6. Adane - Acute Coronary Syndromes Flashcards
What are some clinical presentations of STEMI?
Vigorous physical exercise, emotional stress, medical illness/surgery, can occur at rest
- Pain is deep and visceral (does not have to be chest pain)
What are the two types of Troponin biomarkers for MI?
Troponin T and Troponin I
What are the most common biomarkers for MI?
Troponin T and I, they rise quickly and remain elevated
In the TIMI risk score for STEMI, what does a high risk score mean?
A higher risk score means a higher risk of death from a MI
What are the short term treatment goals of ACS?
Hint, there’s 5
- Restore blood flow ASAP
- Prevent death/MI complications
- Relieve chest discomfort
- Prevent coronary artery reocclusion
- Restore ST segment and T-wave changes on ECG
What are the long term goals for ACS?
Hint, there’s 3
- Control CV risk factors (non-pharm and modifiable risk factors)
- Prevent CV events: re-infarction, stroke, HF
- Improve quality of life
What does MONA stand for?
M: morphine
O: oxygen, when below 9
N: nitrates, to relieve chest pain
A: Aspirin (thromboxane inhibitor)
What are the two strategies for reperfusion?
- Primary Percutaneous Coronary Intervention (PCI)
2. Fibrinolytic drugs (clot busters)
How quickly should a PCI be performed?
90 minutes if at the same institution, 120 minutes if done at another institution
What is the benefit of a PCI?
Safer, with lower mortality and lower risk of intracranial hemorrhaging and other major bleeding
When should fibrinolytic drugs be used over PCI?
- Chest discomfort has lasted longer than 12 hours
2. No catheterization lab on site and cannot get to one in 120 minutes
What are the 3 fibrin specific fibrinolytics and the non-fibrin specific drugs?
Specific: Alteplase, Reteplase, Tenecteplase
Non-fibrin: streptokinase
What are the 7 contraindications of fibrinolytics in STEMI?
- Active internal bleeding
- Previous inter cranial hemorrhage
- Ischemic stroke w/in 3 months
- Know intracranial neoplasm
- Known structural vascular lesion
- Suspected aortic dissection
- Significant closed head or facial trauma w/in 3 months
Along w/ MONA, what other drugs are used to treat STEMI?
Hint, there’s 4 more
- Morphine
- Oxygen
- Nitrates
- Aspirin
- P2Y12 inhibitors
- Anticoagulants
- Stool softeners
- Statins, B-blockers, ACEI/ARBS
Nitrates: which nitrate, how long, and what is its job?
Sublingual nitroglycerin 400 mcg Q5 min, up to 3 doses.
Decreases LV preload and O2 demand, decreases BP, O2 demand and vasospasms
When should IV nitroglycerin be used? And when should it be avoided?
Used: if persistent ischemia
Avoided: after 24 hours of ischemic relief, PDE5 inhibitors used w/in 24-48 hours
Aspirin and ACS: MOA, dose, usage, interactions
MOA: inhibits synthesis of TXA2 (by inhibiting COX-1)
Dose: LD, 162-325mg PO before PCI, then maintenance dose of 81-325mg QD
Usage: prevent thrombotic occlusion, decreased risk of stent thrombosis and decrease mortality w/ fibrinolytics
Interactions: stop NSAIDS and COX-2 inhibits at time of STEMI
Examples of P2Y12 inhibitors, their usage and MOA
Clopidogrel, prasugrel, Tricagrelor
Use: in combination w/ aspirin
MOA: blocks receptor for ADP on platelets, reduced platelet aggregation and activation
Clopidogrel is converted by what and how does it bind?
Clopidogrel is a prodrug converted by CYP 450 and binds irreversibly to P2Y12 receptor
How should clopidogrel be administered if PCI w/ stent?
Use ASA 325mg + loading dose of 600mg clopidogrel
Give maintenance dose of 75mg QD for one year
Clopidogrel and its use w/ fibrinolytics
Use w/ ASA
- if 75, 75mg loading dose
Maintenance dose: 75mg QD for at least 14 days and up to 1 year
Prasugrel and its use if PCI w/ stent
Prasugrel is a prodrug, that irreversibly binds to P2Y12 receptor
Use w/ ASA + 60mg prasugrel loading dose on day 1
On day 2, maintenance dose of 10 mg for 1 year
What are the contraindications of Prasugrel?
- Patients w/ prior history of stroke or TIA
- Increased risk of bleeding in pts >75 yrs and weight
Benefits of Prasugrel
- Least number of drug interactions
2. Pts w/ diabetes and STEMI + PCI
What is the TRITON-TIMI 38 trial?
Compared Clopidogrel vs. Prasugrel in pts w/ ACS scheduled to receive PCI
- Prasugrel has an increased chance of bleeding, but has advantages over Clopidogrel (i.e. Drug interactions)
What is Ticagrelor and why is it different from Clopidogrel and Prasugrel? What CYPs metabolize it?
P2Y12 inhibitors and is not a prodrug and is a reversible inhibitor of P2Y12.
Metabolized by CYP3A4 and 3A5 - potential for drug interactions
Ticagrelor and its use if PCI w/ stent
Use ASA + 180mg Ticagrelor (loading dose) followed by 90mg BID for 1 year
- Recommended maintenance dose of 80mg ASA
- therapy should be discontinued 5 days before surgery
What is the PLATO trial?
Compares Clopidogrel to Ticagrelor
Clopidogrel PO: 300-600mg x1 + 75mg QD
Ticagrelor PO: 180mg x1 + 90 mg BID
Clopidogrel has an increased risk of primary endpoint than Ticagrelor
What is the use of unfractionated hepatic (UFH) w/ or w/o GPIIb/IIIa inhibitor?
Anticoagulant in STEMI managed w/ PCI
- UFH bolus w/ GIIb/IIIa: 50-70 units/kg + UFH infusion
- UFH alone: 70-100 units/kg + UFH infusion
What are some examples of GPIIb/IIIa receptor antagonists, and what is their MOA?
Abciximab, Eptifibatide, Tirofiban
MOA: block GPIIb/IIIa receptors on platelets and inhibit platelet aggregation
What is Bivalirudin?
A specific and reversible direct thrombin inhibitor
4 examples of Anticoagulants
- Bolus and infusion UFH
- Exoxaparin - not for pts w/ end stage renal disease
- Fondaparinux
- Bolus and infusion Bivalirudin
What are some side effects of anticoagulants, heparin/enoxaparin and GPIIb/IIIa?
H/E: bleeding, heparin induced thrombocytopenia
GPIIb/IIIa: bleeding, immune-related thrombocytopenia
- contraindicated if history of hemorrhagic stroke/recent ischemic stroke
What is the use of b-blocks w/ PCI?
Decrease myocardial workload/O2 demand, decrease risk of ischemia, infractions and ventricular arrhythmias
- For use in pts w/o a cardiac or respiratory contraindications
How early should a b-blocker be administered in pts w/ STEMI and for how long?
Started w/in 24 hours if pt has no contraindications and continues for 3 years (or indefinitely)
When is IV b-blocker indicated?
Oral b-blockers are recommended
- IV w/ HTN or signs of ischemia, don’t use w/ pts w/ acute heart failure
When should statins be used in pts w/ STEMI and PCI?
High dose atorvastatin (80mg/day) in all pts w/o contraindications
When should ACEI/ARBs be used in STEMI and PCI?
ACEI: lisinopirl, captopril, ramipril, trandolapril
ARBs: valsartan
For use in pts w/ anterior infarction, post-MI or HF
Don’t use w/ acute kidney injury, but ok w/ chronic injury
When should an aldosterone antagonist be used in pts w/ STEMI and PCI?
- Pts w/ ACE inhibitor and b-blocker
- Have EF
What is a CABG?
CABG stands for coronary artery bypass graft surgery
- indicated for STEMI + cardiogenic shock, failed PCI and coronary anatomy not amenable to PCI
What should and shouldn’t be w/held before a CABG
- ASA should not be w/held before urgent CABG
- Clopidogrel and Ticagrelor should be discontinued 24 hrs before urgent CABG
- Discontinue Eptifibatide, Tirofiban at least 2-4 hrs before urgent CABG
- Discontinue abciximab at least 12 hrs before CABG
Should fibrinolytics be used when pt has NSTE-ACS (Non-ST elevated Acute Coronary Syndrome)?
NEVER!
What is NSTE-ACS?
Non-ST elevated acute cardiac syndrome
- divided on basis of cardiac biomarkers of necrosis
- clinical sign is chest pain
NSTE ACE management
- ECG w/in 10 minutes of arrival
- Measure cardiac Troponin
- Stratify risk to assess prognosis
TIMI risk score for NSTE ACS
Age, >3 risks for CAD, known CAD, aspirin w/in 7 days, >2 episodes of chest discomfort w/in 24 hrs, ST changes, positive markers
NSTEMI management
- Early invasive strategy - assessing. Coronary anatomy w/in 24 hrs
- Ischemia-guided - invasive diagnostic evaluation if pts have refractory/recurrent ischemic symptoms
- PCI or CABG if: risk of death or MI, acute HF, angina, cardiogenic shock
- Fibrinolytic therapy is not indicated in NSTE-ACS
Pharmacotherapy for NSTE-ACS
Hint, there’s 8 (same as STEMI treatment)
- Morphine
- Oxygen
- Nitroglycerin
- Aspirin
- P2Y12 inhibitors
- Anticoagulants
- Stool softeners
- Statins, b-blockers, ACEI/ARBs
NonSTEMI managed w/ PCI
Dual antiplatelet therapy
On ASA already: 81mg - 325 mg ASA before PCI
Not on ASA: 325mg ASA before PCI
Continue ASA 81-325mg QD and add P2Y12 inhibitor
*ASA dose,
NonSTEMI w/ PCI and P2Y12 inhibitors
Clopidogrel: 300-600 mg x1 followed by 75mg QD
Prasugrel: 60mg x1 followed by 10mg QD
Ticagrelor: 180mg x1 followed by 90mg BID
Maintence dose for 1 year
NonSTEMI w/ PCI and anticoagulants
Use to reduce the risk of intracoronary and catheter thrombus formation, discontinue after procedure
UFH w/ or w/o GPIIb/IIIa, Bivalirudin, enoxaparin
Oral b-blockers w/ NonSTEMI
Metoprolol, carvedilol, bisoprolol
W/ in the first 24hrs in the absence of HF, low out-put, cardiogenic shock, other b-blocker contraindications
- IV b-blockers are harmful when risk for shock is present
CCB w/ NonSTEMI
Recommended for ischemic symptoms when b-blockers are not successful/are contraindicated/cause unacceptable side effects
ACEI/ARBs w/ NonSTEMI
Use w/in 24hrs in pts w/ HTN, DM and stable CKD
How many deaths in the US are contributed to CVD?
About 1/3 of all deaths in the US
