Acute Coronary Syndrome

Which of the following medications is an intravenous P2Y12 inhibitor?

A. Cangrelor (kengreal) Kengreal is the only intravenous P2Y12 inhibitor.

While gardening, a patient experienced serious chest pain, diaphoresis, shortness of breath and left arm pain. Emergency medical personnel is contacted and arrives at the scene. What test should the emergency medical personnel perform?

D. 12-lead ECG Emergency medical personnel should perform a 12-lead ECG (electrocardiogram) in the field in patients experiencing symptoms of ACS. It should be performed and evaluated within 10 minutes of the first medical contact.

Which of the following side effects is common with Brilinta?

D. Dyspnea Dyspnea is a common side effect with Brilinta, occurring in more than 10% of patients.

Which of the following NSAIDs would be considered the safest in patients who have had an MI?

B. Naproxen Naproxen has been shown to have the lowest cardiovascular risk of the NSAIDs (other than aspirin).

If indicated, an ACE inhibitor should be started within how many days of a patient having UA/NSTEMI?

A. 1 ACE inhibitors are recommended within the first 24 hours of an MI and continued indefinitely in patients with any of the following: an EF < 40%, hypertension, diabetes or stable CKD. ARBs are reasonable to use if a patient is intolerant of an ACE inhibitor.

A patient is admitted with a STEMI to a rural hospital without a cath lab. If the nearest facility capable of performing PCI is approximately 2 hours away, within how many minutes of arrival at the rural hospital should a fibrinolytic be administered?

A. 30 minutes Fibrinolytic therapy may be administered if the STEMI patient is at a hospital incapable of PCI or is not able to receive PCI within 120 minutes of first medical contact. In a STEMI, the completely occluded coronary artery must be opened as quickly as possible.

FD was diagnosed with an acute STEMI. The physician is determining if she is a candidate for fibrinolysis. Which of the following are contraindications to fibrinolysis for STEMI? (Select ALL that apply.)

A. Active internal bleeding C. Recent Ischemic stroke E. Severe uncontrolled hypertension Contraindications to using a fibrinolytic for STEMI include any prior intracranial hemorrhage, active bleeding, recent stroke (usually defined as within 3 months), intracranial/intraspinal surgery or trauma in the last 2-3 months and others. Severe uncontrolled hypertension (usually defined as > 175/110) is considered a contraindication unless it can be controlled emergently before administering the fibrinolytic. Because of the risk of serious bleeding with fibrinolytics, careful risk/benefit assessment must be conducted. Fibrinolytics are also used for acute ischemic stroke. Contraindications differ for that indication.

RS is a 57-year-old man, presenting for his annual cardiology appointment. He is currently being treated for osteoarthritis, GERD, hypertension and a myocardial infarction he suffered 5 years ago. His current medication list includes acetaminophen, aspirin, atorvastatin, benazepril, famotidine, hydrochlorothiazide, metoprolol and nitroglycerin spray. Which of the following medications must RS continue indefinitely following the myocardial infarction? (Select ALL that apply.)

A. Aspirin B. Atorvastatin C. Benazepril E. Nitroglycerin A statin, aspirin and nitroglycerin should be continued indefinitely for all patients after an MI. An ACE inhibitor should stay on indefinitely in patients with hypertension and a prior MI.

Which of the following are likely signs/symptoms of a heart attack? (Select ALL that apply.)

A. Chest pain or pressure that lasts more than a few minutes. B. Shortness of breath D. Sweating F. Radiating pain Many myocardial infarctions involve chest discomfort that lasts 10 minutes or more, or that goes away and comes back. The pain can radiate (or extend) to one or both arms, the back, neck, jaw or stomach and may be described as "squeezing" or "pressure". Shortness of breath (dyspnea) and sweating (diaphoresis) may also occur.

Which of the following medications can cause thrombotic thrombocytopenic purpura? (Select ALL that apply.)

A. Clopidogrel B. Effient Clopidogrel, prasugrel and ticagrelor all carry a warning for thrombotic thrombocytopenic purpura.

Which of the following medications work by blocking the binding of fibrinogen, von Willebrand factor, and other ligands at the glycoprotein IIb/IIIa receptor?

A. Eptifibatide Eptifibatide is a glycoprotein IIb/IIIa receptor antagonist.

What is the primary reason for using aspirin in a patient with chest pain?

A. Inhibit platelet aggregation Aspirin inhibits platelet aggregation, stabilizes plaque and helps to arrest thrombus formation. Aspirin does not break down the existing clot, but rather prevents it from enlarging and progressing. Aspirin provides very mild analgesia and is not used for analgesia in patients with chest pain.

An 87-year-old male presents to the Emergency Department with complaints of mid-sternal chest pain. He has had intermittent chest pain for two days with some nausea and diaphoresis. The patient is diagnosed with a Non-ST Segment Elevation Myocardial Infarction (NSTEMI). Which of the following are standard medications that may be used to treat a patient with an acute coronary syndrome characterized as NSTEMI? (Select ALL that apply.)

A. Morphine D. Aspirin Look for drugs in the acronym MONA, which represent standard care for a myocardial infarction: Morphine, Oxygen, Nitrates (nitroglycerin in various formulations) and Aspirin (MONA). Additional medications will be added to MONA depending on the clinical situation.

DL is a 77-year-old male (6'3", 315 pounds) who presents to the emergency department with a STEMI. He was given aspirin 325 mg in the field and was started on a nitroglycerin drip at 100 mcg/min. His oxygen saturation is 94% and he has received morphine sulfate 2 mg IV x 2 and metoprolol 5 mg IV in the past 30 minutes. His blood pressure is 164/101, HR is 95 bpm, and his respiratory rate is 22 bpm. Which of the following medications should NOT be given to the patient due to increased mortality?

A. Nifedipine immediate-release Immediate-release nifedipine is associated with increased mortality when used in the acute setting.

GH uses the following medications daily:Clopidogrel for CAD Aspirin for CADCozaar for blood pressureLovastatin for dyslipidemiaAmbien for sleepPrilosec for heartburnZyban for smoking cessation Clopidogrel interacts with which of GH's medications?

A. Prilosec

A patient at the hospital is receiving morphine for chest pain. What are the advantages of using morphine in a patient with chest pain? (Select ALL that apply.)

A. Provides analgesia B. Reduces preload C. Reduces myocardial oxygen demand Morphine reduces preload (venous dilation), provides analgesia and reduces myocardial oxygen demand. Caution is needed because morphine can lower blood pressure, leading to hypotension, and can cause respiratory depression.

GR received an electrocardiogram (ECG) which showed ST-segment elevation in the precordial leads (V2-V6). In the emergency room her troponin I and CK-MB were positive. Her glucose, amylase and blood pressure were elevated, but other labs and vital signs were normal. She went to the cath lab for primary percutaneous coronary intervention (PCI). The coronary angiogram found 100% blockage of the left anterior descending (LAD) coronary artery. Which of the following indicate that GR has had an ST-segment elevation myocardial infarction (STEMI)? (Select ALL that apply.)

A. ST-segment elevation of ECG C. Positive cardiac enzymes A STEMI diagnosis is made in patients with chest pain, positive cardiac enzymes and ST-segment elevation on ECG. The T-wave is part of the ST-segment, so a patient cannot have ST-segment elevation and T-wave inversion. The critical difference between STEMI and NSTEMI (including unstable angina) is that STEMI requires a faster response for reperfusion. Time is of the essence in order to break up the blockage and re-establish blood flow to that section of the heart.

AH is being discharged from the hospital after a myocardial infarction. Two bare-metal stents were placed yesterday. Upon discharge, he will continue taking his Prasugrel therapy which was started yesterday. What is the minimum period of time that AH will need to take Prasugrel?

B. 1 year After an MI, patients should receive aspirin and a P2Y12 inhibitor for a minimum of 12 months. The minimum recommendation is the same for patients managed medically or for those stented.

JM underwent PCI yesterday for a STEMI. He was loaded with clopidogrel prior to PCI and the medical team wants to start the maintenance dose today. What dose of clopidogrel should the pharmacist recommend?

B. 75 mg daily A one-time loading dose of clopidogrel 300-600 mg is given in patients with ACS, followed by a daily maintenance dose of 75 mg starting the day after the loading dose.

A pharmacist covering the emergency department receives an order for tissue plasminogen activator (tPA) 15 mg IV bolus, 50 mg over 30 min, then 35 mg over 1 hour. Total dose = 100 mg. What drug is being ordered?

B. Alteplase Alteplase (Activase) is recombinant tissue plasminogen activator (rtPA or simple "tPA"). Correct dosing is critical due to bleeding risk. The accelerated infusion dosing for STEMI differs from the recommended dose for acute ischemic stroke (see Stroke chapter).

Which label on the figure best represents the site where aspirin exerts its mechanism of action?

B. B Aspirin irreversibly binds and inhibits cyclooxygenase (COX) 1 and 2. This inhibits the production of thromboxane A2 and ultimately platelet aggregation.

A patient at the hospital is receiving a beta-blocker for chest pain. Which of the following is true regarding the use of beta-blockers in this setting?

B. Beta-1 selective beta-blockers without intrinsic sympathomimetic activity are preferred. Beta-1 selective beta-blockers should be given to all patients without contraindications who present with UA/NSTEMI within 24 hours. In STEMI, they should be given promptly. They reduce myocardial oxygen demand and can be administered PO or IV.

A patient on clopidogrel calls the pharmacy with complaints of black, tarry stools. What side effect is he most likely experiencing?

B. Bleeding

A woman calls the pharmacy in a panic. She thinks her husband may be having a heart attack. The pharmacist determines that the husband has a prescription for Nitrostat (sublingual nitroglycerin) at home. What instructions should the pharmacist provide? (Select ALL that apply.)

B. Call 911 if the pain persists or worsens after the first dose of nitroglycerin. C. Use one Nitrostat tablet every 5 minutes for up to three doses. E. Place one Nitrostat tablet under the tongue and let it dissolve. An ACS is a medical emergency. Use 1 dose of short-acting nitroglycerin (SL, spray or powder) immediately. Call 911 if the pain persists or is worse after the first dose. Use one dose Q5 min, but do not exceed 3 doses in 15 minutes. If aspirin is readily available, CHEW 162-325 mg of a non-enteric coated formulation immediately. Review the Ischemic Heart Disease chapter for additional details about nitroglycerin formulations.

All of the following are antiplatelet agents that can be used in the treatment of an acute coronary syndrome EXCEPT:

B. Dalteparin Aspirin, P2Y12 inhibitors and glycoprotein IIb/IIIa receptor antagonists can be globally called "antiplatelet agents" based on their mechanisms of action. Dalteparin is an anticoagulant.

Which of the following are risk factors for an acute coronary syndrome? (Select ALL that apply.)

B. Dyslipidemia C. Diabetes E. Hypertension G. Smoking Risk factors include age (men > 45 years of age, women > 55 years of age or with an early hysterectomy), family history of coronary events before age 55 years (men) or before age 65 years (women), smoking, hypertension, dyslipidemia, diabetes, known coronary artery disease, chronic angina, excessive alcohol use and sedentary lifestyle.

GL is started on aspirin 81 mg PO daily and ticagrelor 90 mg PO BID after PCI with placement of 2 stents. She is now visiting her cardiologist and it has been just over 1 year since her stents were placed. She feels that she is still at risk and would like to continue her regimen. What dose of ticagrelor is appropriate?

C. 60 mg po bid Ticagrelor should be dosed at 60 mg PO BID if continued beyond 1 year.

Which of the following medications should be avoided in a patient presenting with ACS?

C. Celecoxib NSAIDs (except aspirin), regardless of COX selectivity, should be avoided in patients with ACS. If safer agents (acetaminophen, tramadol, small doses of opioids) are not effective, naproxen is generally considered to have the lowest cardiovascular risk (but there is still risk).

A patient at the hospital is receiving nitroglycerin for chest pain. Which of the following is an advantage of using nitroglycerin in a patient with chest pain?

C. Dilates coronary arteries Nitroglycerin dilates coronary vessels to increase blood flow, reduces preload and provides relief of chest pain.

HG presents to the cardiology clinic one year after her STEMI for medication therapy management. Her past medical history is significant for diabetes and her most recent EF is 60%. Her current medications include Zestril, rosuvastatin, metformin, Plavix, aspirin and nitroglycerin SL. Which of the following medications should be added to her regimen?

C. Metoprolol Per the ACC/AHA guidelines, beta-blocker therapy should be given for 3 years after an MI. If there are other evidence-based reasons to continue the beta-blocker (heart failure, atrial fibrillation, etc.), then it may be continued beyond 3 years.

Which of the following laboratory tests is the most sensitive marker for detecting myocardial damage in a patient with an acute coronary syndrome?

C. Troponins Though all of the tests listed as answer choices can be elevated in ACS, troponins (I and T) are the most sensitive and specific for detecting myocardial damage due to ischemia.

What causes an acute coronary syndrome?

D. Reduced blood flow to the heart caused by plaque rupture in the coronary arteries. ACS symptoms result from a mismatch between myocardial oxygen supply and demand. Coronary atherosclerosis is the cause. ACS is a broad term that includes NSTE-ACS and STEMI. NSTE-ACS includes both NSTEMI and unstable angina (UA). It is good to compare and contrast the cause of ACS, stroke, VTE, arrhythmia and heart failure so the drug therapy will make sense.

Paramedics respond to a call for a patient experiencing chest pain that was not relieved by sublingual nitroglycerin. The patient has symptoms consistent with an acute coronary syndrome, so they perform a 12-lead ECG on the way to the hospital. Which of the following is correct regarding administration of aspirin to this patient, assuming there are no contraindications?

D. Administer chewable aspirin 324 mg immediately All patients suspected of having an acute coronary syndrome should receive chewable aspirin 162-325 mg immediately.

SR is a 61-year-old female (5'3", 115 pounds) who presents to the emergency department with a NSTEMI. Her past medical history is significant for diabetes, hypertension, multiple TIAs and a hip fracture. She was given aspirin 325 mg in the field and was started on a nitroglycerin drip at 50 mcg/min. Her oxygen saturation is 93% and she has received morphine sulfate 1 mg IV x 1 in the past 30 minutes. She is transferred to the cardiac catheterization laboratory and angiography confirmed an 85% blockage of her left marginal artery. The cardiac interventionalist wants to start a P2Y12 inhibitor prior to the PCI. Which medication is appropriate?

D. Brillinta This patient has a contraindication to the use of Effient (history of TIA/stroke).Activase, TNKase and Lovenox do not work by P2Y12 inhibition.

The provider orders Integrilin. What is the appropriate generic substitution?

D. Eptifibatide Eptifibatide is the generic name of Integrilin.

Which of the following patients should be placed on statin therapy after an acute coronary syndrome?

E. All patients who have had an acute coronary syndrome Statin therapy should be initiated in all patients with clinical atherosclerotic cardiovascular disease (ASCVD). This is defined in the Dyslipidemia chapter and includes patients with coronary heart disease [acute coronary syndrome (ACS), status post MI, stable or unstable angina, coronary or other arterial revascularization], stroke, TIA or PAD. This is called secondary prevention. A moderate-intensity statin may be considered (instead of a high-intensity statin) in patients > 75 years of age.

JB has been taking ticagrelor 90 mg BID for 3 months. Which of the following new orders should not be filled by the pharmacist?

E. Aspirin 325mg daily Maintenance doses of aspirin > 100 mg reduce the effectiveness of ticagrelor. This is an important distinction to understand. The loading dose of ticagrelor (180 mg) is given with a loading dose of aspirin (325 mg), but the maintenance dose of ticagrelor (90 or 60 mg BID) should be given with an aspirin dose ≤ 100 mg (usually 81 mg in the U.S.). Anticoagulants are sometimes required along with P2Y12 inhibitors (e.g., prior ACS and mechanical valve). Bleeding risk would be increased, but the dual therapy is sometimes required.

The pharmacist received an order for tenecteplase from the emergency department. What is the mechanism of action of tenecteplase?

E. Binds to fibrin and converts plasminogen to plasmin Fibrinolytics work by binding to fibrin and converting entrapped plasminogen to plasmin. Plasmin then degrades the fibrin mesh into soluble end products leading to clot dissolution.

A patient presenting with chest pain underwent a procedure to open a coronary artery. This was done by inflating a small balloon inside the artery and then placing a stent afterward to keep the artery open. What procedure did this patient have done?

E. PCI Percutaneous coronary intervention (PCI) is the preferred method to open a blocked coronary artery in an ACS. It involves inflating a small balloon to open the artery to restore blood flow to the heart. To maintain blood flow, a metal mesh called a stent is placed in the artery, which keeps it open after the procedure is complete.

MG was admitted to the hospital for complaints of shortness of breath, sweating and squeezing chest pain that is radiating to his arm and back. In the emergency room, his ECG showed prominent T-wave inversion, but all labs were normal. Two sets of troponin I levels were drawn (at admission and 6 hours later) and came back negative. His blood pressure is currently 153/87 mmHg with a heart rate of 88 bpm. What is the most likely diagnosis?

E. Unstable angina Chest pain caused by an acute coronary syndrome is usually described as radiating to the arms, back, neck, jaw or epigastric area. Both NSTEMI and unstable angina can present with ECG changes such as ST-segment depression or prominent T-wave inversion, or there may be no notable changes. Unstable angina is identified by the negative cardiac enzymes (troponin I or troponin T).