Heart Disease and ACS Flashcards
What is the treatment summary for Chronic Stable Angina?
A - Antiplatelet & Antianginal medications
B - Blood Pressure & Beta Blockers
C - Cholesterol & Cigarettes
D - Diet & Diabetes
E - Exercise & Education
What is the drug treatment for Chronic Stable Angina?
1) Beta blocker +- CCB +- Nitrates +- Ranolazine, AND
2) ASA (if contraindicated, use Clopidogrel), AND
3) Nitroglycerin SL PRN
-Beta blockers are first line. If they continue to experience symptoms, add CCB or Nitrate or Ranolazine
*These patients are candidates for high-intensity statins
How does Aspirin work?
Aspirin is used first-line in Angina.
It blocks the COX enzyme, which inhibits Thromboxane A2 production. This is a potent vasoconstrictor and platelet aggregator.
Contraindications: Salicylate Allergy
How does Clopidogrel work?
Clopidogrel is a pro-drug which is converted by CYP2C19.
Do we use DAPT therapy for Chronic Stable Angina patient?
Nope..no DAPT unless the patient has a stent.
When should we use Ranolazine for Chronic Stable Angina?
If the patient has low HR or BP, you can use Ranolazine, since it has a unique mechanism which doesn’t lower BP or HR.
Contraindications of Nitrates
1) Concurrent use of PDE-5 Inhibitors (Sildenafil, tadalafil) or Riociguat
Uses of Short-Acting Nitrates
For Immediate Relief
-3 doses given at 5 minute interval
-The SL tablet (Nitroglycerin) is good for 6 months. Keep in original amber bottle.
Uses of Long-Acting Nitrates
To prevent Chest-pain
-Not to be used for acute chest pain
-Nitrate free interval is required to prevent tolerance
What is ACS?
Acute Coronary Syndrome
This results from plaque buildup in the coronary arteries.
ACS covers:
-Unstable Angina
-NSTEMI (Non-ST Segment Elevation MI)
-STEMI (ST Segment Elevation MI)
Signs and Symptoms of ACS
-Chest Pain
-Dyspnea
-Syncope or Lightheadedness
-Diaphoresis (Sweating)
What Cardiac enzymes are specific for ACS?
Troponin I & Troponin T
How can you tell if the patient is experiencing an NSTEMI, UA or STEMI based on Lab Results?
1) ST is elevated on an ECG (This is due to the complete block of the arteries)
2) There isn’t any cardiac enzyme for UA
Drug Treatment of ACS
MONA-GAP-BA
M - Morphine
O - Oxygen
N - Nitrates (SL)
A - Aspirin (non-EC coated preferred)
*These are started right away, PRN
G - gp2b/3a Antagonists (Abciximab, Eptifibatide, Tirofiban)
A - Anticoagulants (LMWH, UFH, Bivalirudin)
P - P2Y12 Inhibitor (Clopidogrel, Prasugrel, Ticagrelor)
B - Beta Blocker
A - ACE Inhibitor
*Think about initiating this within 24 hours
What is the drug treatment for a NSTE-ACS?
MONA-GAP-BA +/- PCI
What is the drug treatment for a STEMI?
MONA-GAP-BA + PCI or fibrinolytic (PCI preferred)
What medications to avoid in the acute setting?
1) NSAIDs
2) IR Nifedipine
How does Aspirin work?
It irreversibly inhibits COX-1 and COX-2, which decreases the production of thromboxane A2, to inhibit platelet aggregation.
How does P2Y12 work?
Clopidogrel, ticagrelor, prasugrel
These bind to the platelet ADP P2Y12 receptor, to inhibit platelet aggregation.
Avoid prasugrel use in Stroke Patients.
How does gp2b/3a receptor antagonists work?
Abciximab, Eptifibatide, Tirofiban
These blocks the platelet aggregation glycoprotein 2b/3a receptor, to inhibit platelet aggregation.
Important information about P2Y12 Inhibitors
Clopidogrel: It is a prodrug. Avoid omeprazole and esomeprazole use with it.
Prasugrel: Do not use in patients with a history of Stroke/TIA
How do Fibrinolytics work?
These cause clot breakdown by binding to fibrin and converting plasminogen to plasmin.
Only used for STEMI (Since this is a complete blockage)
Alteplase (Activase)
Tenecteplase(TNKase)
Reteplase (Retavase)
PCI vs. Fibrinolytics
PCI is always preferred, but in a situation where a Cath Lab is not available within 120 minutes, a fibrinolytic is used.
Secondary prevention after an ACS
1) Aspirin indefinitely
2) P2Y12 Inhibitor (DAPT)
-Medical Management: Clopidogrel or Ticagrelor + ASA for atleast 12 months
-PCI-treated: Any P2Y12 + ASA for atleast 12 months
3) NTG Spray PRN indefinitely
4) BB daily for atleast 3 years
5) ACE Inhibitor
6) Aldosterone Antagonist
7) Statin
