21/22 - Pharmacotherapy ACS Flashcards
- *STEMI** + nonPCI
- *Fibronolytic (>12 hours)_ or _nonprimary PCI**
What P2Y12 Inhibitor do we use?
“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y12 Antagonist
CLOPIDOGREL
preferred if higher bleeding risk
ACS Secondary Prevention Therapy
1st 24 Hours
ABS
Aspirin
indefinitely
- *Beta Blocker**
- *~3 years** / indefinitely if LVEF < 40%
STATIN
indefinitely
N-STEMI** + **Conservative
What P2Y12 Inhibitor do we use?
“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y12 Antagonist
(Ischemia Driven)
CLOPIDOGREL
or
TICAGRELOR
need to limit aspirin < 100 mg daily
doses > 300 = ↑mortality risk
ACS Secondary Prevention Therapies
STATINS
ALL PATIENTS w/ ACS
- *HIGH INTENSITY STATIN**
- *Atorvastatin 80mg** (40mg) or Rosuvastatin 40mg (20mg)
- may use moderate-intensity if risk for ADR*
ADR:
↑LFT
ACS Secondary Prevention Therapy
PRIOR TO DISCHARGE
- *DAPT**
- *Aspirin + P2Y12 Inhibitor**
STATIN** + **BETA BLOCKER
SL NTG
PRN
ACE / ARB / EPLERENONE
discontinue NSAIDS
Clinical Suspicion of ACS + Ischemic Symptoms >10 min
VVV
ECG / Enzymes (CTN) / St-segment Monitoring
VVV
Initial Treatment
VVV
ACUTE SUPPORTIVE CARE
ANO + MBC
Aspirin** + **Oxygen** + **SL NTG
MORPHINE
For symptoms refractory to NTG
- *Beta Blockers**
- *PO** –> IV if ↑BPor ↑HR
CCBs
mainly if CI to BBs –> asthma / cocaine induced
Reperfusion Strategy:
FIBRINOLYTICS
TPA = Alteplase / RPA = Reteplase / TNK = Tenecteplase
ABSOLUTE CONTRAINDICATIONS
BP > 220/110
STROKE 3 months
Active Bleeding / Bleeding Disorder
Recent Head Trauma / Previous Intracranial Hemorrhage
Intracranial MASS or AVM
Intracranial / Intraspinal SURGERY < 2 months
STEMI** + **PCI = Any of the 3
+ High Risk Patient = Diabetes
What P2Y12 Inhibitor do we use?
“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y12 Antagonist
avoid Clopidogrel
PRASUGREL
AVOID if: <60kg / >75yo / Hx TIA-Stroke
TICAGRELOR
Limit aspirin dose < 100mg
possible CABG in future / unknown coronary anatomy
ticagrelor is REVERSIBLE, unlike clopidogrel & prasugrel
Reperfusion Strategy:
FIBRINOLYTICS
TPA = Alteplase / RPA = Reteplase / TNK = Tenecteplase
ADR’s / Risk Factors
BLEEDING / STROKE
specifically INTRACRANIAL BLEEDING
Risk Factor:
Age > 65
Wt < 70kg
Uncontrolled HTN
Clinical Suspicion of ACS + Ischemic Symptoms >10 min
VVV
FIRST STEPS
12-Lead ECG
within 10 minutes
Serial cTn Levels
Cardiac Enzymes = Troponin & CK-MB
Continuous ST-segment MONITORING
AntiCoagulant Therapy
When would we use FONDAPARINUX?
&
When to AVOID?
LEAST USED
Preferred for:
Conservative Strategy** + **HIGH RISK FOR BLEEDING
Avoid if:
- *Cath/PCI performed** - associated w/ cath thrombosis
- *CrCl < 30**
- *Weight < 50kg**
STEMI** + **PCI = Any of the 3
+Possible CABG in future
What P2Y12 Inhibitor do we use?
“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y12 Antagonist
TICAGRELOR
Limit aspirin dose < 100mg
possible CABG in future / unknown coronary anatomy
Because:
- *Ticagrelor** is REVERSIBLE, unlike clopidogrel/prasugrel
- *NO NEED to stop 5-7 days b4 CABG**
N-STEMI** + **INVASIVE PCI
+
Normal cTn & NO ischemic ECG changes
What P2Y12 Inhibitor do we use?
“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y12 Antagonist
ANY OF THE 3
CLOPIDOGREL
good for higher bleeding risk
PRASUGREL
Avoid if: <60kg / >75yo / hx Stroke-TIA
TICAGRELOR
need to limit aspirin < 100 mg daily
doses > 300 = ↑mortality risk
Clinical Suspicion of ACS + Ischemic Symptoms >10 min
VVV
ECG / Enzymes (CTN) / St-segment Monitoring
VVV
INITIAL TREATMENT
A - N - O
ASPIRIN
All patients –> 162-325mg for 1 dose = Chew for RAPID absorption
81mg QD indefinitely
- *SL NTG**
- *q5 min PRN** (<3 doses)
Oxygen
if O2 Sat < 90%
AntiCoagulant Therapy
When would we use HEPARIN = UFH?
&
When to AVOID?
MOST COMMONLY USED = Cheap
B4/during PCI
Fibrinoytic STEMI
Intermediate-High Risk ACS
Weight Based Dosing:
60u/kg (max = 4k) IVP –> 12u/kg/hr (max = 1k)
adjusted to maintain:
aPTT ~60-80 seconds
Duration = 48 hours or after PCI
AntiCoagulant Therapy
When would we use BIVALIRUDIN?
&
When to AVOID?
INVASIVE PCI STRATEGY
usually until PCI is completed & up to 72hours after PCI
Do not use when:
NO PCI planned
↓need for GP IIB/IIIa Inhibitor in most cases