Drug therapy in ACS management

Question 1

THROMBOLYSIS IN ACS

i) what is the gold standard tx?
ii) which patient group does thrombolysis signif reduce mortality in?
iii) what type of MI will have ST depression in V1-V3? do these patients still need thrombolysis?

Answer 1

i) primary PCI
ii) thrombolysis reduces mort in STEMI but not UA/NSTEMI
iii) posterior MI - depress in V1-3 - still need thrombolysis

Question 2

ANTIPLATS IN ACS

i) which drug reduces death/MI in patients with ACS? which dose is given (loading and maint)
ii) name two P2Y12 R antagonists that are also given? what does duration of tx depend on? (3)

Answer 2

i) aspirin
- give 300mg loading then 75mg

ii) prasugrel, ticagrelor or clopidogrel
- duration of tx depends on bleeding risk, age, renal func, drug history

Question 3

GPIIB/IIIA INHIBITORS

i) which type of patients are they usually used for? why?
ii) when may they be reccomended by the cardiologist?
iii) name two

Answer 3

i) used in high risk patients as they are potent IV anti plat drugs

ii) reccom as a bridge to the cath lab in patients with ongoing pain or dynamic ECG changes
- or high thrombus burden/no reflow during PCI

iii) eptifbide and tirofiban

Question 4

ANTICOAGULANTS IN ACS

i) which mode of admin is reccom for all patients?
ii) when should they be given? especially when?
iii) which anticoag should be given at time of diagnosis of ACE?
iv) name two that may be given during PCI? what needs to be monitored during the procedure?

Answer 4

i) parenteral > subcut or IV
ii) give at time of dx and espec during PCI
iii) dx - LMWH or unfrac heparin

iv) PCI - give unfrac hep or enoxaparin
- monitor activated clotting time during the procedure

Question 5

LMWH IN ACS

i) name two reasons why LMWH is used more than UFH?
ii) give four practical adv of LMWH over UFH?
iii) which levels need to be monitored in patients on LMWH?
iv) name two drugs which made be used? which may be used if eGFR 15-29?
v) in which case is LMWH contraindicated and UFH given?
vi) what did the OASIS 5 trial show?

Answer 5

i) LMWH has a more predictable anticoag effect and lower rates of thrombocytopenia compared to UFH

ii) simple to admin (UFH needs IV)
consistent anti thrombin effect
lack of need for monitoring (UFH needs APTT monitor every few hrs)
safety profile is similar in both

iii) monitor creatinine levels for LMWH (contra indic in renal impair)

iv) fondaprinux or enoxaparin
- low eGFR = use enoxaparin 1mg/kg OD (usually BD)

v) signfificant renal impair eGFR <15 = give UGH as LMWH is contra idic

vi) OASIS-5 - fondaparinux and enox are equiv in terms of primary endpoint
fonda reduced major bleeding at 9 days
180 days - fonda signfic reduced mortality

Question 6

BETA BLOCKERS IN ACS

i) how do they affect myocardial oxygen consumption?
ii) name three things that contraindicate BB use in ACS?
iii) did the ISIS-1 trial show that atenolol was superior to placebo after acute MI?

Answer 6

i) decrease myocardial oxygen consumption
ii) CIs - asthma, acute LV dysfunction, impaired AV conduction
iii) ISIS-1 > 15% in vasc mort in first week on atenolol and 8% reduction up to 1 year

Question 7

NITRATES IN ACS

i) what is therapeutic benefit probably related to? what does this ultimately result in?
ii) name three situations where IV nitrates should be given?
iii) when should dose be titrated up until? (2)

Answer 7

i) benefit related to venodilator effects > decrease in myocardial preload and LV end dias vol > results in decreased myocardial oxygen consump
ii) pts with prlonged/recurrent chest pain, evidence of LVSD or patients waiting for the cath lab
iii) titrate up until symptoms are relieved or you get side effects (headache and hypotension)

Question 8

STATINS IN ACS

i) when should lipid lowering therapy be initiated? in which patients?
ii) what did the heart protection study show?
iii) which statin is used first line? what is added in high risk patients with recurrent ACS?

Answer 8

i) start anyone post MI on a statin even if cholesterol is low > before hospital discharge
ii) HMG COA reductase inhibitors decrease mort and coronary events in patients with high/intermed and low levels of LDL cholesterol

iii) start on atorvastatin 80mg OD
add in rosuvastatin if high risk
if no LDLC reduction with simvastatin > add ezetimibe

Question 9

ALDOSTERONE ANTAGONISTS IN ACS

i) name an aldo antag that can be used?
ii) what did the ephesus trial show?

Answer 9

i) eplerenone

ii) ephesus - determine if eplerenone results in better outcomes compared to placebo in patients with post MI LVSD on stanfard therapy eg BB and ACEi
- showed 15% relative risk reduction in all cause mortality, 21% reduction in sudden cardiac death