Antiplatelet Therapy in ACS

Question 1

NSTE-ACS Ischemia Guided antiplatelet Agents

Answer 1

Aspirin; + clopidogrel or TIC

Question 2

NSTE-ACS Invasive Antiplatelet Agents

Answer 2

ASA + Clopidogrel/PRA/TIC

Question 3

STEMI Primary PCI Antiplatelet Agents

Answer 3

ASA + Clopidogrel/PRA/TIC

Question 4

STEMI+ Fibrinolytic Antiplatelet Agents

Answer 4

ASA+ Clopidrogrel

Question 5

Aspirin in ACS dose

Answer 5

Initiate 81–325 mg of non–enteric-coated ASA before PCI in patients already taking ASA; in patients not taking ASA, give 325 before PCI; after PCI, continue ASA 81 mg indefinitely

Question 6

ticagrelor over clopidogrel in ACS

Answer 6

NSTE-ACS or STEMI treated with an early invasive strategy or coronary stenting

Question 7

prasugrel over clopidogrel in ACS

Answer 7

NSTE-ACS or STEMI who undergo PCI and who are not at high risk of bleeding complications and have no history of transient ischemic attack or stroke

Question 8

Clopridogrel ACS dosing

Answer 8

600 mg (300 mg if within 24 hr of event) followed by 75 mg daily, Avoid LD if patient is ≥ 75 yr in STEMI when fibrinolysis is given

Question 9

Prasugrel dosing for ACS

Answer 9

60 mg followed by 10 mg daily

Question 10

Ticagrelor dosing ACS

Answer 10

180 mg followed by 90 mg BID

Question 11

Ticagrelor Interactions

Answer 11

Strong 3A4 inhibitors increase TIC conc; NTE 40 mg of simvastatin or lovastatin, Limit aspirin to < 100 mg; monitor digoxin conc

Question 12

Oral P2Y12 surgery holding time

Answer 12

Clopidogrel/TIC - 5 days (24 hr for emergency CABG)
PRA- 7 days

Question 13

Prasugrel Contraindications/Cautions

Answer 13

TIA, CVA; avoid > 75 yr unless the patient has diabetes mellitus or a history of MI

Question 14

Ticagrelor Contraindications

Answer 14

ICH; severe hepatic disease

Question 15

Intravenous GP IIb/IIIa inhibitor benefit

Answer 15

when added aspirin therapy benefit is greatest among those with highest-risk features (those with elevated biomarkers, diabetes, undergoing revascularization) and in those not receiving adequate pretreatment with clopidrogel or TIC.

Question 16

Eptifibatide (Integrilin) Dosing for ACS

Answer 16

Bolus: 180 mcg/kg x2 q10 min for PCI (x1 w/o PCI)
2 mcg/kg/min initiated after first bolus for 18–24 hr;
CrCl < 50 mL/min, reduce infusion by 50%

Question 17

Tirofiban (Aggrastat) Dosing for ACS

Answer 17

PCI: 25 mcg/kg IVB over 3 min; then 0.15 mcg/kg/min for 18 hr; CrCl ≤ 60 mL/min, reduce infusion by 50%

Question 18

GP IIb/IIIa inhibitors CABG Holding TIme

Answer 18

discontinued for at least 2 hours before surgery to limit blood loss and transfusion