C274: NSTEMI

Question 1

Parameters (7) involved in TIMI Risk Markers

Answer 1

• Age ≥ 65
• Known CAD ( ≥ 50% stenosis)
• ST deviation > 0.5mm on presenting ECG
• increased cardiac markers
• ≥ 2 original episodes in prior 24hrs
• prior angina
• ≥ 3 CAD risk factors

Question 2

Difference between myocardial injury vs myocardial necrosis

Answer 2

• Myocardial injury - elevations of cTN >99th percentile of the upper reference limit in patients WITHOUT a clear clinical histoy or ECG features of acute myocardial ischemia

Question 3

3 RISK STRATIFICATION EME used in NSTEMI

Answer 3

• TIMI - Thrombolysis in Myocardial Infarction
• GRACE - Global Registry of Acute Coronary Event
• HEART - History, ECG, Age, Risk fx, Troponin

Question 4

What does HEART risk stratification stand for in NSTEMI

Answer 4

History, ECG, Age, Risk fx, Troponin

Question 5

When is AMBULATION allowed in NSTEMI

Answer 5

• if with no recurrence of ischemia for 24hrs
• and if no development of elevation of cTn for 24 hrs

Question 6

How should Nitrates be given in NSTEMI

Answer 6

• given sublingually or by buccal spray (0.3 to 0.6mg ) up to 3 doses , 5 mins apart
• if still with chest pain, may give IV nitroglycerin (5-10ug/min)

Question 7

ABSOLUTE CONTRAINDICATION FOR USE OF NITRATES

Answer 7

• hypotension
• Sildenafil / Vardenafil (within 24hrs)
• Taladafil (within 48 hrs )

Question 8

Target heart rate in NSTEMI patients on BETA BLOCKERS

Answer 8

Target heart rate in NSTEMI patients on BETA BLOCKERS —> 50-60 bpm

Question 9

CCBs for NSTEMI

Answer 9

• Verapamil or Diltiazem

Question 10

Patients who have persistent severe chest pain despite maximal anti-ischemic therapy may be given ________

Answer 10

MORPHINE IV 1-5mg every 5-30 mins

Question 11

High dose statins should be given in NSTEMI. If patients who still failed to have adequate response to statins, the other drugs that can be given are: ( 2 DRUGS)

Answer 11

• Ezetimibe 10mg OD
• PCSK9 inhibitor - Alirocumab, Evolocumab

Question 12

Two other P2Y12 inhibitors that are superior to Clopidogrel in preventing recurrent cardiac ischemic events both both increase bleeding

Answer 12

• Prasugrel
• Ticagrelor - REVERSIBLE

Question 13

Gene involved why some have inadequate response to Clopidogrel

Answer 13

• genetic variant of CYP450 —> 2C19 gene that leads to reduced conversion of clopidgorel into its active metabolite

Question 14

DAPT should continue at least _______months and preferably _______months in NSTEMI patients

Answer 14

DAPT should continue at least 3 months and preferably 12 months in NSTEMI patients

Question 15

The only intravenous P2Y12 inhibitor

Answer 15

Cangrelor

Question 16

LOADING DOSE and MAINTENANCE DOSE OF Aspirin vs Clopidogrel vs Prasugrel vs Ticagrelor

Answer 16

Aspirin - 150-325mg then 75-100mg OD

Clopidogrel - 600mg if for PCI vs 300mg if not for PCI THEN 75mg OD

Prasugrel - 60mg (PCI) then 10mg OD

Ticagrelor - 180mg then 90mg OD

Question 17

Anticoagulant that is mainstay of therapy in NSTEMI

Answer 17

• Unfractionated heparin

Question 18

LMWH that is superior to UFH in reducing recurrent cardiac events

Answer 18

• Enoxaparin

Question 19

Direct thrombin inhibitor that has same efficacy w/ LMWH and UFH and is used just prior and /or during PCI

Answer 19

• Bivalirudin

Question 20

Synthetic factor Xa inhibitor that is same efficay with Enoxaparin but has lower risk of major bleeding

Answer 20

• Fondaparinux

Question 21

Difference in timing among intermediate invasive, early invasive, and invasive strategy:

Answer 21

• intermediate invasive - less than 2 hrs
• early invasive - less than 24hrs
• invasive - less than 72 hrs

Question 22

If an early invasive strategy is indicated, _____ artery access is recommended to reduce the risk of bleeding

Answer 22

• radial artery

Question 23

Recommended anti thrombotic regimen for patients with Afib and NSTEMI who underwent PCI

Answer 23

• duration of DAPT should be shortened
  
  • ( ex: Stop aspirin after hospital discharge or up to 4 weeks post PCI except for patients at very high risk of ischemic events)
• then continue P2Y12 inhibitor plus DOAC for 1 year
• then after 1 year, DOAC monotherapy na laaaaang

Question 24

Difference between invasive VS selective invasive approach

Answer 24

• In an invasive strategy, following initiation of anti-ischemic and antithrombotic agents as described above, coronary arteriography is carried out within ~48 h of presentation, followed by coronary revascularization (PCI or coronary artery bypass grafting), depending on the coronary anatomy
• consists of anti-ischemic and antithrombotic therapy followed by a “selective invasive approach,” in which the patient is observed closely and coronary arteriography is carried out if coronary computed angiography shows the presence of epicardial coronary stenosis, rest pain or ST-segment changes recur, a biomarker of necrosis becomes positive, or there is evidence of severe ischemia on a stress test.

Question 25

Recommended antiplatelet regimen for NSTEMI:

Answer 25

- low-dose (75–100 mg/d) aspirin PLUS - P2Y 12inhibitor (clopidogrel, prasugrel, or ticagrelor) . . - Duration: for 12 months, unless there is a high risk of bleeding. Antiplatelet monotherapy should be continued thereafter, - unless long-term full-dose anticoagulation is indicated, in which case anticoagulant without antiplatelet therapy is recommended after 1 year

Question 26

What is Prinzmental’s variant angina

Answer 26

Prinzmental’s variant angina is syndrome of severe ischemic pain that usually occurs at rest and is associated with STsegment elevation.

Question 27

Cause of Prinzmetal’s variant angina (PVA)

Answer 27

Prinzmetal’s variant angina (PVA) is caused by focal spasm of an epicardial coronary artery with resultant transmural ischemia and abnormalities in left ventricular function that may lead to acute MI, ventricular tachycardia or fibrillation, and sudden cardiac death.

Question 28

clinical diagnosis of PVA

Answer 28

made by the detection of transient ST-segment elevation with rest pain, although many patients may also exhibit episodes of silent ischemia

Question 29

diagnostic hallmark of PVA.

Answer 29

Coronary angiography demonstrates transient **coronary spasm** as the diagnostic hallmark of PVA.

Question 30

2 ways provoke transient coronary spasm for establishing diagnosis of PVA

Answer 30

- Hyperventilation - intracoronary acetylcholine

Question 31

main therapeutic agents for PVA (2)

Answer 31

Nitrates calcium channel blockers

Question 32

Effect of Aspirin on PVA

Answer 32

Aspirin may actually increase the severity of ischemic episodes, possibly as a result of the sensitivity of coronary tone to modest changes in the synthesis of prostacyclin

Question 33

Statin is useful in PVA. How?

Answer 33

- Statin therapy has been shown to reduce the risk of major adverse events, although the precise mechanism is not established

Question 34

Duration of acute active phase of PVA

Answer 34

first 6 months after initial presentation . . - after which, the symptoms and cardiac events may diminish over time