Acute Coronary Syndromes Flashcards
What is ACS?
•Plague buildup in the coronary arteries (coronary atherosclerosis)
•Plague can rupture, leading to clot (thrombus) and sudden, reduced blood flow (ischemia)
•This causes imbalance between myocardial oxygen supply and demand
Risk Factors
•Age: men >45 years, women >55 years (or early hysterectomy
•Family hx: 1st degree relative with coronary event before 55 years (men) or 65 years (women)
•Smoking
•HTN
•Known coronary artery disease
•Dyslipidemia
•Diabetes
•Chronic angina
•Lack of exercise
•Excessive alcohol
S/Sx
*Chest pain (pressure, squeezing) lasting >=10 min
*Severe dyspnea, diaphoresis
*Chest pain can radiate to the arms, back, neck, jaw or epigastric region
Diagnosis
- Non-segment elevation acute coronary syndromes (NSTE-ACS)
- Unstable angina (UA)
- non-ST segment elevation MI (NSTEMI)
- ST-segment elevation myocardial infarction (STEMI)
- 12-lead ECG (first medical contact)
- Patients should be transported to a hospital with percutaneous coronary intervention (PCI) capability
- Cardiac troponins I and T (TnI/TnT) are the most sensitive cardiac enzymes;
- obtained at presentation and 3-6 hrs after symptom onset in all patients with ACS symptoms
Compare UA, NSTEMI, STEMI
-
UA
*Symptoms: chest pain
*Cardiac enzymes: negative
*ECG changes: none or transient ischemic changes
*Blockage: partial -
NSTEMI
*Symptoms: chest pain
*Cardiac enzymes: positive
*ECG changes: none or transient ischemic changes
*Blockage: partial -
STEMI
*Symptoms: chest pain
*Cardiac enzymes: positive
*ECG changes: ST segment elevation
*Blockage: complete
Drug Treatment
-
NSTE-ACS
*Medications alone or PCI -
STEMI
*Needs to be opened quickly
*PCI; if not at the reasonable time frame, fibrinolytics given
*Multiple vessel disease: CABG surgery
PCI: revascularization procedure that involves inflating a balloon inside a coronary artery to widen it and improve blood flow; usually a stent is placed afterward to keep the artery open
Drug Treatment
- Immediate relief of ischemia and preventing MI expansion is aimed;
*Antianginals: decrease O2 demand
*Antiplatelets: prevent clot formation/growth
*Anticoagulants: prevent clot formation/growth
Antianginals: morphine, nitrates, BBs
Antiplatelets: aspirin, P2Y12 inhibitors, glycoprotein IIb/IIIa inhibitors
Anticoagulants: UFH, LMWH, bivalirudin
MONA-GAP-BA
- Morphine
- Oxygen
- Nitrates
- Aspirin
- GPIIb/IIIa antagonists
- Anticoagulants
- P2Y12 inhibitors
- BBs
- ACE inhibitors
NSTE-ACS: MONA-GAP-BA +/- PCI
STEMI: MONA-GAP-BA + PCI or fibrinolytic (PCI preferred)
MONA - drug effects
-
Morphine
*Antianginal: arterial and venous dilation, pain relief - Oxygen
-
Nitrates
*Antianginal: dilate arteries, improve blood flow by decreasing preload (reduces chest pain)
*Sublingual NTG (0.4 mg)
*Reduces BP
*PDE-5 inhibitors are contraindicated -
Aspirin
*Non-enteric coated, chewable (162-325 mg)
*Given all patients asap
*A maintenance dose 81-162 mg daily should continued indefinitely
Give these ASAP (PRN)
GAP - drug effects
-
GPIIb/IIIa Receptor Antagonist
*Abciximab, eptifibatide and tirofiban -
Anticoagulants
*LMWHs, UFH, bivalirudin -
P2Y12 Inhibitors
*Clopidogrel, prasugrel and ticagrelor
Give these next
BA - drug effects
-
BBs
*Increases long term survival
*Beta-1 selective without ISA is preffered -
ACE Inhibitors
*Should be continued indefinitely in all patients with LVEF <=40%
*Use ARB if intolerant
Give within 24 hrs (PRN); continue as an outpatient
Medications to avoid in the acute setting
-
NSAIDs
*Whether nonselective or COX-2 selective - Immediate release nifedipine
P2Y12 Inhibitors - MOA
- Clopidogrel and prasugrel bind to the ADP P2Y12 receptor
- Classified as thienopyridines
- Prodrugs that irreversibly bind to the receptor
- Commonly used with aspirin after an ACS; DAPT
P2Y12 Inhibitors - Clopidogrel
- Clopidogrel (Plavix)
*MD:75 mg PO daily - BW: prodrug converted to its active metabolite by CY450 2C19;
*tests to check CYP2C19 genotype - CIs: serious bleeding
- Warnings: bleeding risk;
*stop 5 days prior to elective surgery, do ot use with omeprazole or esomeprazole
P2Y12 Inhibitors - Prasugrel
- Prasugrel (Effient)
*Dispense in original container - BW: Stop at least 7 days prior to elective surgery
- CIs: serious bleeding, Hx of TIA or stroke
- Warnings: bleeding risk
P2Y12 Inhibitors - Ticagrelor
- Ticagrelor (Brilinta)
*MD: 90 mg PO BID for 1 year, then 60 mg BID - BW: do not exceed aspirin 10o mg for maintenance doses, stop 5 days before any surgery
- CIs: serious bleeding
- Warnings: bleeding risk
- SEs: bleeding, dyspnea
P2Y12 DDIs
- NSAIDs, warfarin, SSRIs, SNRIs increase the bleeding risk
GPIIb/IIIa Receptor Antagonists
- MOA: blocks platelet GPIIb/IIIa receptor
- Abciximab (ReoPro)
- Eptifibatide (Integrillin)
*SEs: bleeding, thrombocytopenia
Protease-Activated Receptor-1 Antagonist
- MOA: binds to the PAR-1
- Vorapaxar
Fibrinolytics - MOA
- MOA: cause clot breakdown by binding to fibrin and converting plasminogen to plasmin
- Used only for STEMI
- PCI is preferred; within 90 min (optimal door-to-balloon time) or within 120 min of first medical contact
- If PCI not possible, fibrinolytic therapy should be given within 30 min of hospital arrival (door-to-needle time)
Fibrinolytic - drug effects
- Alteplase (Activase)
*Recombinant tissue plasminogen activator - Tenecteplase (TNKase)
- CIs: active internal bleeding, Hx of recent stroke, severe uncontrolled HTN
- SEs: bleeding (including ICH)
- Monitoring: Hgb, Hct, s/sx of bleeding
Alteplase contraindication adn dosing differ when used for ischemic stroke
Drugs for secondary prevention after ACS
Aspirin, P2Y12 Inhibitors, Nitroglycerin, BBs
-
Aspirin
*Indefinitely (81 mg daily) -
P2Y12 Inhibitor
*Medical Therapy Patients (fibrinolytics): ticagrelor or clopidogrel with aspirin 81 mg for at least 12 months
*PCI: clopidogrel, prasugrel or ticagrelor with aspirin 81 mg daily for at least 12 months; may continue beyond if tolerating and are not at risk of bleeding -
Nitroglycerin
*Indefinitely -
BBs
*3 years; continue indefinitely if HF or if needed for management of HTN
Drugs for secondary prevention after ACS
ACE Inhibitors, Aldosterone Antagonists, Statins
-
ACE Inhibitor
*Indefinitely if EF <40%, HTN, CKD or diabetes; consider for all MI patients -
Aldosterone Antagonist
*Indefinitely if EF <=40% and either symptomatic HF or DM receiving target doses of an ACE inhibitor and BBs
*CIs: renal impairment (SCr >2.5 in men, SCr >2 in women) or hyperkalemia (K>5) -
Statin
*Indefinitely
*High-intensity statin
*Patients >=75 yeas: consider moderate or high intensity
Other Considerations
Pain relief, ACS+Afib
-
Pain relief
*Naproxen can be used if nothing works (less CV risk)
*COX-2 selective NSAIDs shuld be avoided -
ACS+Afib
*PPIs should be used if patient has a hx of GI bleeding while taking triple antithrombotic therapy
