5 - ACS Part 2 Flashcards
What is DAPT?
dual anti platelet therapy
2 options for treating a STEMI?
1) fibrinolytics
2) primary PCI
2 options for treating a UA/NSTEMI?
**assess risks
THEN either:
1) early invasive strategy (surgery)
2) ischemia guided strategy (medicine)
What is the initial treatment once ACS is suspected but we don’t know which type (UA, STEMI or NSTEMI)?
MONA
- morphine
- oxygen
- nitrates
- ASA 325 mg
Describe what points are given for to determine a patient’s TIMI Risk Score
1 point is given for each of the following:
- > 65 yo
- > 3 risk factors for CAD
- prior coronary stenosis > 50%
- ST deviation on ECG
- > 2 anginal events in prior 24 hours
- use of aspirin in prior 7 days
- elevated cardiac biomarkers
**see slide 10
If they have a TIMI score >2, what should happen?
they should be considered for early invasive strategy (surgery)
If they have a TIMI score of 0 or 1, what should happen?
they would be considered for ischemia guided strategy (medicine)
What is entailed in early invasive strategy?
- Angiography +/- revascularization (PCI) within 24 hours
- Indicated for high risk patients (TIMI risk score > 2, or presence or other high risk characteristics)
What is entailed in ischemia-guided strategy?
- medical management
- patients with low risk features
- may be referred for revascularization if schema worsens or if new high risk features occur
Who is a CABG indicated for?
-high risk patients with multi vessel disease may be referred for CABG (hold DAPT 5-7 days prior to surgery if possible)
Antiplatelets:
Options?
ASA
Ticagrelor
Clopidogrel
Prasugrel
ASA:
Initial dose
160-325 mg STAT (chewed)
ASA:
Maintenance dose
80-325 mg daily
Ticagrelor:
Initial dose
180 mg LD
Ticagrelor:
Maintenance dose
90 mg BID
Clopidogrel:
Initial dose
150-300 mg LD
Clopidogrel:
Maintenance dose
75 mg daily
Prasugrel:
Initial dose
60 mg LD
Prasugrel:
Maintenance dose
10 mg daily
Who is DAPT indicated for?
- UA/NSTEMI patients who underwent early invasive strategy with PCI should receive DAPT as outlined for STEMI patients
- For patients with ischemia-guided strategy (medical management), current guidelines recommend DAPT with ASA plus ticagrelor or clopidogrel
How long is DAPT indicated for?
for 1 year in all ACS patients whether they are treated medically, with PCI or CABG
MOA of GP 2b/3a inhibitors
block binding of fibrinogen to GP 2b/3a receptor on platelet surface, therefore inhibit platelet aggregation
What are examples of GP 2b/3a inhibitors
- abciximab
- eptifibatide
- tirofiban
What is the dose of enoxaparin?
1mg/kg SC Q12H (max 100 mg) until PCI or hospital discharge shown to decrease risk of death, MI and stroke
Advantage of enoxaparin?
easier to give, no monitoring, lower incidence of HIT ?, similar cost to UFH
Dose of UFH?
60 units/kg LD then 12 units/kg/hr infusion
- titrate to APTT 1.2-2x control
- until PCI or 48 hrs
What is the standard heparin?
LMWH = standard
*if it’s someone who is morbidly obese and we can’t dose properly or they are known to have chronic failure - switch to UFH
Describe fondaparinux
indirect-acting factor Xa inhibitor
Dose of Fondaparinux?
2.5mg SC once daily (until PCI or hospital discharge)
What advantage does fondaparinux have over enoxparin?
lower rate of major bleeding
Goals of adjunct therapy
- reduce the risk of short term and long term complications associated with ACS
- slow progression of coronary heart disease and minimize the risk of future cardiovascular events and other morbidities
- improve mortality and restore QOL
List 4 ACS complications
- heart failure
- cardiogenic shock
- arrhythmias
- pericarditis
Describe how heart failure could occur after an ACS
LV myocardium may be ischemic, stunned, hibernating or irrevocably injured after MI
Describe how cardiogenic shock could occur after an ACS
- Decreased cardiac output & evidence of tissue hypoxia in presence of adequate intravascular volume
- Often due to extensive LV infarction
Describe how arrhythmias could occur after an ACS
-arrhythmias may occur post MI due to ischemia and severe HF
Describe pericarditis after an ACS
- uncommon and usually presents within 72 hour post MI
- symptoms usually resolve within 3-4 days
What is the treatment for pericarditis?
ASA 650 mg po QID or NSAIDs
Why are BB used in ACS?
- prevent extension of infarction by reducing oxygen demand
- decrease cardiovascular mortality, recurrent nonfatal MI and all-cause mortality
When should BB be initiated after an MI?
within 24 hours after onset of MI unless contraindicated
BB:
Start at low dose and titrate to maintain resting HR of ____ bpm
55-60
What conditions would make someone contraindicated to get a BB?
- hypotension
- bradycardia
- acute heart failure
- cardiogenic shock
- asthma
- 2nd or 3rd degree AV block
Metoprolol:
Initial dose
25mg BID
Metoprolol:
Max dose
100mg BID
Atenolol:
Initial dose
12.5-25 mg daily
Atenolol:
Max dose
100 mg daily
Carvedilol:
Initial dose
3.125 mg BID
Carvedilol:
Max dose
25 mg BID
Why are ACEi used in ACS?
-minimize ventricular remodelling, reduce oxygen demand and myocardial wall stress by reducing after load or preload
When should someone start an ACEi after MI?
within 24 hour of MI once BP has been stabilized unless CI
What types of patients should we use ACEi with caution?
those with renal impairment and hyperkalemia
What do we monitor for BB?
- BP
- HR
- signs/symptoms of HF
What do we monitor for ACEi?
- SCr
- electrolytes
- watch for hyperkalemia (K > 5.5)
Ramipril:
Initial dose
1.25 - 2.5 mg daily
Ramipril:
Target dose
10mg/day
Enalapril:
Initial dose
2.5mg BID
Enalapril:
Target dose
10-20 mg BID
Lisinopril:
Initial dose
2.5-5 mg daily
Lisinopril:
Target dose
40 mg daily
Captopril:
Initial dose
6.25 TID
Captopril:
Target dose
25-50 mg TID
Who are ARBs indicated for?
People who cannot tolerate ACEi
Monitoring of an ARB is the same as an ____
ACEi
Candesartan:
Initial dose
4 mg daily
Candesartan:
Target dose
32 mg daily
Telmisartan:
Initial dose
40 mg daily
Telmisartan:
Target dose
80 mg daily
Valsartan:
Initial dose
20 mg BID
Valsartan:
Target dose
160 mg BID
Statins: If not at max dose already, titrate to achieve _____% reduction in LDL
50-60
Monitoring for statins?
- Lipid panel (LDL-C, chol, HDL-C)
- LFTs
- CK
- signs and symptoms of myopathy and rhabdomyolysis
Atorvastatin doses
20-80 mg daily
Fluvastatin doses
20-80 mg daily
Pravastatin doses
20-40 mg daily
Lovastatin doses
20-80 mg daily
Simvastatin doses
20-80 mg daily
Rosuvastatin doses
5-40 mg daily
What types of patients should get an MRA (mineralocorticoid receptor antagonist)?
for consideration in patients with significant LV dysfunction (EF < 40%)
Should caution MRAs in what types of patients?
CrCl < 30
K > 5
When should K+ be monitored when on an MRA
at baseline and then within 1 week of initiation
Spironolactone:
Initial dose
12.5 mg daily
Spironolactone:
Target dose
25 mg daily
Eplerenone:
Initial dose
25 mg daily
Eplerenone:
Target dose
50 mg daily
What are some modifiable CHD risk factors?
- smoking cessation
- hypertension
- dyslipidemia
- obesity
- sedentary lifestyle
- stress
List some non-pharm therapies
- weight management
- physical exercise
- smoking cessation
- ICD (implantable cardioverter defibrillator)
- stress management/depression screening
Goals for weight management?
- BMI 18.5 - 25
- Waist circumference (<100 cm males & < 90 cm in females)
- Goal of 5-10% weight reduction
Goals for exercise?
30-60 mins of moderate-vigorous physical exercise 3-5x per week
*This may change based on each individual’s starting exercise habits
How much does smoking cessation lower risk of recurrent MI after 2 years?
by half !!!!
Are omega 3 fatty acids beneficial for preventing cardiovascular disease?
No evidence, but don’t tell patients to stop taking them
Are antioxidants such as vitamins A, C, E and beta carotene beneficial for preventing cardiovascular disease?
No
How about folic acid with/without vitamin B6 of B12? Is it good for preventing cardiovascular disease?
NOPE
Why is hormonal therapy not indicated in post menopausal women post MI?
may increase CV risk
Post MI patients need to avoid _____
NSAIDs, including selective COX2 inhibitors
Post MI:
For active, ongoing users of cocaine and meth, ____ ________ should be avoided due to risk of potentiating coronary spasm
beta blockers
