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
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
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
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 < 120mmhg
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 LevelsorIschemic 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
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
Alteplase / Reteplase / Tenecteplase
Contraindicadted for recent STROKE < 3 months
- *PRASUGREL**
- *<60kg** // >75years
- *Hx TIA** or STROKE
Reperfusion Strategy:
FIBRINOLYTICS
TPA = Alteplase / RPA = Reteplase / TNK = Tenecteplase
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
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
