Dr. Rogers ACS Part 3 Flashcards
What maintenance dose of aspirin should patients with ACS take?
81 mg every day
What type of antiplatelet therapy should all ACS patients take?
-Dual antiplatelet therapy recommended for 12 months in STEMI or NSTEMI/UA
-DAPT always ASA + P2Y12 inhibitor
How are P2Y12 inhibitors dosed for DAPT?
Loading dose followed by maintenance dose in addition to aspirin
When should cangrelor be used?
Use during PCI when patient did not receive loading dose of P2Y12 inhibitor
Loading dose of clopidogrel
300-600 mg
Maintenance dose of clopidogrel
75 mg daily
Loading dose of ticagrelor
180 mg
Maintenance dose of ticagrelor
90 mg bid
Loading dose of prasugrel
60 mg
Maintenance dose of prasugrel
10 mg daily
Cangrelor loading dose
-30 mcg/kg
-Followed by 4 mcg/kg/min for 2 hours
When would you not use a loading dose of 600 mg of clopidogrel?
When using a fibrinolytic
What loading dose of P2Y12 inhibitor would you use if the patient is using a fibrinolytic and is over the age of 75?
No loading dose
What loading dose of P2Y12 inhibitor would you use if the patient is using a fibrinolytic and is under the age of 75?
300 mg loading dose
What are the main differences between clopidogrel and ticagrelor?
-Clopidogrel is a prodrug converted by CYP 2C19
-Ticagrelor has greater inhibition of platelet aggregation than clopidogrel
What is the max dose of aspirin allowed with ticagrelor?
-81 mg daily
-325 loading dose is fine
What is prasugrel not recommended in?
-Ischemia guided strategy
-Patients 75 years old or older
-Patients less than 60 kg
-Patients with a high bleeding risk
What is prasugrel contraindicated in?
Patients with a history of TIA/stroke
What is a pro of prasugrel?
Greater inhibition of platelet aggregation than clopidogrel post PCI
Why would you switch from clopidogrel to one of the other P2Y12 inhibitors?
Inadequate response to clopidogrel
Why would you switch from ticagrelor to clopidogrel?
-Bleeding
-Cost
-Dyspnea
-Adherence
Why would you switch from prasugrel to clopidogrel?
-Bleeding
-Cost
-Stroke/TIA
Which P2Y12 inhibitor would you use for ischemia guided therapy in NSTEMI/UA?
Clopidogrel or ticagrelor
Which P2Y12 inhibitor would you use for a PCI in NSTEMI/UA?
Any could be used but there is a preference for prasugrel or ticagrelor
Which P2Y12 inhibitor would you use for a PCI in STEMI?
Ticagrelor or prasugrel preferred
Which P2Y12 inhibitor would you use with a fibrinolytic in STEMI?
Clopidogrel preferred
Patient counseling for aspirin
-Need to take lifelong to prevent heart attack
-Take with food
-Risk of bleeding
Patient counseling for P2Y12 inhibitors
-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)
Minor signs and symptoms of bleeding
-Bruising
-Light nosebleeds
-Bleeding gums when flossing
Major signs and symptoms of bleeding
-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
When must you hold aspirin prior to a CABG?
Does not need to be held prior to CABG
When must you hold P2Y12 inhibitors prior to an urgent CABG?
Hold for 24 hours prior to urgent CABG if possible
When must you hold P2Y12 inhibitors prior to an elective CABG?
-Ticagrelor: 3 days
-Clopidogrel: 5 days
-Prasugrel: 7 days
When are GP IIb/IIIa inhibitors given?
-Given at the time of a PCI
-Given in addition to aspirin and P2Y12 inhibitors
When would an NSTEMI patient receive GP IIb/IIIa inhibitors?
-High risk features such as positive troponin
-Inadequate P2Y12 loading
-Bail out
When would a STEMI patient receive GP IIb/IIIa inhibitors?
-Large thrombus burden
-Inadequate P2Y12 loading
-Bail out
What does it mean to bail out?
Use during the procedure if thrombus develops or low blood after stenting
Bolus dose of abciximab
0.25 mg/kg IV
Maintenance dose of abciximab
-0.125 mcg/kg/min up to 12 hours
-No renal adjustment
Bolus dose of eptifibatide
180 mcg/kg IV x 2 10 minutes apart
Maintenance dose of eptifibatide
-2 mcg/kg/min up to 18 hours
-Renal adjustment: 1 mcg/kg/min when CrCl is less than 50
Bolus dose of tirofiban
25 mcg/kg IV
Maintenance dose of tirofiban
-0.15 mcg/kg/min up to 18 hours
-Renal adjustment: 0.075 mcg/kg/min when CrCl is less than 60
