Acute coronary syndrome meds Flashcards
List all meds used in acute MIs
Oxygen Nitrates (anti-ischemics) Analgesia BB CCB Cholesterol lowering agents RAAS inhibitors Anti-platelet agents Parenteral anticoagulation Other anti-ischemics
When do you give O2 to AMI pts?
O2 sat < 90%
Respiratory distress
Other high risk features of hypoxemia
When might O2 have negative effects in coronary pts?
Increased coronary vascular resistance
Reduced coronary blood flow
Increased risk of mortality
Significantly larger infarct sizes than those w/o O2 therapy
What do nitrates do for AMI?
Dilate capacitance vessels which decreases preload
For what do you administer nigtoglycerin and how do you give it?
Continued pain
SL
How do you dose SL nitro?
0.3-0.4 mg q 5 minutes x3
After the q5 dosing, then what do you do with nitro?
Evaluate for need for IV nitro
When do you NOT give nitro?
Why?
If on phosphodiesterase inhibitor
(If taken sildenafil in last 24 hours, or tedalafil in last 48 hours)
Decrease in BP
What is a common analgesia given to AMI pts for continued CP? How is it administered?
Morphine sulfate
IVP
Why do you give morphine sulfate for continued cp?
If pt is already on max tolerated nitro
What is another analgesia combo that is actually not given to AMI pts?
NSAIDS (not asprin) + COX2 inhibitors
Why are NSAIDS + COX2 inhibitors not given to AMI pts?
Enhances platelet aggregation by inhibiting PG synthesis
What NSAID can be used for its anti-platelet effects?
Aspirin
When do you begin BB for AMI pts?
WIthin 24 hours
Are there some exceptions to starting BB in AMI pts?
Yes
signs of HF, low output state, etc.
What BB should AMI pts w/ stable HF be continued on?
Metorpolol succinate
Carvedilol
Bisoprolol
Why do we avoid IV BBs in AMI pts?
May increase risk of shock
When do you give CCB?
Ischemic/continued pain pts with:
Contraindications to BBs
Unacceptable side-effects from BBs
Continued pain after appropriate use of BBs and nitrates
Which non-dihydropyridine CCBs are used as initial therapy for AMI pts?
Verapamil (PO)
Diltiazem (PO)
What CCB shouldnt be used for AMI pts? Why?
Imediate release nifedipine
Causes a dose-related increase in mortality in CAD and harm in ACS pts
What antianginal with minimal effects on HR and BP do we have for AMI pts?
Ranolazine
What are the AEs of ranolazine?
Constipation
Dose related QTc prolongation
What must you start AMI pts on?
Benign high-intensity statin therapy
Give the two high intensity statins that we give AMI pts and their dosing
Atorvastatin titrate 10-80 mg po once daily
Rosuvastatin titrate 5-40 mg po once daily
When do you start AMI pts on ACEI? How long do you keep them on this?
When LVEF < 40%
Indefinitely
What ACEI do you start AMI pts on in the hospital? When do you switch to a long acting ACEI?
Catopril (tid) or enalaprin (bid)
Switch to long acting @ max dose
What do you use in AMI pts intolerant to ACEIs?
ARBs
What do you add to pharmacotherapy for AMI pts who are on therapeutic doses of ACEIs and BB?
ARA
What two drugs do you never combine for heart pts?
ACEI and ARB
What is your acute anti-platelet agent? What is the dose?
Non-enteric-coated chewable aspirin
162-324 mg
Why do you not order enteric coated ASA acutely?
It delays absorption
Does 325 mg ASA = 324 mg ASA in the computerized dispensing systems?
No
What do you give to pts who are allergic or intolerant to aspirin?
Clopidogrel
What is the chronic dosing of aspirin for anti-platelet therapy for AMI pts?
81-325 mg indefinitely
What else do you add to anti-platelet therapy for AMI pts? For how long?
P2Y12 aspirin receptor inhibitor
12 months
What are the two P2Y12 aspirin agents used post AMI? How often are they dosed
Clopidogrel: daily
Ticegralor: bid
Why is pasugrel not recommended for chronic anti-platelet therapy?
Increased risk of spontaneous, life-threatening, and fatal bleeding
What other category of therapy related to blood is recommended in addition to antiplatelet therapy for all AMI pts?
Anticoagulation
What LMWH is preferred for ACS?
Enoxaparin
What is the dosing of enoxaparin for pts with CrCl > 30 mL/min for ACS?
1 mg/kg SC q 12 hours
actual body weight
What is the dosing of enoxaparin for pts with CrCl < 30 mL/min for ACS?
1 mg/kg SC q 24 hours
actual body weight
When do you avoid giving LMWH?
In dialysis pts w/ ACS
Where is anticoagulant bivalrudin often used?
Cath labs
What are the two advantages of bivalrudin over UFH or LMWH?
Will bind to clot bound thrombin (unlike heparin)
No significant protein binding (more predicatble anticoagulant response)
What kind of drug is fondaparinux?
A synthetic pentasaccharide
selective factor Xa inhibitor
Is there a risk of HITT with fondaparinux?
Minimal if any
When is fondaparinux contraindicated? Why?
CrCl < 30 mL/min
Increased risk of bleeding
When do you use fondaparinux with caution?
CrCl 30-50 mL/min
Is the half life of unfractionated heparin (UFH) long or short?
Short
1.5 hours
Can you simply d/c IV UFH or do you need to taper it in urgent interventions?
Just d/c it
How do you indicate to the pharmacist how much UFH you need?
You specify the indication (DVT, PE, NSTEMI, STEMI, PCI)
What is the initial bolus max dose of weight based UFH regimens?
4000 units
What is the initial maintenance infusion max dose for weight based UFH regimens?
1000 units/hour
When do we use the anticoagulant argatroban for ACS pts?
In pts w/ h/o HITT undergoing PCI
