ACS NSTEMI med tx Flashcards
med therapy of NSTEMI
ASA anticoag } Beta blockers } ACE inhibitors } Statin therapy } Nitroglycerin (long-acting vs rescue)
beta blockers
} Anti-ischemic
} Reduction of tachyarrhythmias
} Prevention of adverse remodelling
} Oral beta blockade to be started within the
first 24 hours unless:
◦ Heart failure
◦ Risk for shock or evidence of low output state
◦ Contraindications – i.e. heart block
◦ In these cases, beta blocker initiation may need to
be delayed to when the patient is more stable
Who should continue oral beta blockers
long-term?
◦ All patients with heart failure or left ventricular
systolic dysfunction (LVSD)
◦ All others, except those at low risk (by score or
assessment at follow-up) or with contraindications
} Target doses if tolerated:
◦ metoprolol 100mg BID
◦ carvedilol 25mg BID
◦ bisoprolol 10mg daily
ACEi and NSTEMI
} Continued indefinitely for cardiovascular protection, if no contraindications
◦ Dosing from different trials in stable CAD
} Heart failure or left ventricular systolic dysfunction (LVSD)
} Hypertension, diabetes or stable chronic kidney disease
} ARBs for those intolerant of ACEi
} Hypotension, hyperkalemia and renal dysfunction
statin therapy and NSTEMI
} Acute management of unstable atheroma
} Early and intensive statin therapy (in comparison to
placebo) significantly decreased combined endpoint of death, MI, cardiac arrest and recurrent ischemia
} Initiate high intensity statin therapy
◦ Atorvastatin 80mg po daily
◦ Rosuvastatin 40mg po daily
} For ACS, more intensive statin therapy long-term decreased clinical events
} Intensive vs less intensive comparisons rather than specific LDL level achieved
nitroglycerin and NSTEMI
} Long-Acting
◦ No benefit on clinical outcomes
◦ Useful for recurrent angina if treatment does not preclude beta blockers
◦ Importance of nitrate free interval
} Useful chronically for symptomatic management of stable angina
} Sublingual for rescue
◦ All patients should have available
recommendations for MRAs and PPIs
MRAs are recommended in patients with heart failure with reduced LVEF (<40%) in order to reduce all-cause and cardiovascular mortality and cardiovascular morbidity.
Proton pump inhibitors
Concomitant use of a proton pump inhibitor is recommended in patients receiving aspirin monotherapy, DAPT, DAT, TAT, or OAC monotherapy who are at high risk of gastrointestinal bleeding in order to reduce the risk of gastric bleeds
secondary prevention recommendations for ACS
} Referral to a comprehensive outpatient
cardiovascular rehabilitation program
} Reasonable to screen for depression
} Annual influenza vaccination and pneumococcal vaccination initially and at 5 years
tobacco use
pharmacist role
} At every visit: ◦ Ask about tobacco use ◦ Advise users to quit ◦ Assess willingness to quit ◦ Assist by counselling and development of plan for quitting – including pharmacotherapy and/or referral as required ◦ Arrange follow-up
bleed risk with low dose ASA
} ASA vs placebo
◦ Risk of any major bleed 1.71 (1.41-2.08)
◦ Risk of major GIB 2.07 (1.61-2.66)
NNH=833 at one year
Doub;les risk of bleed from placebo
} 5 year observational cohort from Denmark
◦ RR of hospitalization for upper GIB with low-dose
ASA alone 2.6 (2.2-2.9)
◦ No difference with enteric coated and uncoated ASA
Baseline bleed risk is quite low so baby ASA a day is ok
Dual antiplatelet further increases the risk
Intracranial bleeding
bleed risk with dual antiplatelet
tic + ASA more bleeding than ASA alone
dual tx with tic + ASA does not sig increase major b leeding compared to clop + ASA
ASA vs ASA/clopidogrel (CURE)
◦ Risk of any major bleed RRR 0.27 (0.12-0.40)
◦ Risk of major GIB RRR 0.44 (0.20-0.61)
◦ Risk of intracranial bleed NS
} Clopidogrel vs ASA/clopidogrel (MATCH)
◦ Risk of any major bleed RRR 0.58 (0.45-0.68)
◦ Risk of major GIB RRR 0.66 (0.49-0.77)
◦ Risk of intracranial bleed NS
further increases bleeding
TIMI majopr bleeds
one type of scoring system
cohorts
◦ Any intracranial bleeding
◦ Bleeding that results in death
◦ Clinically overt signs of hemorrhage associated with
a drop in Hgb of >50
} Rates of 2-3% with dual antiplatelet therapy
nuisance bleeding with dual antiplatelet tx
} Single center observational study of 2360
patients with DES implantation
} Bleeding events included superficial – easy
bruising, bleeding from small cuts, petechia,
ecchymosis, as well as internal and alarming
} Telephone follow-up or office visit
} Bleeding events self-reported
diff tyoes of bleeding events (3)
} 32.5% of patients reported bleeding events
} Most bleeding events were classified as
} Nuisance – 85.7%
} Internal – 13.6%
} Alarming – 0.7%
rates of d/c tx high in intrnal bleeding vs nuisance, highest dropout in clopidogrel
least with both therapy
chronic DAPT therapy
considerations
} Careful patient hx, physical examination
and assignment to therapy
◦ Individual patient’s risk factors
◦ Impact of non-cardiac concomitant therapies
} Appropriate duration of antithrombotic
regimens
} Consider use of proton pump inhibitors for
mitigating GI bleed risk
} Consider more frequent monitoring and
closer follow-up in high risk patients
