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CardioPulm II > ACS > Flashcards

ACS Flashcards

1
Q

Clopidogrel

A

Plavix®

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2
Q

Prasugrel

A

Effient®

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3
Q

Ticagrelor

A

Brilinta

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4
Q

Unfractionated Heparin

A

UFH

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5
Q

Fondaparinux

A

Arixtra®

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6
Q

Bivalirudin

A

Angiomax®

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7
Q

Tirofiban

A

Aggrastat®

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8
Q

Eptifibatide

A

Integrilin®

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9
Q

Abciximab

A

Reopro®

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10
Q

Ticlopidine

A

Ticlid®

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11
Q

Omeprazole

A

Prilosec®

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12
Q

Metoprolol tartrate

A

Lopressor®

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13
Q

Metoprolol succinate

A

Toprol XL®

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14
Q

Atenolol

A

Tenormin®

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15
Q

Carvedilol

A

Coreg®

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16
Q

Ischemia

A

Reduction of blood supply or increase in oxygen demand of myocardium

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17
Q

Infarction

A

Interruption of blood flow that leads to necrosis of myocardium

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18
Q

What is ACS?

A

Spectrum of conditions that result from myocardial ischemia and/or infarction

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19
Q

Atherothrombosis

A
  • Disruption of an atherosclerotic plaque
  • Results in thrombosis
  • Reduced myocardial perfusion → infarction (death
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20
Q

STEMI

A

Complete artery occlusion by the thrombus

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21
Q

UA/NSTEMI

A

Incomplete artery occlusion by the thrombus

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22
Q

Risk factors of ACS: Modifiable

A

Physical Inactivity

Obesity - (especially abdominal)

Smoking- counsel

HTN

Hyperlipidemia

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23
Q

Risk Factors for ACS: Non-modifiable

A

Age

Male gender <55

Family history of premature CHD

History of CAD, including MI

DM

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24
Q

Clinical Presentation: Classic

A
  • Chest discomfort, squeezing sensation

- Chest pressure can radiate to shoulder, left arm, back or jaw

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25
Q

Clinical Presentation: Rest

A

occurs at rest and lasts > 20 min

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26
Q

Clinical Presentation: New-onset

A

severe (marked limitation of physical activity)

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27
Q

Clinical Presentation: Increasing

A

more frequent, longer in duration or higher intensity

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28
Q

Clinical Presentation: Atypical

A 
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

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29
Q

Diagnosis: ACS

A

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
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30
Q

Diagnosis: ACS : Gold standard

A

Cardiac Catheterization

–>Gold standard for diagnosis

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31
Q

Diagnosis: ACS: Biomarker of choice

A

Troponin I/T

measured x 3

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32
Q

Classification of ACS: STEMI

No different in the extent of symptoms- Chest Pain or Severe Chest Paint.

A

Symptoms: Present
EKG Change: ST Elevation
Biomarkers: High

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33
Q

Classification of ACS: NSTEMI

No different in the extent of symptoms- Chest Pain or Severe Chest Paint.

A

Symptoms: Present

EKG Changes:
ST segment depression or T wave inversion

Biomarkers Medium

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34
Q

Classification of ACS: UA

No different in the extent of symptoms- Chest Pain or Severe Chest Paint.

A

Symptoms: Present
EKG Changes: ST segment depression or T wave inversion
Biomarkers: No Elevation

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35
Q

Initial Therapy: STEMI

A 
Aspirin
Nitroglycerin
UFH/LMWH
\+/-Beta-blocker (IV)
\+/-Morphine
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36
Q

Initial Therapy: STEMI

acronym

A 
M – Morphine (+/-)
O – Oxygen (+/-)
N – Nitroglycerin
A – Aspirin
A -  Anticoagulant
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37
Q

Initial Therapy: Asprin

A

First dose 162-325 mg chewed

Not EC

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38
Q

Initial Therapy: Nitroglycerin (NTG)

Outside Hospital

A

Call EMS if angina not relieved 5 min after 1 dose (0.4 mg sublingual)

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39
Q

Initial Therapy: Nitroglycerin (NTG)

In Hoptial

A

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

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40
Q

Initial Therapy: Anticoagulation

A

Unfractionated heparin (UFH) – preferred

Enoxaparin as alternative to UFH

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41
Q

Reperfusion Therapy

A

Goal: re-open partially or completely occluded coronary artery

Re-establish blood flow

Improve perfusion to the affected myocardial tissue

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42
Q

Initial Therapy: Beta-blocker (+/-)

A

IV beta-blockers upon presentation in pts who are hypertensive or ongoing ischemia and do NOT have:

  1. Signs of HF
  2. PR interval > 0.24 seconds
  3. Heart block
  4. Active asthma/COPD
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43
Q

Initial Therapy: Morphine (+/-)

Dosing and indication

A

For continued chest pain***

Dose: 2-4 mg IV repeated q 5-15 min prn

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44
Q

Reperfusion Therapy: Non-Pharmacologic

A

Percutaneous Coronary Intervention (PCI)

  • -Invasive procedure – NOT surgery
  • -Mechanical revascularization - dilation of the coronary artery – “stenting”
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45
Q

Reperfusion Therapy: Pharmacologic

A

Fibrinolytic Therapy—NON PREFERRED - BREAK CLOT

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46
Q

Timing of Reperfusion Therapy: Door to Balloon Time

A

Door to Balloon Time”: < 90 min
Target time from hospital presentation to PCI
HAVE 90MIN TO GET THEM TO CATH LAB

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47
Q

Timing of Reperfusion Therapy: Door to Needle Time

A

Door to Needle Time”: < 30 min

Target time from hospital presentation to fibrinolytic

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48
Q

WHY PCI preferred over fibrinolytics?

A

↓ Mortality rate

↓ Risk of stroke (ICH) & major bleeding

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49
Q

Fibrinolytic Therapy

A

STEPTOKINANCE IS NOT FIBRIN SPECIFIT—INCREASES SYSTEMIC BLEEDING

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50
Q

Fibrinolytic Therapy: Indications

A

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)

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51
Q

When shouldn’t Fibrinolytic therapy be used?

A

Fibrinolytic therapy NOT recommended in UA/NSTEMI patients!!

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52
Q

Absolute Contraindications – to Fibrinolytic therapy

A

Previous intracranial hemorrhage (at ANY time)***

Ischemic stroke within 3 months**

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53
Q

Relative Contraindications – more than one Relative ContraIND is Absolute—Risk for Intracranial Hemorrhage

Fibrinolytic therapy

A

Uncontrolled HTN (SBP > 180 or DBP >110 mmHg)
History of stroke > 3 months
Current use of anticoagulants
Age > 75

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54
Q

Fibrin-Specific Agents

A

Alteplase (tPA): Activase ®
Reteplase (rPA): Retavase ®
Tenecteplase (TNK-tPA):TNKase ®

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55
Q

Alteplase (tPA): Activase ®

Dosage*****

A

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)

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56
Q

Choice of Fibrinolytic Agent

A

Fibrin-specific agents more effective
Alteplase, reteplase, tenecteplase
—Preferred agents as per ACC/AHA guidelines

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57
Q

Fibrinolytic Agent: Risk of bleeding

A

ICH risk higher with fibrin-specific agents

Systemic bleeding higher with streptokinase

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58
Q

Fibrinolytic Agent : ADR or Side Effects

A

SE:

Bleeding: Intracranial hemorrhage (ICH): largest risk

Reperfusion arrhythmia: usually self limiting

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59
Q

Antiplatelet Therapy with Fibrinolytics:

Loading Dose

A

Aspirin 162-325 mg X 1 AND

Clopidogrel
Pts ≤ 75 yo: 300 mg x 1
Pts > 75 yo: no LD, give 75 mg

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60
Q

Antiplatelet Therapy with Fibrinolytics:

Maintenance Dose

A

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

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61
Q

Anticoagulation with Fibrinolytics: Indications

A

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**

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62
Q

Anticoagulation with Fibrinolytics

A

Enoxaparin (Lovenox®)

Unfractionated heparin
(UFH)

Fondaparinux (Arixtra®)

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63
Q

Enoxaparin (Lovenox®)- Preferred

Dosing for anticoagulation

A

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

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64
Q

Unfractionated heparin
(UFH)

Dosing for anticoagulation

A

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

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65
Q

Fondaparinux (Arixtra®)

A

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

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66
Q

Stenting “PCI”

A

Bare metal stent (BMS)

Drug-eluting stents (DES)

  • Paclitaxel
  • Sirolimus
  • Everolimus
  • Zotarolimus
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67
Q

Restenosis

A

blood vessel grow over the stent and cause a blockage.

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68
Q

PCI indications

A

Don’t know

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69
Q

Primary PCI:

A

Decreases Chance of Intracranial hemorrhage.

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70
Q

PCI timing

A

should be performed if immediately available (within 90 min of hospital presentation)

Should be performed within 12 hrs of symptom onset

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71
Q

Complications of PCI:

Contrast - Induced nephropathy
PCI = IV dye administration

A

High risk patients:

  1. Advanced age >75 years!!!
  2. Chronic kidney disease (CKD)
  3. DM
  4. Heart failure
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72
Q

How to prevent In-stent restenosis & rethrombosis?

A

Prevent with dual antiplatelet therapy (DAPT)

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73
Q

Prevention of Contrast-induced Nephropathy

A
  1. Risk stratification & monitoring
    BUN/SrCr daily after PCI
  2. Hydration (NSS) pre- and post-procedure (#1 way to prevent contrast neuropathy)

+/- N-acetylcysteine (Mucomyst®)
+/- Sodium bicarbonate

  1. Concomitant medication assessment
    - >Hold metformin at time of PCI, then x 48 hrs
    - >Nephrotoxic drugs (ACE-I, ARBS, diuretics
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74
Q

Dual Antiplatelet Therapy with PCI

A

Clopidogrel (Plavix®)

600 mg-PCI LOADING DOSE!!!

75
Q

Anticoagulants with PCI

Unfractionated Heparin (UFH)

A 
Unfractionated Heparin (UFH)
Inhibits factors Xa & IIa (thrombin
76
Q

Anticoagulants with PCI

Fondaparinux (Arixtra®)

A

Fondaparinux (Arixtra®) –Hx of HIT ok**

Pentasaccharide that inhibits factor Xa only

77
Q

Anticoagulants with PCI

Bivalirudin (Angiomax®)

A

Bivalirudin (Angiomax®) – Hx of HIT ok**

Direct thrombin inhibitor that inhibits factor IIa
Has anticoagulant & antiplatelet activity
“2 for 1” drug

78
Q

Anticoagulants with PCI

Recommendations

A

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

79
Q

Anticoagulants with PCI

Unfractionated heparin (UFH)

A

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

80
Q

Anticoagulants with PCI

Bivalirudin (Angiomax®)

A

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

81
Q

Anticoagulants with PCI

Fondaparinux (Arixtra®)

A

Not recommended as the sole anticoagulant for PCI due to risk of catheter thrombosis

82
Q

Anticoagulants with PCI

Contraindications/Precautions

A

History of HIT (UFH/LMWH)

CrCl < 30 ml/min

  • –↓ Bivalirudin infusion to 1 mg/kg/hr
  • –Fondaparinux contraindicated
83
Q

Glycoprotein IIb/IIIa Inhibitors

Glyo- sugar

A

Tirofiban (Aggrastat®)
Eptifibatide (Integrilin®)
Abciximab (Reopro)

TEA

84
Q

Glycoprotein IIb/IIIa Inhibitors

Benefits

A

Clinical Benefits:

Maintain patency of coronary artery during PCI

↓ Thrombosis & mortality following PCI**

85
Q

should Glycoprotein IIb/IIIa Inhibitors be recommended with fibrinolytic therapy?

A

NEVER recommended with fibrinolytic therapy

(↑ bleeding risk)

86
Q

Whats the preferred Glycoprotein IIb/IIIa Inhibitors?

A

Abciximab (Reopro®)

PREFERRED

87
Q

When are Glycoprotein IIb/IIIa recommended?

A

Recommended at the time of PCI (downstream)

In STEMI pts undergoing primary PCI, it is reasonable to administer a GP IIb/IIIa inhibitor

88
Q

Glycoprotein IIb/IIIa dosing??

A

Don’t do that

89
Q

What type of elimination is
Tirofiban and Eptifibatide?

What must you do to counter it?

A

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
90
Q

GP IIb/IIIa Inhibitors:

Contraindications?

A

Active bleeding

Thrombocytopenia

Prior stroke

91
Q

Secondary prevention

A

Nice SAAB

N – NTG (SL)
S – Statin
A – Aspirin
A – Antiplatelet
B – Beta-blocker
92
Q

Secondary prevention:

Who gets aspirin?

A

All STEMI patients: ASA should be administered ASAP and continued indefinitely

93
Q

Secondary prevention:

Aspirin dosing?

A

Initial dose
162 – 325 mg (chewed ASAP) _HIGHDOSE!!!

Maintenance Dose
81 – 325 mg po daily indefinitely

94
Q

Secondary prevention:

Thienopyridines

A

Ticlopidine (Ticlid®) – risk of neutrapenia—Inhbiti P2Y12

Clopidogrel (Plavix®)

Prasugrel (Effient®)

95
Q

Secondary prevention:

Cyclopentyltriazolopyrimidine

A

Ticagrelor (Brilinta®)-Reversible inhibitor, shorter T1/2 too

96
Q

Secondary prevention:

Benefits of Antiplatelet Therapy:P2Y12 Inhibitors

A

Clinical Benefit:

↓ Restenosis/rethrombosis s/p STEMI

97
Q

Secondary prevention:

Prasugrel & ticagrelor warnings?

A

More potent anti-platelet effects

Higher bleeding risk (WHY PLAVIX is still around

98
Q

Secondary prevention:

Who gets Clopidogrel (Plavix®)?

How long?

A

Alternative for patients with true ASA allergy
Continue indefinitely

Duration:
Continue for at least 12 months

99
Q

Secondary prevention:

Clopidogrel (Plavix®) dosing?

A

Loading dose: 600 mg po x 1 (standard for PCI)

Maintenance dose: 75 mg po daily

Discontinue 5 days prior to surgery (ie, CABG)

100
Q

is Clopidogrel (Plavix®) a produrg?

A

Yes,Metabolized by CYP2C19 to active metabolite

101
Q

Clopidogrel (Plavix®) boxed warning?

A

Genetic polymorphisms and ↓ CYP2C19 activity

Clopidogrel may have ↓ antiplatelet effects

102
Q

Clopidogrel and PPIs

A

PPIs inhibit CYP2C19; risk of stent thrombosis.

Omeprazole (Prilosec®): greatest risk

103
Q

COGENT Trial

A

Pts on ASA + clopidogrel randomized to receive omeprazole vs. placebo

No difference in CV events, only ↓ GI bleeding

104
Q

PPI+ clopidogrel mangagment?

A

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)

105
Q

Prasugrel (Effient®)

Recommendations?

A

addition to ASA in STEMI patients undergoing PCI only***

106
Q

Prasugrel (Effient®)

Duration

A

Continue for at least 12 months

107
Q

Prasugrel (Effient®)

Dosing

A

Loading dose: 60 mg po x 1

Maintenance Dose: 10 mg po daily

D/C 7 days prior to surgery (ie, CABG

108
Q

Prasugrel (Effient®)

Black box warning?

A

Black Box Warning: may cause significant or fatal bleeding

109
Q

Prasugrel (Effient®)

contraindication?

A

History of TIA or stroke!

110
Q

Prasugrel (Effient®)

precaution

A

Age > 75 years

Weight < 60 kg: (↓ MD to 5mg daily)

111
Q

Ticagrelor (Brilinta®)

A

addition to aspirin in STEMI patients

* undergoing PCI or medical management*

112
Q

Ticagrelor (Brilinta®)

Duration

A

Continue for at least 12 months

113
Q

Ticagrelor (Brilinta®)

Dosing:

A

Loading dose: 180 mg

Maintenance dose: 90 mg po BID** (compliance)

D/C at least 5 days prior to surgery

114
Q

Ticagrelor (Brilinta®)

Contraindication?

A

Severe hepatic impairment

115
Q

Ticagrelor & Aspirin Dose

What’s the proper maintence aspirin dose?

A

Maintenance ASA dose should be 75-100 mg daily with ticagrelor

116
Q

Ticagrelor: Drug Interactions?

A

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

117
Q

Monitoring: P2Y12 Inhibitors

A

All:
S/sx of ischemia
Bleeding, Hg/Hct
N/V/D

Ticagrelor
Dyspnea (usually transient)
Bradycardia

118
Q

Ticagrelor & Adenosine

A

Looks the same: chemical structure.

119
Q

Beta-Blockers:

indications

A

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

120
Q

Beta-Blockers:

Contraindications/Precautions

A

Bradycardia (HR < 60)
Hypotension (SBP < 90)

Signs of HF
Active asthma or COPD (wheezing)

121
Q

Beta-Blockers

Dosing

A

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

122
Q

Choice of Beta-Blocker

A

EF ≥ 40%:
May use any b-blocker without ISA

EF < 40%: (stabilized HF)
Metoprolol succinate, carvedilol or bisoprolol

123
Q

What beta blockers to use?

EF < 40%: (stabilized HF)

A

EF < 40%: (stabilized HF)

Metoprolol succinate, carvedilol or bisoprolol

124
Q

What beta blockers to use?

EF ≥ 40%:

A

May use any b-blocker without ISA

125
Q

Beta-Blockers

Metoprolol tartrate (Lopressor®)

Dosing

A

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

126
Q

Metoprolol succinate
(Toprol XL®)

Dosing

A

25 – 200 mg po daily

127
Q

Nitrates:

Clinical Benefits

A

No effect on overall mortality – relief of CP only

128
Q

Nitrates:

Indications

A

Take ONE dose of SL nitroglycerin.

If symptoms worsen or do not improve, call 9-1-1 immediately

129
Q

Nitrates:

Contraindications

A

Do not administer within 24 hrs of phosphodiesterase inhibitors (sildenafil or vardenafil) or 48 hrs for tadalafil

130
Q

Nitrates:

Sublingual

A

0.4 mg SL q 5 min x 3 doses

131
Q

Nitrates:

IV infusion

A

5 - 10 mcg/min IV, titrated to 75 - 100 mcg/min IV

until relief of symptoms or limiting SE’s (HA)

132
Q

Nitrates

Oral

A

Depends on formulation

Isosorbide mononitrate or Isosorbide dinitrate

133
Q

Nitrates

Duration

A

Continue nitrates for (up to) 24 hrs after ischemia is relieved

134
Q

Nitrates

Contraindications:

A

Hypotension (SBP < 90 or > 30% below baseline)

Bradycardia (HR < 50)

Tachycardia (HR > 100)

Right ventricular infarction

135
Q

who gets Nitroglycerin?

doses?

A

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

136
Q

Counseling:

Nitroglycerin

A

Call 911 if no relief after 5 min

May cause HA, dizziness, tingling (sit down)

Store in a cool, dry place

137
Q

Lipid-Lowering Agents:

Decrease morbidity & mortality s/p MI

A

High-intensity or moderate-intensity statin based on patient factors

138
Q

High-intensity Statins?

A 
Atorvastatin (40*)-80 mg
Rosuvastatin 20 (40) mg
139
Q

Consider a moderate-intensity statin

A

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

140
Q

Moderate intensity Statins?

A

Atorvastatin 10 (20) mg
Rosuvastatin (5) 10 mg
Simvastatin 20-40 mg
Pravastatin 40 (80) mg

141
Q

Statin follow up?

A

Lipid panel in 4-8 weeks

To assess adherence & patient’s response

142
Q

ACEI and ARBs

Mortality?

A

Reduce overall mortality!

143
Q

ACEI and ARBs

Indications

ARBs for pts who cannot tolerate ACEI (ie, cough)

A

ACEI within 24 hrs & continue indefinitely in pts with:

LVEF < 40%
HTN
DM
CKD

Class IIb
ACEI for ALL patients

144
Q

Lisinopril (Zestril®)
Enalapril (Vasotec®)
Ramipril (Altace®)
Captopril (Capoten®)

Initial Dosing

A

Lisinopril (Zestril®)
Enalapril (Vasotec®)
Ramipril (Altace®)
Captopril (Capoten®)

5 mg po daily

  1. 5 mg po po BID
  2. 25 – 2.5 mg po daily
  3. 25 – 12.5 mg po TID
145
Q

Lisinopril (Zestril®)
Enalapril (Vasotec®)
Ramipril (Altace®)
Captopril (Capoten®)

Target Dose

A

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

146
Q

ARBs?

Valsartan (Diovan®)
Candesartan (Atacand®)
Losartan (Cozaar®)

A

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

147
Q

ACEI and ARBs

contraindications?

A

Hypotension (SBP < 100 mmHg)

Renal dysfunction (SrCr > 2.5)

Hyperkalemia (K > 5.5 mEq/L)

Bilateral renal artery stenosis

Pregnancy (category D

148
Q

Aldosterone Antagonists

mortality?

A

Decreases morbidity & mortality

149
Q

Aldosterone Antagonists

Indication

A

Indications

For ACS pts on ACEI & B-blocker with:
-LVEF < 40%, DM or HF

Continue indefinitely

150
Q

Aldosterone Antagonists

Spironolactone (Aldactone®)

A

Initial
12.5 mg po daily

Target
25 – 50 mg po daily

151
Q

Aldosterone Antagonists

Eplerenone (Inspra®)

A

Initial
25 mg po daily

Target
50 mg po daily

152
Q

Calcium Channel Blockers

Indications:

A

Verapamil or diltiazem when beta-blockers are ineffective or contraindicated for relief of ongoing ischemia

153
Q

Calcium Channel Blockers

Drug of Choice

A

(avoid beta-blockers):

Cocaine-induced ACS
Variant (Prinzmetal angina)
–>Cause coronary vasodilation

154
Q

Glycemic Control:

BG < 180 mg/dL s/p STEMI

A

insulin-based regimen to achieve BG < 180 mg/dL s/p STEMI

155
Q

ACS Blood pressure guidelines?

A

Goal BP < 140/90

156
Q

Recommendation to all with STEMI?

A

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

157
Q

Initial therapy: NSTEMI

A 
Aspirin
Nitroglycerin
UFH/LMWH
\+/-Beta-blocker (IV)
\+/-Morphine

MONAA”

Oxygen?? and no beta blocker??

158
Q

TIMI or GRACE score

A

Risk assessment tools

  • used to identify NSTEMI pts at high risk
  • ->Thrombolic in Mi

Can aid in treatment decisions
Invasive vs. ischemia-guided strategy

159
Q

TIMI Risk Score: Ranges

A

High Risk
5 -7 points

Medium Risk
3 - 4 points

Low Risk
0 -2 points

160
Q

Reperfusion:

Fibrinolytic therapy in NSTEMI?

A

NO, Don’t do that.

Only STEMI patient

161
Q

NSTEMI: Invasive strategy

A

PCI within 24-72 hrs)

High & moderate risk pts

162
Q

NSTEMI:

Ischemia-guided strategy

A

(medication therapy)

Low risk pts

163
Q

NSTEMI: Antiplatelet Therapy

A

PCI: Dual antiplatelet therapy (DAPT)

  1. ASA on presentation +
  2. P2Y12 Inhibitor added to ASA on presentation or at time of PCI:

Clopidogrel (Plavix®)
Ticagrelor (Brilinta®)
Prasugrel (Effient®) -at time of PCI only

164
Q

NSTEMI: Antiplatelet Therapy

PCI: Clopedigrel Loading Dose,

and Maintenance and duration

A

LD: 600g

MN: 75mg Daily

at least 12 months, all,
P2Y12 Inhibitors: PCI:

Clopidogrel (Plavix®)
Ticagrelor (Brilinta®)
Prasugrel (Effient®

165
Q

Anticoagulants: PCI

Whats the preferred agent for NSTEMI?

A

Enoxaparin (Lovenox®)

166
Q

Enoxaparin

A

(Lovenox®)

167
Q

(Lovenox®)

Duration for PCI: NSTEMI

A

D/C at end of successful PCI!!

168
Q

NSTEMI: GP IIb/IIIa Inhibitors

A

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
  1. Pts treated with clopidogrel + UFH only

Preferred agents:
Eptibifibitide (Integrilin®) or
Tirofiban (Aggrastat®)

169
Q

NSTEMI: Antiplatelet Therapy

Ischemia-guided strategy

A

Medical Management

  1. ASA on presentation +
  2. P2Y12 inhibitor added to ASA as soon as possible after admission

Clopidogrel (Plavix®) or
Ticagrelor (Brilinta®)

170
Q

Ischemia-guided strategy: Dose and medication management.

A

Clopidogrel (1B)
LD: 300* or 600 mg

Duration Up to
12 months

Ticagrelor (Brilinta®)
Up to 12 months

171
Q

Anticoagulants: Medical Management
Conservative Strategy

Preferred?

A

Enoxaparin (Lovenox®)

172
Q

Anticoagulants: Medical Management

A

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

173
Q

. Prasugrel
(Effient®

Indication?

A

NSTEMI pts with PCI

174
Q 
Dual Antiplatelet Therapy (DAPT)
1. Clopidogrel
    (Plavix®)
2. Ticagrelor
    (Brilinta®)
3. Prasugrel
    (Effient®)
-With aspirin
Duration?
A

12 months

175
Q

Dual Antiplatelet Therapy (DAPT)

Asprin:Dose & Duration

+ choice of P2Y12 Inhibitor

A

Indefinitely

81mg

176
Q

Core Measures for ACS

A
  • 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
177
Q

NSTEMI:
PCI

DAPT and Anticoagulant Therapy

High Risk:
Invasive Strategy

A
  1. ASA +
  2. P2Y12 Inhibitor +
    Clopidogrel/ prasugrel/ ticagrelor (LD)
  3. Anticoagulant (d/c after PCI)
    * *Enoxaparin**/ UFH/ fondaparinux/ bivalirudin

GPI + P2Y12 inhibitor in high risk pts

178
Q

NSTEMI:
Medical Management
DAPT and Anticoagulant Therapy

Low Risk:
Ischemia-Guided Therapy

A
  1. ASA +
  2. P2Y12 Inhibitor +
    Clopidogrel or ticagrelor (LD)
  3. Anticoagulant
    * *Enoxaparin**/ UFH/ fondaparinux

PCI for refractory angina/ischemia

179
Q

Secondary Prevention

A 
Aspirin (indefinitely)
 Clopidogrel, prasugrel or ticagrelor  (12 months)
 Beta-blocker (indefinitely)
 Nitroglycerin SL prn
 Statin (indefinitely)
\+/- ACEI or ARB
\+/- Aldosterone antagonist
180
Q

STEMI: Reperfusion therapy

Fibrinolytic Therapy

A

Fibrinolytic Therapy

Within 30 min of hospital presentation

181
Q 
STEMI: Reperfusion therapy 
Primary PCI (preferred
A 
Primary PCI (preferred)
Within 90 min of hospital presentation
182
Q

After
STEMI: Reperfusion therapy
Primary PCI (preferred)

DAPT + Anticoagulant Therapy + GPI–Explain

A

DAPT + Anticoagulant Therapy + GPI

  1. ASA +
  2. Clopidogrel or Prasugrel or Ticagrelor (LD) +
    A. UFH (d/c after PCI) + GP IIb/IIIa Inhibitor
    OR
    B. Bivalirudin (d/c after PCI)
183
Q

After
STEMI: Reperfusion therapy
Fibrinolytic Therapy

DAPT + Anticoagulant Therapy–explain

A
  1. ASA +
  2. Clopidogrel (LD) +
    A. UFH (x 48 hrs)
    OR
    B. LMWH or fondaparinux if tx > 48 hrs

CardioPulm II (11 decks)

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