used in a low risk patient? ASA, heparin, GPIIb/IIIa, and prasugrel ASA, heparin, and prasugrel ASA, heparin, GPIIb/IIIa, and clopidogrel ASA, heparin, and clopidogrel A or C B or D C or D F