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PDAT5 CV > 21/22 - Pharmacotherapy ACS > Flashcards

21/22 - Pharmacotherapy ACS Flashcards

1
Q
  • *STEMI** + nonPCI
  • *Fibronolytic (>12 hours)_ or _nonprimary PCI**

What P2Y12 Inhibitor do we use?

“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y12 Antagonist

A

CLOPIDOGREL
preferred if higher bleeding risk

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2
Q

ACS Secondary Prevention Therapy

1st 24 Hours

A

ABS

Aspirin
indefinitely

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

STATIN
indefinitely

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3
Q

N-STEMI** + **Conservative

What P2Y12 Inhibitor do we use?

“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y12 Antagonist

(Ischemia Driven)

A

CLOPIDOGREL

or

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

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4
Q

ACS Secondary Prevention Therapies

STATINS

A

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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5
Q

ACS Secondary Prevention Therapy

PRIOR TO DISCHARGE

A
  • *DAPT**
  • *Aspirin + P2Y12 Inhibitor**

STATIN** + **BETA BLOCKER

SL NTG
PRN

ACE / ARB / EPLERENONE

discontinue NSAIDS

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6
Q

Clinical Suspicion of ACS + Ischemic Symptoms >10 min
VVV
ECG / Enzymes (CTN) / St-segment Monitoring
VVV
Initial Treatment
VVV
ACUTE SUPPORTIVE CARE

A

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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7
Q

Reperfusion Strategy:
FIBRINOLYTICS
TPA = Alteplase / RPA = Reteplase / TNK = Tenecteplase

ABSOLUTE CONTRAINDICATIONS

A

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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8
Q

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

+ High Risk Patient = Diabetes

What P2Y12 Inhibitor do we use?

“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y12 Antagonist

A

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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9
Q

Reperfusion Strategy:
FIBRINOLYTICS
TPA = Alteplase / RPA = Reteplase / TNK = Tenecteplase

ADR’s / Risk Factors

A

BLEEDING / STROKE
specifically INTRACRANIAL BLEEDING

Risk Factor:
Age > 65

Wt < 70kg

Uncontrolled HTN

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10
Q

Clinical Suspicion of ACS + Ischemic Symptoms >10 min
VVV
FIRST STEPS

A

12-Lead ECG
within 10 minutes

Serial cTn Levels
Cardiac Enzymes = Troponin & CK-MB

Continuous ST-segment MONITORING

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11
Q

AntiCoagulant Therapy

When would we use FONDAPARINUX?

&

When to AVOID?

A

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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12
Q

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

+Possible CABG in future

What P2Y12 Inhibitor do we use?

“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y12 Antagonist

A

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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13
Q

N-STEMI** + **INVASIVE PCI
+
Normal cTn & NO ischemic ECG changes

What P2Y12 Inhibitor do we use?

“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y12 Antagonist

A

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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14
Q

Clinical Suspicion of ACS + Ischemic Symptoms >10 min
VVV
ECG / Enzymes (CTN) / St-segment Monitoring
VVV
INITIAL TREATMENT

A

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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15
Q

AntiCoagulant Therapy

When would we use HEPARIN = UFH?

&

When to AVOID?

A

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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16
Q

AntiCoagulant Therapy

When would we use BIVALIRUDIN?

&

When to AVOID?

A

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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17
Q

STEMI

Reperfusion Therapy

Goal for reperfusion (STEMI):

30 minutes door to drug (thrombolytics)

90 minutes door-to-balloon (primary PCI)

A

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)

18
Q

Acute Supportive Care for ACS

Calcium Channel Blockers

Indication / Cautions

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

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

ASTHMA** / **COPD

Tachycardia** due to **AFIB/Flutter

Cocaine-induced

19
Q

Acute Supportive Care for ACS

NITROGLYCERIN

Indication / Cautions

A

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
20
Q

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

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

TICAGRELOR** or **CLOPIDOGREL

21
Q

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

+ High Bleeding Risk

What P2Y12 Inhibitor do we use?

“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y12 Antagonist

A

CLOPIDOGREL
preferred if higher bleeding risk

22
Q

ACS

What LABS must be gathered?

A

PTT + CBC + BUN + CR

Lipid profile

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

CBC
Hgb / Hct / Platelets

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

23
Q

AntiCoagulant Therapy

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

&

When to AVOID?

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

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

24
Q

Symptoms of ACS

A

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

25
Q

Acute Supportive Care for ACS

BETA BLOCKERS

Indication / Cautions

A

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

26
Q

Acute Supportive Care for ACS

NITROGLYCERIN

WHEN TO AVOID?

A

AVOID:

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

SBP <90** or **HR < 50

27
Q

ACS

Diagnostic & Baseline Workup

A

PHYSICAL EXAM
Need to see evidence of HEART FAILURE / Pulmonary Edema

Cardiac Monitor
Vitals / Arrythmia monitoring

Serial 12 Lead ECGs

28
Q

ACS Antiplatelet Therapy

Glycoprotein IIb/IIa Inhibitors
Eptifibatide / Tirofiban = Renal
Abciximab

WHEN WOULD WE AVOID / CONTRAINDICATIONS

A
  • NOT RECOMMENDED WHEN:*
  • *Bivalirudin** used
  • *Fibronolytic (-plase’s)**

PRECAUTIONS:
CrCl < 30mL/min or Hemodialysis

29
Q

Which Drug do we have to AVOID if

CARDIOGENIC SHOCK
risk or Presence

& What are those risks?

A

BETA BOCKERS -olols

Age > 70

Systolic BP < 120mmhg

60< HR >110

Also:
Asthma / COPD / Wheezing
HEAR FAILURE**or**HEART BLOCK

30
Q

ACS Antiplatelet Therapy

Glycoprotein IIb/IIa Inhibitors
Eptifibatide / Tirofiban = Renal
Abciximab

WHEN WOULD WE USE?

A

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
31
Q

ACS Secondary Prevention Therapies

When would we use a ACE/ARB?

A

ALL PATIENTS - POST MI

Strongest evidence if:

  • *LVEF_ _<_ _40%**
  • indefinitely*

3mo if Anterior MI

ADR:
HyperKalemia + Renal Dysfunction

32
Q

N-STEMI** + **INVASIVE PCI
+
↑cTn LevelsorIschemic ECG changes

What P2Y12 Inhibitor do we use?

“DAPT - Dual Antiplatelet Therapy”
Aspirin + P2Y12 Antagonist

A

PRASUGREL
Avoid if: <60kg / >75yo / hx Stroke-TIA

or

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

33
Q

ACS Secondary Prevention Therapies

When would we consider

EPLERENONE > Ace/Arb
(Anti Aldosterone)

A

SYMPTOMATIC HF

or

Post MI + low LVEF & DIABETES

ADR:
HYPERKalemia > 10% incidence over ACE/Arm

CONTRAINDICATED if CrCl <30mL/min

34
Q

Acute Supportive Care for ACS

Morphine Sulfate

Indication / Cautions

A

1-8 mg IVP q5-15min

  • *Symptoms REFRACTORY to NTG**
  • *Anxiolytic** / Analgesic / IV –> Vasodilator

Cautions:
Respiratory Depression & HypoTension

35
Q

How LONG do we use DAPT (Dual Antiplatelet Therapy)

P2Y12 Antagonist Therapy?

+ Special Considerations

A

> 12 MONTHS

STOP DRUG 5-7 DAYS B4 CABG
Clopidogrel / Prasugrel = IRREVERSIBLE inhibitors

14 days for STEMI + FIBRONOLYTIC

36
Q

Which drug can we NOT use if the patient had a:

PREVIOUS STROKE?

A

FIBRONOLYTICS
Alteplase / Reteplase / Tenecteplase
Contraindicadted for recent STROKE < 3 months

  • *PRASUGREL**
  • *<60kg** // >75years
  • *Hx TIA** or STROKE
37
Q

Reperfusion Strategy:
FIBRINOLYTICS
TPA = Alteplase / RPA = Reteplase / TNK = Tenecteplase

INDICATIONS

A

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)

38
Q

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%)
A

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

39
Q

Reperfusion Strategy:
FIBRINOLYTICS
TPA = Alteplase / RPA = Reteplase / TNK = Tenecteplase

Relative Contraindications

A

BP > 180/100

Taking Oral Anticoagulants

Recent Trauma / Surgery
< 2 weeks

Hx of GI/GU Surgery
<6 months

Active PUD

40
Q

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

A

TICAGRELOR
P2Y12 Antagonist

Doses >300 = ↑Mortality Risk

PDAT5 CV (30 decks)

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