ACS Flashcards
Clopidogrel
Plavix®
Prasugrel
Effient®
Ticagrelor
Brilinta
Unfractionated Heparin
UFH
Fondaparinux
Arixtra®
Bivalirudin
Angiomax®
Tirofiban
Aggrastat®
Eptifibatide
Integrilin®
Abciximab
Reopro®
Ticlopidine
Ticlid®
Omeprazole
Prilosec®
Metoprolol tartrate
Lopressor®
Metoprolol succinate
Toprol XL®
Atenolol
Tenormin®
Carvedilol
Coreg®
Ischemia
Reduction of blood supply or increase in oxygen demand of myocardium
Infarction
Interruption of blood flow that leads to necrosis of myocardium
What is ACS?
Spectrum of conditions that result from myocardial ischemia and/or infarction
Atherothrombosis
- Disruption of an atherosclerotic plaque
- Results in thrombosis
- Reduced myocardial perfusion → infarction (death
STEMI
Complete artery occlusion by the thrombus
UA/NSTEMI
Incomplete artery occlusion by the thrombus
Risk factors of ACS: Modifiable
Physical Inactivity
Obesity - (especially abdominal)
Smoking- counsel
HTN
Hyperlipidemia
Risk Factors for ACS: Non-modifiable
Age
Male gender <55
Family history of premature CHD
History of CAD, including MI
DM
Clinical Presentation: Classic
- Chest discomfort, squeezing sensation
- Chest pressure can radiate to shoulder, left arm, back or jaw
Clinical Presentation: Rest
occurs at rest and lasts > 20 min
Clinical Presentation: New-onset
severe (marked limitation of physical activity)
Clinical Presentation: Increasing
more frequent, longer in duration or higher intensity
Clinical Presentation: Atypical
Epigastric pain Nausea and vomiting Diaphoresis Shortness of breath Light-headedness, syncope Weakness
Atypical sx more common in women, elderly (≥ 75 yo) & pts with DM, CKD, dementia
Diagnosis: ACS
Electrocardiogram changes (EKG, ECG)
Positive cardiac biomarkers (measured x 3)
- > Creatinine Kinase (CK)
- > Creatinine Kinase – MB isoenzyme (CK-MB)
- > Troponin I/T – Biomarker of CHOICE
Diagnosis: ACS : Gold standard
Cardiac Catheterization
–>Gold standard for diagnosis
Diagnosis: ACS: Biomarker of choice
Troponin I/T
measured x 3
Classification of ACS: STEMI
No different in the extent of symptoms- Chest Pain or Severe Chest Paint.
Symptoms: Present
EKG Change: ST Elevation
Biomarkers: High
Classification of ACS: NSTEMI
No different in the extent of symptoms- Chest Pain or Severe Chest Paint.
Symptoms: Present
EKG Changes:
ST segment depression or T wave inversion
Biomarkers Medium
Classification of ACS: UA
No different in the extent of symptoms- Chest Pain or Severe Chest Paint.
Symptoms: Present
EKG Changes: ST segment depression or T wave inversion
Biomarkers: No Elevation
Initial Therapy: STEMI
Aspirin Nitroglycerin UFH/LMWH \+/-Beta-blocker (IV) \+/-Morphine
Initial Therapy: STEMI
acronym
M – Morphine (+/-) O – Oxygen (+/-) N – Nitroglycerin A – Aspirin A - Anticoagulant
Initial Therapy: Asprin
First dose 162-325 mg chewed
Not EC
Initial Therapy: Nitroglycerin (NTG)
Outside Hospital
Call EMS if angina not relieved 5 min after 1 dose (0.4 mg sublingual)
Initial Therapy: Nitroglycerin (NTG)
In Hoptial
EVERYONE GETS AN ORDER FOR NTG AND RX
Sublingual NTG can be repeated q 5 min x 3 doses
Consider IV NTG if angina not relieved
Initial Therapy: Anticoagulation
Unfractionated heparin (UFH) – preferred
Enoxaparin as alternative to UFH
Reperfusion Therapy
Goal: re-open partially or completely occluded coronary artery
Re-establish blood flow
Improve perfusion to the affected myocardial tissue
Initial Therapy: Beta-blocker (+/-)
IV beta-blockers upon presentation in pts who are hypertensive or ongoing ischemia and do NOT have:
- Signs of HF
- PR interval > 0.24 seconds
- Heart block
- Active asthma/COPD
Initial Therapy: Morphine (+/-)
Dosing and indication
For continued chest pain***
Dose: 2-4 mg IV repeated q 5-15 min prn
Reperfusion Therapy: Non-Pharmacologic
Percutaneous Coronary Intervention (PCI)
- -Invasive procedure – NOT surgery
- -Mechanical revascularization - dilation of the coronary artery – “stenting”
Reperfusion Therapy: Pharmacologic
Fibrinolytic Therapy—NON PREFERRED - BREAK CLOT
Timing of Reperfusion Therapy: Door to Balloon Time
Door to Balloon Time”: < 90 min
Target time from hospital presentation to PCI
HAVE 90MIN TO GET THEM TO CATH LAB
Timing of Reperfusion Therapy: Door to Needle Time
Door to Needle Time”: < 30 min
Target time from hospital presentation to fibrinolytic
WHY PCI preferred over fibrinolytics?
↓ Mortality rate
↓ Risk of stroke (ICH) & major bleeding
Fibrinolytic Therapy
STEPTOKINANCE IS NOT FIBRIN SPECIFIT—INCREASES SYSTEMIC BLEEDING
Fibrinolytic Therapy: Indications
STEMI patients with:
Symptom onset within 12 hrs AND
ST-elevation in at least 2 contiguous EKG leads
Indicated for STEMI patients at non-PCI hospitals
Age < 75 (controversial)
When shouldn’t Fibrinolytic therapy be used?
Fibrinolytic therapy NOT recommended in UA/NSTEMI patients!!
Absolute Contraindications – to Fibrinolytic therapy
Previous intracranial hemorrhage (at ANY time)***
Ischemic stroke within 3 months**
Relative Contraindications – more than one Relative ContraIND is Absolute—Risk for Intracranial Hemorrhage
Fibrinolytic therapy
Uncontrolled HTN (SBP > 180 or DBP >110 mmHg)
History of stroke > 3 months
Current use of anticoagulants
Age > 75
Fibrin-Specific Agents
Alteplase (tPA): Activase ®
Reteplase (rPA): Retavase ®
Tenecteplase (TNK-tPA):TNKase ®
Alteplase (tPA): Activase ®
Dosage*****
15 mg IV bolus followed by
0.75 mg/kg (max 50 mg) IV infusion over 30 min followed by 0.5 mg/kg (max 35 mg) IV over 1 hr (100 mg TOTAL)
Choice of Fibrinolytic Agent
Fibrin-specific agents more effective
Alteplase, reteplase, tenecteplase
—Preferred agents as per ACC/AHA guidelines
Fibrinolytic Agent: Risk of bleeding
ICH risk higher with fibrin-specific agents
Systemic bleeding higher with streptokinase
Fibrinolytic Agent : ADR or Side Effects
SE:
Bleeding: Intracranial hemorrhage (ICH): largest risk
Reperfusion arrhythmia: usually self limiting
Antiplatelet Therapy with Fibrinolytics:
Loading Dose
Aspirin 162-325 mg X 1 AND
Clopidogrel
Pts ≤ 75 yo: 300 mg x 1
Pts > 75 yo: no LD, give 75 mg
Antiplatelet Therapy with Fibrinolytics:
Maintenance Dose
Aspirin 81 to 325 mg po daily indefinitely
–>81 mg dose preferred ( hiegher doses are not more effective)
Clopidogrel 75 mg po daily for at least 14 days and up to 1 year
Anticoagulation with Fibrinolytics: Indications
Anticoagulant tx for a min of 48 hrs and preferably for the duration of hospitalization or up to 8 days
If anticoagulant tx continued > 48 hrs, therapies other than UFH recommended due to risk of HIT**
Enoxaparin is preferred anticoagulant in patients receiving fibrinolytic therapy**
Anticoagulation with Fibrinolytics
Enoxaparin (Lovenox®)
Unfractionated heparin
(UFH)
Fondaparinux (Arixtra®)
Enoxaparin (Lovenox®)- Preferred
Dosing for anticoagulation
30 mg IV bolus followed immediately by 1 mg/kg sub cut q12h***
Age ≥ 75 yo, no bolus, 0.75 mg/kg subcut q12h
CrCl < 30 ml/min: 1 mg/kg subcut q24h- when to RENAL DOSE
Unfractionated heparin
(UFH)
Dosing for anticoagulation
60 units/kg IV bolus (max 4000 Units) followed by 12 units/kg/hr (max 1000 Units/hr)
Adjusted to maintain aPTT 1.5 - 2 X control
Fondaparinux (Arixtra®)
2.5 mg IV, then 2.5 mg subcut daily in 24 hrs
Contraindicated if CrCl < 30 ml/min– Can give in HISTORY OF HIT
Stenting “PCI”
Bare metal stent (BMS)
Drug-eluting stents (DES)
- Paclitaxel
- Sirolimus
- Everolimus
- Zotarolimus
Restenosis
blood vessel grow over the stent and cause a blockage.
PCI indications
Don’t know
Primary PCI:
Decreases Chance of Intracranial hemorrhage.
PCI timing
should be performed if immediately available (within 90 min of hospital presentation)
Should be performed within 12 hrs of symptom onset
Complications of PCI:
Contrast - Induced nephropathy
PCI = IV dye administration
High risk patients:
- Advanced age >75 years!!!
- Chronic kidney disease (CKD)
- DM
- Heart failure
How to prevent In-stent restenosis & rethrombosis?
Prevent with dual antiplatelet therapy (DAPT)
Prevention of Contrast-induced Nephropathy
- Risk stratification & monitoring
BUN/SrCr daily after PCI - Hydration (NSS) pre- and post-procedure (#1 way to prevent contrast neuropathy)
+/- N-acetylcysteine (Mucomyst®)
+/- Sodium bicarbonate
- Concomitant medication assessment
- >Hold metformin at time of PCI, then x 48 hrs
- >Nephrotoxic drugs (ACE-I, ARBS, diuretics
Dual Antiplatelet Therapy with PCI
Clopidogrel (Plavix®)
600 mg-PCI LOADING DOSE!!!
Anticoagulants with PCI
Unfractionated Heparin (UFH)
Unfractionated Heparin (UFH) Inhibits factors Xa & IIa (thrombin
Anticoagulants with PCI
Fondaparinux (Arixtra®)
Fondaparinux (Arixtra®) –Hx of HIT ok**
Pentasaccharide that inhibits factor Xa only
Anticoagulants with PCI
Bivalirudin (Angiomax®)
Bivalirudin (Angiomax®) – Hx of HIT ok**
Direct thrombin inhibitor that inhibits factor IIa
Has anticoagulant & antiplatelet activity
“2 for 1” drug
Anticoagulants with PCI
Recommendations
Preferred agents: UFH (need GP too) or bivalirudin (decrease risk of bleeding-preferred) -CLASS I
Bivalirudin for pts at high risk of bleeding in PCI
D/c UFH & bivalirudin after successful PCI
Anticoagulants with PCI
Unfractionated heparin (UFH)
IV GPI planned: 50-70 U/kg IV bolus
No IV GPI planned: 70-100 U/kg IV bolus
Supplemental IV bolus to target ACT
Anticoagulants with PCI
Bivalirudin (Angiomax®)
0.75 mg/kg IV bolus
Infusion:
1.75 mg/kg/hr
RENALLY DOSE(need to reduce dose) CrCl < 30 ml/min: 1 mg/kg/hr
Anticoagulants with PCI
Fondaparinux (Arixtra®)
Not recommended as the sole anticoagulant for PCI due to risk of catheter thrombosis
Anticoagulants with PCI
Contraindications/Precautions
History of HIT (UFH/LMWH)
CrCl < 30 ml/min
- –↓ Bivalirudin infusion to 1 mg/kg/hr
- –Fondaparinux contraindicated
Glycoprotein IIb/IIIa Inhibitors
Glyo- sugar
Tirofiban (Aggrastat®)
Eptifibatide (Integrilin®)
Abciximab (Reopro)
TEA
Glycoprotein IIb/IIIa Inhibitors
Benefits
Clinical Benefits:
Maintain patency of coronary artery during PCI
↓ Thrombosis & mortality following PCI**
should Glycoprotein IIb/IIIa Inhibitors be recommended with fibrinolytic therapy?
NEVER recommended with fibrinolytic therapy
(↑ bleeding risk)
Whats the preferred Glycoprotein IIb/IIIa Inhibitors?
Abciximab (Reopro®)
PREFERRED
When are Glycoprotein IIb/IIIa recommended?
Recommended at the time of PCI (downstream)
In STEMI pts undergoing primary PCI, it is reasonable to administer a GP IIb/IIIa inhibitor
Glycoprotein IIb/IIIa dosing??
Don’t do that
What type of elimination is
Tirofiban and Eptifibatide?
What must you do to counter it?
Reduce dose.
Tirofiban (Aggrastat®)
Renal
CrCl < 30 ml/min:
↓ infusion by 50%
Eptifibatide (Integrilin®) Renal CrCl < 50 ml/min: ↓ infusion by 50% Avoid in HD pts
GP IIb/IIIa Inhibitors:
Contraindications?
Active bleeding
Thrombocytopenia
Prior stroke
Secondary prevention
Nice SAAB
N – NTG (SL) S – Statin A – Aspirin A – Antiplatelet B – Beta-blocker
Secondary prevention:
Who gets aspirin?
All STEMI patients: ASA should be administered ASAP and continued indefinitely
Secondary prevention:
Aspirin dosing?
Initial dose
162 – 325 mg (chewed ASAP) _HIGHDOSE!!!
Maintenance Dose
81 – 325 mg po daily indefinitely
Secondary prevention:
Thienopyridines
Ticlopidine (Ticlid®) – risk of neutrapenia—Inhbiti P2Y12
Clopidogrel (Plavix®)
Prasugrel (Effient®)
Secondary prevention:
Cyclopentyltriazolopyrimidine
Ticagrelor (Brilinta®)-Reversible inhibitor, shorter T1/2 too
Secondary prevention:
Benefits of Antiplatelet Therapy:P2Y12 Inhibitors
Clinical Benefit:
↓ Restenosis/rethrombosis s/p STEMI
Secondary prevention:
Prasugrel & ticagrelor warnings?
More potent anti-platelet effects
Higher bleeding risk (WHY PLAVIX is still around
Secondary prevention:
Who gets Clopidogrel (Plavix®)?
How long?
Alternative for patients with true ASA allergy
Continue indefinitely
Duration:
Continue for at least 12 months
Secondary prevention:
Clopidogrel (Plavix®) dosing?
Loading dose: 600 mg po x 1 (standard for PCI)
Maintenance dose: 75 mg po daily
Discontinue 5 days prior to surgery (ie, CABG)
is Clopidogrel (Plavix®) a produrg?
Yes,Metabolized by CYP2C19 to active metabolite
Clopidogrel (Plavix®) boxed warning?
Genetic polymorphisms and ↓ CYP2C19 activity
Clopidogrel may have ↓ antiplatelet effects
Clopidogrel and PPIs
PPIs inhibit CYP2C19; risk of stent thrombosis.
Omeprazole (Prilosec®): greatest risk
COGENT Trial
Pts on ASA + clopidogrel randomized to receive omeprazole vs. placebo
No difference in CV events, only ↓ GI bleeding
PPI+ clopidogrel mangagment?
History of GI bleed
Patients at high risk for GI bleed -Advanced age, concomitant warfarin, steroids, NSAIDS
Choose alternative PPI (ie, pantoprazole) or H2 blocker (ie, famotidine, ranitidine)
Prasugrel (Effient®)
Recommendations?
addition to ASA in STEMI patients undergoing PCI only***
Prasugrel (Effient®)
Duration
Continue for at least 12 months
Prasugrel (Effient®)
Dosing
Loading dose: 60 mg po x 1
Maintenance Dose: 10 mg po daily
D/C 7 days prior to surgery (ie, CABG
Prasugrel (Effient®)
Black box warning?
Black Box Warning: may cause significant or fatal bleeding
Prasugrel (Effient®)
contraindication?
History of TIA or stroke!
Prasugrel (Effient®)
precaution
Age > 75 years
Weight < 60 kg: (↓ MD to 5mg daily)
Ticagrelor (Brilinta®)
addition to aspirin in STEMI patients
* undergoing PCI or medical management*
Ticagrelor (Brilinta®)
Duration
Continue for at least 12 months
Ticagrelor (Brilinta®)
Dosing:
Loading dose: 180 mg
Maintenance dose: 90 mg po BID** (compliance)
D/C at least 5 days prior to surgery
Ticagrelor (Brilinta®)
Contraindication?
Severe hepatic impairment
Ticagrelor & Aspirin Dose
What’s the proper maintence aspirin dose?
Maintenance ASA dose should be 75-100 mg daily with ticagrelor
Ticagrelor: Drug Interactions?
Avoid strong CYP3A4 inducers
Rifampin, dexamethasone, phenytoin, carbamazepine, phenobarbital
Avoid strong CYP3A4 inhibitors
Ketoconazole, itraconazole, voriconazole, clarithromycin, ritonavir, indinavir, atazanavir
Limit simvastatin & lovastatin to 40 mg daily
Monitor digoxin levels closely
Monitoring: P2Y12 Inhibitors
All:
S/sx of ischemia
Bleeding, Hg/Hct
N/V/D
Ticagrelor
Dyspnea (usually transient)
Bradycardia
Ticagrelor & Adenosine
Looks the same: chemical structure.
Beta-Blockers:
indications
Initiate oral beta-blocker therapy in ALL PATIENTS in 1st 24 hours!
IV beta-blocker may be administered at presentation in pts who are hypertensive or have ongoing ischemia
Beta-Blockers:
Contraindications/Precautions
Bradycardia (HR < 60)
Hypotension (SBP < 90)
Signs of HF
Active asthma or COPD (wheezing)
Beta-Blockers
Dosing
Titrate beta-blockers by doubling the dose to goal HR
Titrate to goal resting HR 50 – 60!!
Avoid beta-blockers with intrinsic sympathomimetic activity (ISA) - ie, acebutolol
Choice of Beta-Blocker
EF ≥ 40%:
May use any b-blocker without ISA
EF < 40%: (stabilized HF)
Metoprolol succinate, carvedilol or bisoprolol
What beta blockers to use?
EF < 40%: (stabilized HF)
EF < 40%: (stabilized HF)
Metoprolol succinate, carvedilol or bisoprolol
What beta blockers to use?
EF ≥ 40%:
May use any b-blocker without ISA
Beta-Blockers
Metoprolol tartrate (Lopressor®)
Dosing
Acute: 5 mg slow IV push (over 1-2 min)
q 5 min x 3, then 25 – 50 mg po q6hrs
Maintenance: 25 – 100 mg po BID
Metoprolol succinate
(Toprol XL®)
Dosing
25 – 200 mg po daily
Nitrates:
Clinical Benefits
No effect on overall mortality – relief of CP only
Nitrates:
Indications
Take ONE dose of SL nitroglycerin.
If symptoms worsen or do not improve, call 9-1-1 immediately
Nitrates:
Contraindications
Do not administer within 24 hrs of phosphodiesterase inhibitors (sildenafil or vardenafil) or 48 hrs for tadalafil
Nitrates:
Sublingual
0.4 mg SL q 5 min x 3 doses
Nitrates:
IV infusion
5 - 10 mcg/min IV, titrated to 75 - 100 mcg/min IV
until relief of symptoms or limiting SE’s (HA)
Nitrates
Oral
Depends on formulation
Isosorbide mononitrate or Isosorbide dinitrate
Nitrates
Duration
Continue nitrates for (up to) 24 hrs after ischemia is relieved
Nitrates
Contraindications:
Hypotension (SBP < 90 or > 30% below baseline)
Bradycardia (HR < 50)
Tachycardia (HR > 100)
Right ventricular infarction
who gets Nitroglycerin?
doses?
NTG Rx for ALL patients with ACS!
NTG 0.4 (1/150 gr) mg SL prn CP
NTG spray, 1-2 sprays onto/under tongue prn CP
May repeat q 5min x 3 doses TOTAL
Counseling:
Nitroglycerin
Call 911 if no relief after 5 min
May cause HA, dizziness, tingling (sit down)
Store in a cool, dry place
Lipid-Lowering Agents:
Decrease morbidity & mortality s/p MI
High-intensity or moderate-intensity statin based on patient factors
High-intensity Statins?
Atorvastatin (40*)-80 mg Rosuvastatin 20 (40) mg
Consider a moderate-intensity statin
Serious comorbidities
Renal or hepatic dysfunction
History of statin intolerance/muscle disorders
Unexplained ALT elevations > 3X ULN
Drug interactions affecting statin metabolism
> 75 years of age
Moderate intensity Statins?
Atorvastatin 10 (20) mg
Rosuvastatin (5) 10 mg
Simvastatin 20-40 mg
Pravastatin 40 (80) mg
Statin follow up?
Lipid panel in 4-8 weeks
To assess adherence & patient’s response
ACEI and ARBs
Mortality?
Reduce overall mortality!
ACEI and ARBs
Indications
ARBs for pts who cannot tolerate ACEI (ie, cough)
ACEI within 24 hrs & continue indefinitely in pts with:
LVEF < 40%
HTN
DM
CKD
Class IIb
ACEI for ALL patients
Lisinopril (Zestril®)
Enalapril (Vasotec®)
Ramipril (Altace®)
Captopril (Capoten®)
Initial Dosing
Lisinopril (Zestril®)
Enalapril (Vasotec®)
Ramipril (Altace®)
Captopril (Capoten®)
5 mg po daily
- 5 mg po po BID
- 25 – 2.5 mg po daily
- 25 – 12.5 mg po TID
Lisinopril (Zestril®)
Enalapril (Vasotec®)
Ramipril (Altace®)
Captopril (Capoten®)
Target Dose
Lisinopril (Zestril®)
Enalapril (Vasotec®)
Ramipril (Altace®)
Captopril (Capoten®)
20-40 mg po daily
10 mg po BID
10 mg po daily
50 mg po TID
ARBs?
Valsartan (Diovan®)
Candesartan (Atacand®)
Losartan (Cozaar®)
Valsartan (Diovan®)
Candesartan (Atacand®)
Losartan (Cozaar®)
Initial Dose
20 mg po BID
4 mg po daily
12.5-25 mg po daily
Target Dose
160 mg po BID
32 mg po daily
150 mg po daily
ACEI and ARBs
contraindications?
Hypotension (SBP < 100 mmHg)
Renal dysfunction (SrCr > 2.5)
Hyperkalemia (K > 5.5 mEq/L)
Bilateral renal artery stenosis
Pregnancy (category D
Aldosterone Antagonists
mortality?
Decreases morbidity & mortality
Aldosterone Antagonists
Indication
Indications
For ACS pts on ACEI & B-blocker with:
-LVEF < 40%, DM or HF
Continue indefinitely
Aldosterone Antagonists
Spironolactone (Aldactone®)
Initial
12.5 mg po daily
Target
25 – 50 mg po daily
Aldosterone Antagonists
Eplerenone (Inspra®)
Initial
25 mg po daily
Target
50 mg po daily
Calcium Channel Blockers
Indications:
Verapamil or diltiazem when beta-blockers are ineffective or contraindicated for relief of ongoing ischemia
Calcium Channel Blockers
Drug of Choice
(avoid beta-blockers):
Cocaine-induced ACS
Variant (Prinzmetal angina)
–>Cause coronary vasodilation
Glycemic Control:
BG < 180 mg/dL s/p STEMI
insulin-based regimen to achieve BG < 180 mg/dL s/p STEMI
ACS Blood pressure guidelines?
Goal BP < 140/90
Recommendation to all with STEMI?
Smoking cessation
Goal BP < 140/90
Goal Resting HR 50-60
Exercise
Weight loss (diet control)
- ↓ Body weight by 10% from baseline
- BMI < 30 kg/m2
- Waist < 40 inches for men & < 35 inches for women
Influenza & pneumococcal vaccination
VTE prophylaxis
Initial therapy: NSTEMI
Aspirin Nitroglycerin UFH/LMWH \+/-Beta-blocker (IV) \+/-Morphine
MONAA”
Oxygen?? and no beta blocker??
TIMI or GRACE score
Risk assessment tools
- used to identify NSTEMI pts at high risk
- ->Thrombolic in Mi
Can aid in treatment decisions
Invasive vs. ischemia-guided strategy
TIMI Risk Score: Ranges
High Risk
5 -7 points
Medium Risk
3 - 4 points
Low Risk
0 -2 points
Reperfusion:
Fibrinolytic therapy in NSTEMI?
NO, Don’t do that.
Only STEMI patient
NSTEMI: Invasive strategy
PCI within 24-72 hrs)
High & moderate risk pts
NSTEMI:
Ischemia-guided strategy
(medication therapy)
Low risk pts
NSTEMI: Antiplatelet Therapy
PCI: Dual antiplatelet therapy (DAPT)
- ASA on presentation +
- P2Y12 Inhibitor added to ASA on presentation or at time of PCI:
Clopidogrel (Plavix®)
Ticagrelor (Brilinta®)
Prasugrel (Effient®) -at time of PCI only
NSTEMI: Antiplatelet Therapy
PCI: Clopedigrel Loading Dose,
and Maintenance and duration
LD: 600g
MN: 75mg Daily
at least 12 months, all,
P2Y12 Inhibitors: PCI:
Clopidogrel (Plavix®)
Ticagrelor (Brilinta®)
Prasugrel (Effient®
Anticoagulants: PCI
Whats the preferred agent for NSTEMI?
Enoxaparin (Lovenox®)
Enoxaparin
(Lovenox®)
(Lovenox®)
Duration for PCI: NSTEMI
D/C at end of successful PCI!!
NSTEMI: GP IIb/IIIa Inhibitors
PCI:
For high risk pts (↑↑ troponin), GP IIb/IIIa Inhibitors may added at time of PCI for :
1.Pts not pretreated with a P2Y12 inhibitor
OR
- Pts treated with clopidogrel + UFH only
Preferred agents:
Eptibifibitide (Integrilin®) or
Tirofiban (Aggrastat®)
NSTEMI: Antiplatelet Therapy
Ischemia-guided strategy
Medical Management
- ASA on presentation +
- P2Y12 inhibitor added to ASA as soon as possible after admission
Clopidogrel (Plavix®) or
Ticagrelor (Brilinta®)
Ischemia-guided strategy: Dose and medication management.
Clopidogrel (1B)
LD: 300* or 600 mg
Duration Up to
12 months
Ticagrelor (Brilinta®)
Up to 12 months
Anticoagulants: Medical Management
Conservative Strategy
Preferred?
Enoxaparin (Lovenox®)
Anticoagulants: Medical Management
Enoxaparin
(Lovenox®)
- 1 mg/kg subcut q12 h
- CrCl < 30 ml/min: 1 mg/kg subcut daily***
Unfractionated heparin (UFH
• 60 Units/kg IV LD (max 4000 Units)
• 12 Units/kg/hr IV infusion (max 1000 Units/hr)
• Adjusted to goal aPTT range
Fondaparinux (Arixtra®
• 2.5 mg subcut daily
• CrCl < 30 ml/min: contraindicated severe renal imparment
. Prasugrel
(Effient®
Indication?
NSTEMI pts with PCI
Dual Antiplatelet Therapy (DAPT)
1. Clopidogrel
(Plavix®)
2. Ticagrelor
(Brilinta®)
3. Prasugrel
(Effient®)
-With aspirin
Duration?12 months
Dual Antiplatelet Therapy (DAPT)
Asprin:Dose & Duration
+ choice of P2Y12 Inhibitor
Indefinitely
81mg
Core Measures for ACS
- ACEI or ARB for LVSD at discharge
- Time to fibrinolytic therapy: within 30 min
- Time to PCI: within 90 min
- Smoking cessation counseling
- ASA at arrival
ASA at discharge
- Beta-blocker at discharge
- Statin at discharge
NSTEMI:
PCI
DAPT and Anticoagulant Therapy
High Risk:
Invasive Strategy
- ASA +
- P2Y12 Inhibitor +
Clopidogrel/ prasugrel/ ticagrelor (LD) - Anticoagulant (d/c after PCI)
* *Enoxaparin**/ UFH/ fondaparinux/ bivalirudin
GPI + P2Y12 inhibitor in high risk pts
NSTEMI:
Medical Management
DAPT and Anticoagulant Therapy
Low Risk:
Ischemia-Guided Therapy
- ASA +
- P2Y12 Inhibitor +
Clopidogrel or ticagrelor (LD) - Anticoagulant
* *Enoxaparin**/ UFH/ fondaparinux
PCI for refractory angina/ischemia
Secondary Prevention
Aspirin (indefinitely) Clopidogrel, prasugrel or ticagrelor (12 months) Beta-blocker (indefinitely) Nitroglycerin SL prn Statin (indefinitely) \+/- ACEI or ARB \+/- Aldosterone antagonist
STEMI: Reperfusion therapy
Fibrinolytic Therapy
Fibrinolytic Therapy
Within 30 min of hospital presentation
STEMI: Reperfusion therapy Primary PCI (preferred
Primary PCI (preferred) Within 90 min of hospital presentation
After
STEMI: Reperfusion therapy
Primary PCI (preferred)
DAPT + Anticoagulant Therapy + GPI–Explain
DAPT + Anticoagulant Therapy + GPI
- ASA +
- Clopidogrel or Prasugrel or Ticagrelor (LD) +
A. UFH (d/c after PCI) + GP IIb/IIIa Inhibitor
OR
B. Bivalirudin (d/c after PCI)
After
STEMI: Reperfusion therapy
Fibrinolytic Therapy
DAPT + Anticoagulant Therapy–explain
- ASA +
- Clopidogrel (LD) +
A. UFH (x 48 hrs)
OR
B. LMWH or fondaparinux if tx > 48 hrs
