_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: \ 75yo / hx Stroke-TIA _TICAGRELOR_ need to limit aspirin \ 300 = ↑mortality risk

21/22 - Pharmacotherapy ACS Flashcards by Karlo Sison

*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

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ACS Secondary Prevention Therapy

1st 24 Hours

ABS

Aspirin
indefinitely

*Beta Blocker**
*~3 years** / indefinitely if LVEF < 40%

STATIN
indefinitely

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N-STEMI** + **Conservative

What P2Y₁₂ Inhibitor do we use?

“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y₁₂ Antagonist

(Ischemia Driven)

CLOPIDOGREL

TICAGRELOR
need to limit aspirin < 100 mg daily
doses > 300 = ↑mortality risk

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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

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ACS Secondary Prevention Therapy

PRIOR TO DISCHARGE

*DAPT**
*Aspirin + P2Y₁₂ Inhibitor**

STATIN** + **BETA BLOCKER

SL NTG
PRN

ACE / ARB / EPLERENONE

discontinue NSAIDS

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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

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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

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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

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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

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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

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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**

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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**

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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

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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%

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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

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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

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STEMI

Reperfusion Therapy

Goal for reperfusion (STEMI):

30 minutes door to drug (thrombolytics)

90 minutes door-to-balloon (primary PCI)

Preferred = INVASIVE Therapy:

*PRIMARY PCI**
lower mortality vs fibronolysis*
*Angiogram first** = gold standard to diagnose CAD

If PCI can NOT be performed <120 minutes:
FIBRONOLYTICS
TPA / RPA / TNK (-eplase)

Acute Supportive Care for ACS

Calcium Channel Blockers

Indication / Cautions

*Diltiazem_ / _Verapamil**
Vasodilate / ↓*HR/↓ Contractility

RARELY USED BUT MAINLY FOR:
Refractory / Contraindicated to B-Blockers

ASTHMA** / **COPD

Tachycardia** due to **AFIB/Flutter

Cocaine-induced

Acute Supportive Care for ACS

NITROGLYCERIN

Indication / Cautions

SL Initial –> IV or Topical if Symptoms persist

*Titrate to Pain Relief & BP**
*SBP > 90-100**mmHg

Adr:
HypoTension / Tachycardia / Headache

AVOID:

*RIGHT VENTRICULAR INFARCT**
*PDE Inhibitors**:
*Viagra/Levitra - 24 hrs** // Tadalafil - 48 hours

STEMI** + **PCI = Any of the 3

<60 kg or >75yo or Hx TIA or STROKE

What P2Y₁₂ Inhibitor do we use?

“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y₁₂ Antagonist

AVOID PRASUGREL*
<60 kg or >75yo or Hx TIA or STROKE*

TICAGRELOR** or **CLOPIDOGREL

STEMI** + **PCI = Any of the 3

+ High Bleeding Risk

What P2Y₁₂ Inhibitor do we use?

“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y₁₂ Antagonist

CLOPIDOGREL
preferred if higher bleeding risk

ACS

What LABS must be gathered?

PTT + CBC + BUN + CR

Lipid profile

*Coagulation** profile:
*PTT** + INR

CBC
Hgb / Hct / Platelets

Chem 7:
electrolytes + BUN** + **Cr

AntiCoagulant Therapy

When would we use LMWH?
Enoxaparin 1mg/kg SC q12 // dalteparin 120 iu/kg q12 SC

When to AVOID?

*STEMI_ + _FIBRINOLYTIC**
non invasive treatment strategy*
N-STEMI** + *noPCI

Consider ALTERNATIVE if:
↑Bleeding risk –> Fonda
Renal Insufficiency –> UFH(heparin)
Obesity –> Fonda/heparin

Symptoms of ACS

Hx of + risk factors for CAD

Symptoms:
Classical CAD symptoms
may occur @rest or with exercise
LITTLE or NO relief with
REST +/- NTG

LAST > 20 MINUTES
regular angina = 3-5 min

_Acute Supportive Care for ACS_ ## Footnote **_BETA BLOCKERS_** **Indication / Cautions**

**_PO within 24 hours_** **_Consider IV if_**: ↑**BP** or ↑**HR** Avoid if: **_CHF**_ / _**Heart Block**_ / _**ASTHMA_** / **COPD-WHEEZING** & **_RISK OF CARDIOGENIC SHOCK_** **\> 70** / **BP \<120mmHg** / **HR \>110** or **\<60** long time since Sx onset

_Acute Supportive Care for ACS_ ## Footnote **_NITROGLYCERIN_** **WHEN TO AVOID?**

AVOID: * *_RIGHT VENTRICULAR INFARCT_** * *PDE Inhibitors**: * *Viagra/Levitra - 24 hrs** // **Tadalafil - 48 hours** **_SBP \<90**_ or _**HR \< 50_**

**ACS** **Diagnostic & Baseline Workup**

**_PHYSICAL EXAM_** Need to see evidence of **_HEART FAILURE_** / **Pulmonary Edema** **_Cardiac Monitor_** Vitals / Arrythmia monitoring **_Serial 12 Lead ECGs_**

ACS Antiplatelet Therapy **_Glycoprotein IIb/IIa Inhibitors_** Eptifibatide / Tirofiban = Renal Abciximab **WHEN WOULD WE AVOID / CONTRAINDICATIONS**

* _NOT RECOMMENDED WHEN:_* * *Bivalirudin** used * *Fibronolytic (-plase's)** _PRECAUTIONS:_ **CrCl \< 30mL/min** or **Hemodialysis**

**Which Drug do we have to AVOID if** **_CARDIOGENIC SHOCK_** risk or Presence **& What are those risks?**

**_BETA BOCKERS -olols_** **Age \> 70** **Systolic BP \< 120**mmhg **60\< HR \>110** Also: **Asthma / COPD / Wheezing _HEAR FAILURE**_or_**HEART BLOCK_**

ACS Antiplatelet Therapy **_Glycoprotein IIb/IIa Inhibitors_** Eptifibatide / Tirofiban = Renal Abciximab **WHEN WOULD WE USE?**

*NOT commonly used* * *_ACS undergoing PCI_** * not used w/o PCI* Also: GP IIB/IIa Inhibitor OR Cangrelor if.. **_If NO P2Y12 used prior to PCI_** * _DO NOT USE IF:_* * *Bivalirudin** used / **Fibronolytic Therapy** * *CrCl \< 30mL** or **Hemodialysis**

_ACS Secondary Prevention Therapies_ **When would we use a ACE/ARB?**

_**ALL PATIENTS** - **POST MI**_ Strongest evidence if: * *_LVEF**_ _**\<**_ _**40%_** * indefinitely* ***3mo if Anterior MI*** ADR: **HyperKalemia + Renal Dysfunction**

**_N-STEMI**_ + _**INVASIVE PCI_** + _**↑****cTn Levels**or**Ischemic ECG changes**_ **What P2Y₁₂ Inhibitor do we use?** "DAPT - Dual Antiplatelet Therapy" Aspirin + P2Y₁₂ Antagonist

**_PRASUGREL_** Avoid if: **\<60kg** / **\>75yo** / **hx Stroke-TIA** or **_TICAGRELOR_** need to limit **aspirin \< 100 mg daily** doses \> 300 = ↑mortality risk

_ACS Secondary Prevention Therapies_ **When would we consider** **EPLERENONE \> Ace/Arb** (Anti Aldosterone)

**_SYMPTOMATIC HF_** or **Post MI + low LVEF** & **_DIABETES_** ADR: **HYPERKalemia** \> 10% incidence over ACE/Arm **CONTRAINDICATED if CrCl \<30mL/min**

_Acute Supportive Care for ACS_ ## Footnote **_Morphine Sulfate_** **Indication / Cautions**

**1-8 mg** **IVP q5-15min** * *_Symptoms REFRACTORY to NTG_** * *Anxiolytic** / **Analgesic** / IV --\> Vasodilator Cautions: **Respiratory Depression** & **HypoTension**

**How LONG do we use DAPT (Dual Antiplatelet Therapy)** **_P2Y₁₂ Antagonist Therapy?_** + **Special Considerations**

**_\> 12 MONTHS_** **_STOP DRUG 5-7 DAYS B4 CABG_** Clopidogrel / Prasugrel = IRREVERSIBLE inhibitors **_14 days for STEMI + FIBRONOLYTIC_**

**Which drug can we NOT use if the patient had a:** **_PREVIOUS STROKE?_**

**_FIBRONOLYTICS_** **Alte**plase / **Rete**plase / **Tenect****e**plase Contraindicadted for recent STROKE \< 3 months * *_PRASUGREL_** * *\<60kg** // **\>75years** * *Hx TIA** or **STROKE**

**Reperfusion Strategy: _FIBRINOLYTICS_** TPA = Alteplase / RPA = Reteplase / TNK = Tenecteplase ## Footnote **INDICATIONS**

**_STEMI**_ + _**PCI can NOT be performed \< 120 minutes_** Indications: **_Hx consistant with AMI/Angina**_ within _**\<12 hours of Sx onset_** *no mortality benefit if start \> 12 hours after Symptoms* + **_EKG_** shows **_ST ELEVATION_** \>1mV / **new onset LBBB** left bundle branch block + **_Elevated Enzymes_** --\> to confirm (CK-MB +/- Troponin)

_Risk Calculator in ACS Patients_ * *_TIMI SCORE_** * there is also = GRACE & HEART* scores * *_TIMI Risk level: score (MACE %)_** * *Low: 0–2** (4.7–8.3%) * *Intermediate: 3–4** (13.2–18.9%) * *High: 5–7** (26.2–40.9%)

**HEAT-R** * *_History_** * *_\>_** **2 events/24hrs** or **known CAD** (**\>50% block)** or **Aspirin use \<7d** * *_ECG_** * *ST Changes** **_Age**_ _**\>_** **65y/o** **_↑Troponin_** **_Risk Factors**_ _**\>_** **3RFs**

Reperfusion Strategy: **_FIBRINOLYTICS_** TPA = Alteplase / RPA = Reteplase / TNK = Tenecteplase ## Footnote **Relative Contraindications**

**_BP \> 180/100_** Taking **_Oral Anticoagulants_** Recent **Trauma / Surgery \< 2 weeks** Hx of **GI/GU Surgery** **\<6 months** **Active PUD**

**What drug must we: LIMIT Aspirin Dose \< 100mg?**

**_TICAGRELOR_** P2Y12 Antagonist Doses **\>300 = ↑Mortality Risk**