Dr. Rogers ACS Part 3

Question 1

What maintenance dose of aspirin should patients with ACS take?

Answer 1

81 mg every day

Question 2

What type of antiplatelet therapy should all ACS patients take?

Answer 2

-Dual antiplatelet therapy recommended for 12 months in STEMI or NSTEMI/UA
-DAPT always ASA + P2Y12 inhibitor

Question 3

How are P2Y12 inhibitors dosed for DAPT?

Answer 3

Loading dose followed by maintenance dose in addition to aspirin

Question 4

When should cangrelor be used?

Answer 4

Use during PCI when patient did not receive loading dose of P2Y12 inhibitor

Question 5

Loading dose of clopidogrel

Answer 5

300-600 mg

Question 6

Maintenance dose of clopidogrel

Answer 6

75 mg daily

Question 7

Loading dose of ticagrelor

Answer 7

180 mg

Question 8

Maintenance dose of ticagrelor

Answer 8

90 mg bid

Question 9

Loading dose of prasugrel

Answer 9

60 mg

Question 10

Maintenance dose of prasugrel

Answer 10

10 mg daily

Question 11

Cangrelor loading dose

Answer 11

-30 mcg/kg
-Followed by 4 mcg/kg/min for 2 hours

Question 12

When would you not use a loading dose of 600 mg of clopidogrel?

Answer 12

When using a fibrinolytic

Question 13

What loading dose of P2Y12 inhibitor would you use if the patient is using a fibrinolytic and is over the age of 75?

Answer 13

No loading dose

Question 14

What loading dose of P2Y12 inhibitor would you use if the patient is using a fibrinolytic and is under the age of 75?

Answer 14

300 mg loading dose

Question 15

What are the main differences between clopidogrel and ticagrelor?

Answer 15

-Clopidogrel is a prodrug converted by CYP 2C19
-Ticagrelor has greater inhibition of platelet aggregation than clopidogrel

Question 16

What is the max dose of aspirin allowed with ticagrelor?

Answer 16

-81 mg daily
-325 loading dose is fine

Question 17

What is prasugrel not recommended in?

Answer 17

-Ischemia guided strategy
-Patients 75 years old or older
-Patients less than 60 kg
-Patients with a high bleeding risk

Question 18

What is prasugrel contraindicated in?

Answer 18

Patients with a history of TIA/stroke

Question 19

What is a pro of prasugrel?

Answer 19

Greater inhibition of platelet aggregation than clopidogrel post PCI

Question 20

Why would you switch from clopidogrel to one of the other P2Y12 inhibitors?

Answer 20

Inadequate response to clopidogrel

Question 21

Why would you switch from ticagrelor to clopidogrel?

Answer 21

-Bleeding
-Cost
-Dyspnea
-Adherence

Question 22

Why would you switch from prasugrel to clopidogrel?

Answer 22

-Bleeding
-Cost
-Stroke/TIA

Question 23

Which P2Y12 inhibitor would you use for ischemia guided therapy in NSTEMI/UA?

Answer 23

Clopidogrel or ticagrelor

Question 24

Which P2Y12 inhibitor would you use for a PCI in NSTEMI/UA?

Answer 24

Any could be used but there is a preference for prasugrel or ticagrelor

Question 25

Which P2Y12 inhibitor would you use for a PCI in STEMI?

Answer 25

Ticagrelor or prasugrel preferred

Question 26

Which P2Y12 inhibitor would you use with a fibrinolytic in STEMI?

Answer 26

Clopidogrel preferred

Question 27

Patient counseling for aspirin

Answer 27

-Need to take lifelong to prevent heart attack -Take with food -Risk of bleeding

Question 28

Patient counseling for P2Y12 inhibitors

Answer 28

-Take with aspirin for one year to prevent heart attack -Risk of bleeding -Take 12 hours apart (ticagrelor) -Let your doctor know if you experience increased shortness of breath (ticagrelor)

Question 29

Minor signs and symptoms of bleeding

Answer 29

-Bruising -Light nosebleeds -Bleeding gums when flossing

Question 30

Major signs and symptoms of bleeding

Answer 30

-Blood in urine -Blood in stool (often dark and tarry) -Coughing up blood (looks like coffee grounds) -Cut that will not stop bleeding after putting strong pressure on it for 10 minutes

Question 31

When must you hold aspirin prior to a CABG?

Answer 31

Does not need to be held prior to CABG

Question 32

When must you hold P2Y12 inhibitors prior to an urgent CABG?

Answer 32

Hold for 24 hours prior to urgent CABG if possible

Question 33

When must you hold P2Y12 inhibitors prior to an elective CABG?

Answer 33

-Ticagrelor: 3 days -Clopidogrel: 5 days -Prasugrel: 7 days

Question 34

When are GP IIb/IIIa inhibitors given?

Answer 34

-Given at the time of a PCI -Given in addition to aspirin and P2Y12 inhibitors

Question 35

When would an NSTEMI patient receive GP IIb/IIIa inhibitors?

Answer 35

-High risk features such as positive troponin -Inadequate P2Y12 loading -Bail out

Question 36

When would a STEMI patient receive GP IIb/IIIa inhibitors?

Answer 36

-Large thrombus burden -Inadequate P2Y12 loading -Bail out

Question 37

What does it mean to bail out?

Answer 37

Use during the procedure if thrombus develops or low blood after stenting

Question 38

Bolus dose of abciximab

Answer 38

0.25 mg/kg IV

Question 39

Maintenance dose of abciximab

Answer 39

-0.125 mcg/kg/min up to 12 hours -No renal adjustment

Question 40

Bolus dose of eptifibatide

Answer 40

180 mcg/kg IV x 2 10 minutes apart

Question 41

Maintenance dose of eptifibatide

Answer 41

-2 mcg/kg/min up to 18 hours -Renal adjustment: 1 mcg/kg/min when CrCl is less than 50

Question 42

Bolus dose of tirofiban

Answer 42

25 mcg/kg IV

Question 43

Maintenance dose of tirofiban

Answer 43

-0.15 mcg/kg/min up to 18 hours -Renal adjustment: 0.075 mcg/kg/min when CrCl is less than 60