ACS tx Flashcards
Goals of short-term ACS therapy
-restore blood flow
-relieve chest pain
-prevent morbidity
-prevent re-occlusion of srtery
-prevent mortality
Overview of UA, NSTEMI, STEMI tx
- MONA
- Reperfusion (different)
- Antiplatelets (different)
- Anticoagulation (different)
- BB
- ACE/ARB
- Statin
- NTG PRN
- MONA
-Morphine
-Oxygen
-Nitroglycerin
-Aspirin
-immediately upon arrival for all ACS
Morphine
-relieve pain
-initial: 4-8mg IV, then 2-8mg IV q5-15min
-AVOID NSAIDs (sodium and water retention inc MACE risk)
Morphine side effects
-sedation
-respiratory depression
-NV
Oxygen
-maintain oxygen saturation >90%
Nitrates
-vasodilator
-SL NTG 0.3-0.4mg q 5min x 3
-IV NTG for persistent ischemia, HF, HTN (start at 10mcg/min and titrate by 5mcg/min (max200mcg/min)
-HA and hypotension effects
-cant use transdermal NTG, too slow
Nitrate considerations
-tolerance (inc dose or change to intermittent admin, >10h NTG free interval qd)
-CI w PDE5 (24 hours of sildenafil or vardenafil or 48h of tadalafil)
Aspirin
-162-325mg chewable aspirin ASAP
-dont use enteric, too slow
- Reperfusion
-PCI (stent), CABG (open heart surgery), or fibrinolytic therapy (side effects!!)
Coronary angiography
-heart cath
-shows where heart is blocked
-cath in radial or femoral artery up into heart
-dye and xray
-place stent if needed
Percutaneous Coronary Intervention (PCI)
-cath places stent
-blows up stent w balloon
Coronary Artery Bypass Graft (CABG)
-open heart surgery
-remove vein or artery from another part of body
-attach to heart to bypass blocked arteries
Fibrinolytic therapy
-least preferred )big bleeding risk)
-dissolves clots
-Tenecteplase (TNK-tPA)
-Reteplase (rPA)
-Alteplase (tPA)
-Streptokinase (SK): first fibrinolytic, less specific for fibirn, not really used
-Tenecteplase (TNK-tPA)
-Reteplase (rPA)
-Alteplase (tPA)
-fibrinolytic therapy
-v expensive
-use interchangably
Contraindications to fibrinolytics
-brain and bleeding
-lots of risks but specific on slide 30-31
- Reperfusion for STEMI
-PCI or fibrinolytic
-admin within 12h
-PCI has higher rates of infarct artery patency, lower rates od recurrent ischemia/reinfarction, lower rates of intracranial hemorrhage and death within 90 min of arrival
-fibrinolytics when pt is >120min away from PCI capable hospital, give within 30min of arrival*
- Reperfusion for UA/NSTEMI
-Ischemia guided strategy vs early invasive strategy
-fibrinolytics NOT recommended
Ischemia guided strategy
-reperfusion option for UA/NSETMI
-medical management (UA/NSTEMI)
-evidence based meds to tx
-no heart cath unless refractory or recurrent ischemic sx or hemodynamic instability
Early Invasive Strategy
-Reperfusion option for UA or NSTEMI
-coronary angiography +/- revascularization
-preferred for high risk pt w: refractory angina, new-onset HF, rising troponin, new ST depression
Antiplatelets
-12 month DAPT for UA, NSTEMI, and STEMI
-consider GPIIb/IIIa inhibitor in STEMI
Aspirin antiplatelet therapy
-325mg loading dose as part of MONA
-81mg qd indenfinitely
-take w food
Oral P2Y12
-clopigogrel
-prasugrel
-ticagrelor
-loading dose followed by maintenance dose in addition to aspirin (DAPT)*
IV P2Y12
-Cangrelor
-expensive
-works in 2 minutes
-only a loading dose no maintenance
-use during PCI when pt did NOT receive loading dose of P2Y12
Clopidogrel
-Plavix
-300-600mg loading
-75mg maintenance
-prodrug (may not work in all pt)
-lowest bleeding risk
Clopigogrel loading dose
-300-600mg
-600mg preferred
-EXCEPT w fibrinolytic
-NO loading dose if over 75 on fibrolytic
-300mg loading dose if 75 or under w fibrinolytic
Ticagrelor
-Brillinta
-180mg loading
-90mg BID maintenance
-more effective than clopidogrel (not a prodrug)
-MAX dose of ASA is 81mg for DAPT
-side effects include dyspnea and ventricular pauses
Prasugrel
-more effective than clopidogrel
-Effient
-60mg loading
-10mg maintenance
Prasugrel considerations
-CI in TIA/stroke
-not for pt 75 or older, <60kg, or high bleeding risk (may use maintenance dose of 5mg if necessary
-not recommended for ischemia guided strategy!!! (ticagrelor or clopidogrel preffered)
reasons to switch from clopidogrel
-in adequate response (genetic, CV event)
reasons to switch from ticagrelor to clopidogrel
-bleeding
-cost
-dyspnea
-adherence
reasons to switch from prasugrel to clopidogrel
-bleeding
-cost
-stroke/TIA
Switching between P2Y12 inhibitors
-acute (1-30 days) vs late
-do we need to reload pt if they switch?
-good tool to look it up
P2Y12 for NSTEMI and UA
-ischemia guided therapy: clopidogrel or ticagrelor (NOT PRASUGREL)
-PCI: use any, preference for ticagrelor or prasugrel
P2Y12i for STEMI
-fibrinolytic: clopidogrel (consider loading dose)
-PCI: ticagrelor or prasugrel
Aspirin counseling
-take w food
-take forever to prevent heart attack
-bruising or bleeding more after cut
-risk of bleeding
if ASA allergy?
-give loading dose of clopidogrel (or P2Y12) followed by mainteneance of clopidogrel 75mg (or same P2Y12)
-NEVER combo P2Y12s
P2Y12i counseling
-take w aspirin for one year to prevent heart attack
-risk of bleeding
-ticagrelor take 12h apart
-call dr if SOB on ticagrelor
s and sx of bleeding
-bruising
-light nosebleeds
-bleeding gums when flossing
-blood in urine (call dr)
-blood in stool (call dr)
-coughing up blood (call dr)
-cut wont stop bleeding (call dr)
antiplatelets and CABG
-do not need to hold ASA
-hold ticagrelor 3 days
-hold clopidogrel 5 days
-hold prasugrel 7 days
-hold for 24h if possible before urgent CABG
GP IIb/IIIa inhibitor drugs
-Abciximab (no renal adjustment)
-Eptifibatide (CrCl <50)
-Tirofiban (CrCl <60)
-don’t need to know dosing woooo
GP IIb/IIIa inhibitors
-abciximab, eptifibatide, tirofiban
-potent IV antiplatelets
-give IN ADDITION to DAPT
-give at time of PCI (no benefit in giving before)
-expensive
-not very common (inc risk of bleeding) (more common in STEMI)
-most trials were conducted before DAPT was standard
GP IIb/IIIa inhibitor MOA
-GP IIb/IIIa activated by agonist
-GP IIb/IIIa binds fibrinogen to bridge together platelets for aggregation
-inhibitors block fibrinogen from binding
When to use GP IIb/IIIa
-individual basis at time of PCI
-NSTEMI: use if high risk, positive troponin
-STEMI: use if large thrombus burden!!
-inadequate P2Y12 loading
-bail out (use during procedure if thrombus develops or low BP after stenting)!!
Abciximab
-ReoPro
-no renal adjustment
-GP IIb/IIIa inhibitor
Eptifibatide
-Integrilin
-if CrCl < 50mL/min: half maintenance dose
-GP IIa/IIIb
Tirofiban
-Aggrastat
-if CrCl <60: half maintenance dose
-GP IIa/IIIb
GP IIb/IIIa contraindications (not on exam)
-different for each agent
-active bleeding
-stroke
-severe uncontrolled HTN
-major surgery in 6 weeks
-dialysis
Anticoagulation therapy
-add to antiplatelet therapy to improve vessel patency and prevent re-occlusion
-STEMI: UFH or bivalrudin
-UA/NSTEMI: LMWH (enoxaparin) or UFH
Unfractionated heparin (UFH)
-anti-Xa and anti-IIa activity
-risk of HIT!
-quick onset and short half life
-admin as continuous infusion
-dose based on activated partial thromboplastin time (aPTT) or activated clotting time (ACT)
Heparin Induced Thrombocytopenia (HIT)
-drop in platelet count AND inc thrombosis
-caused by formation of antibodies that activate platelets
-if suspected, calculate 4T score
-dx with ELISA (quick, high false positive rate) or SRA!! (serotonin release assay) (gold standard, send-out lab) tests
-highest risk w UFH but can occur in LMWH
-if pt has hx of HIT, DO NOT give UFH or LMWH
4T score (not on exam)
-Thrombocytopenia: unexplained > 50% drop in platelet count from baseline
-Timing of platelet count drop: onset of HIT usually 5-10days after start of heparin or within hours if patient has been exposed to heparin within the past 3 months
-Thrombosis: new suspected or confirmed thrombus or skin lesions
-oTther causes: rule out other probable causes of HIT to inc likelihood of dx
Enoxaparin
-LMWH
-higher ratio of anti-XA:anti-IIa than UFH
-eliminated by kidneys (accumulates in renal impairment)
-do we check anti-Xa levels? No, consider in high or low body weight, renal impairment, or new or worsening clot
Bivalirudin
-direct thrombin inhibitor
-not used w GPIIb/IIIa unless bail out
-idk if its better than UFH
-may not be as effective for MACE and stent thrombosis
-may have lower bleeding risk
Fondaparinux
-Factor Xa inhibitor
-uncommon (can use in hx of HIT)
-do not use alone for PCI (high rates of thrombosis)
-must switch to UFH or bivalrudin if already given and pt needs PCI
-DO NOT USE in CrCl < 30mL/min
UFH tx
-UA, NSTEMI, STEMI
-48h or until PCI
-60 units/kg IV (max 4000units) bolus
-50-100 units/kg bolus during PCI
-12 units/kg/h titrated to aPTT target maintenance
-no maintenance dose during PCI
-no renal adjustment
Enoxaparin tx
-UA/NSTEMI: during hospital stay (up to 8 days) or until PCI
-STEMI: duration of hospital stay (upto 8 days) NOT if PCI
-30mg IV bolus
-1mg/kg sc q12h 15min after bolus (reduce to 0.75mg if 75 or older)
-1mg/kg q24h if CrCl <30mL/min
Bivalrudin tx
-Only use until PCI in NSTEMI and STEMI
-dont use in ischemia guided strategy (UA/NSTEMI)
-may consider in fibriolytic for HIT (STEMI)
-0.75mg/kg IV bolus
-1.75mg/kg/h infusion
-CrCl <30: 1mg/kg/h
-Dialysis: 0.25mg/kg/h
Fondaparinux tx
-Duration of stay for ischemia guided strategy (NSTEMI) or fibrinolytic tx (STEMI) up to 8 days
-do NOT use for PCI
-2.5mg IV bolus
-2.5mg sc q24h
-DO NOT use in CrCl < 30
