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3154 Haematology > IC6 AIS, AMI + Antiplatelets > Flashcards

IC6 AIS, AMI + Antiplatelets Flashcards

1
Q

What are the 3 things to check when suspect have MI/ACS?

A

b. Acute Coronary Syndrome
i. *3 things to check:
ii. S&S e.g. Chest pain – exertional (CCS), at rest (ACS)
iii. ECG changes within 10min of presentation – STEMI (worse), NSTEACS
iv. Cardiac enzyme changes (troponin) for NSTEACS – enzyme rise (NSTEMI), never rise (unstable angina)

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2
Q

What are the S&S of MI?

A

S&S:

  • Chest pain, heaviness on chest, breathlessness & feeling suffocated, widespread pain at epigastric area but cannot pinpoint
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3
Q

What are the possible differential diagnosis of MI?

A

Differential Diagnosis:

  • GERD/PUD/hyperacidity secondary to skipping meals (similar widespread pain in epigastric area)
  • Hypoglycaemia
  • Infection/fever
  • AIS
  • HF (troponin levels can rise too, where cardiac muscles will die)
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4
Q

What are the S&S of stroke?

A

S&S:

  • Face droop
  • Arm weakness
  • Speech difficulty and slurring
  • Time –> 3-4.5hrs time window, as ischaemic but not dead yet
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5
Q

What does NIHSS and ABCD2 tells us?

A

NIHSS → tell us where the infarct is in the brain (location and extent)

  • 0-5: minor stroke, thus no need rTPA
  • > 5: major stroke, thus need rTPA (when you decide to give rTPA, look at the checklist in IC4)

ABCD2 → tell us the risk of ischaemic stroke in the 1st 2 days after TIA

  • only when person have TIA
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6
Q

What is the treatment algorithm for new onset AIS (not on antithrombotic therapy)?

A
  1. eligible for rTPA → SAPT after 24hrs within 48hrs → evaluate stroke mechanism
  2. not eligible for rTPA → minor stroke /high risk TIA → DAPT ASAP for 21 days
    → not minor stroke /high risk → SAPT ASAP → evaluate stroke mechanism

After stroke mech evaluation → IF cardioembolic → stop ATP → start OACG if underlying AF

→ IF non-cardioembolic → severe major ICAS → may consider adding clopi to ASA for 90 days → SAPT lifelong
→ non-severe major ICAS → SAPT lifelong

*start high intensity statins Atorvastatin 40mg/rosuvastatin 20mg

A&E:
Thrombolytics once confirm is AIS

ICU:
**Aspirin + clopidogrel **after 24hrs (within 48hrs)
OR
IF stroke due to AF, give DOACs after 24hrs (within 48hrs)

Gen ward:
VTEP (since immobile after stroke), give LMWH after 24hrs if rTPA used (within 48hrs)
OR
IPC (compression stockings) for high bleeding risk within 72hrs

Home:
SAPT lifelong; DAPT duration 21d or 90d (per indication)

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7
Q

What are the 3 ICAS arteries?

A
  • Intracranial Artery Stenosis
    o 3 main large arteries involved:
    o Anterior, middle, posterior cerebral artery
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8
Q

What is the follow up for AIS?

A

Follow up:

  1. Duration of ATP/ACG
    a. DAPT 21d or 90d, ASA: lifelong
  2. Monitoring and follow up
    a. Labs: FBC, Hg (bleeding)
    b. ADR
    c. RF: HTN; High dose statin therapy
  3. Counselling
    a. Education on use of DAPT/SAPT
    b. Adherence
    c. Manage RF
    d. Bleeding risk
    e. Surgery what to do
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9
Q

What is the place in therapy, dose, monitoring/SE of concern, quirks of Aspirin?

A

Aspirin (PO)

*commonly monotherapy

1) Load 300mg
(if currently not on aspirin)

2) then 100mg OM lifelong

Bleeding

1) 1 of the DAPT, unless allergic (cross reactivity with NSAIDs)
2) NO longer for primary prevention for ASCVD e.g. MI, unless atherosclerosis Cardiac, Neuro

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10
Q

What is the place in therapy, dose, monitoring/SE of concern, quirks of Clopidogrel?

A

Clopidogrel (PO)

*can be monotherapy
1) Load 300mg OR 600mg
Onset: 6h OR 2h
2) Then 75mg OM

Bleeding, hypersensitivity

1) CYP2C19 LoF pts have increased risk of MACCE
2) non-LoF pts have similar risk of MACCE
3) GoF pts have no benefit/loss

Cardiac, Neuro

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11
Q

What is the place in therapy, dose, monitoring/SE of concern, quirks of dipyridamole?

A

Dipyridamole (PO)

*not in Sg
*combi drug w aspirin

25-150mg TDS

Flushing, dizziness, abdominal distress

1) PO used as secondary prevention of stroke post AIS
2) IV used as imaging agent in cardiology

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12
Q

What is the place in therapy, dose, monitoring/SE of concern, quirks of ticagrelor?

A

Ticagrelor (PO)

*can be monotherapy

generally for ACS after PCI

1) Load 180mg
2) 90mg BD for 12m
3) 60mg BD (extended therapy)

Bleeding, dyspnea, bradycardia

1) Not metabolized by CYP2C19 –> preferred over clopi for ACS [those PCI with stent inserted] (but NOT CCS)
2) Bleeding risk higher than clopi
3) possibly genotype pts to select P2Y12i for ACS+PCI
Cardiac, Neuro (Large vessel)

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13
Q

When is eptifibatide used?

A

Eptifibatide (IV)

Short t1/2, needs to be infused for 72hrs (esp. after PCI where thrombus is evolving)

1) Renal dose adjust when CrCL < 50mL/min, not used in ESRD

PCI (before using potent APT)

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14
Q

What are the difference btwn Clopi and Tica?

A

Clopidogrel Prasugrel Ticagrelor
Prodrug?: Prodrug Prodrug No
MOA: Irreversible Irreversible Reversible
Time to Peak: 300mg LD,75mg MD – 6h
**600mg LD, 75mg MD – 2h **
Time to reach steady state: 5-6days 2days
***recovery from stopping Tica is 2x faster than for clopi
*but need good adherence **
When to stop for surgery: Min 5 days Min 7 days ** Min 3 days **
Metabolism CYP2C19 Not affected by CYP2C19 Not affected by CYP2C19
Quirks: Clopi effects decrease in individuals with CYP2C19 LoF
(less metabolized, less active metabolite)
Tica has Adenosine effect:
Dyspnea, bradycardia

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15
Q

What are the goals of therapy?

A

AIS then AMI
Thrombolytic agents:
reperfusion
reperfusion
ACG:
For 2nd prevention of Cardioembolic stroke (SPAF)
Combat thrombus expansion
ATP:
SAPT, DAPT 21d or 90d
DAPT Tica 12m for ACS; Clopi 6m for CCS
Treatment of CV RF:
2nd prevention (ASCVD):
H, D, L

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16
Q

What is the acute management of MI?

A

On the way to hospital: Load aspirin

A&E: Load P2Y12i if go for PCI (OR thrombolytics is an alt to PCI)

Cath: UFH bolus (ACT) + eptifibatide (to prevent growth of thrombus)

ICU: DAPT (usually tica if ACS)

Gen Ward: DAPT (usually tica if ACS; clopi if CCS)
DAPT (min 12m if ACS; 6m if CCS)

*but if high bleeding risk, will give 3-6months

17
Q

How to choose DAPT?

A

How to choose DAPT for ACS?

  1. IF CCS + did PCI –> clopidogrel (600mg LD, 75mg MD) + aspirin for 6 months –> then aspirin lifelong
  2. IF ACS STEMI + gave thrombolytics –> clopidogrel (300mg LD, 75mg MD) + aspirin
  3. IF ACS + did PCI –> 12 months of DAPT (aspirin + tica/clopi/prasu)
    a. Unless bleeding risk is high –> reduce duration to 3-6months DAPT
18
Q

What are the major and minor criteria for bleeding risk to shorten duration of therapy?
How many major/minor criteria needed to be considered as high bleeding risk?
What do you shorten the duration to?

A

Bleeding risk assessment –> to determine high risk, which shortens duration of therapy:
Need 1 major criteria OR 2 minor criteria for high bleeding risk
Major criteria:

  1. Anticipated long term OACG
  2. Severe / end stage CKD (eGFR<30)
  3. Hg < 11
  4. Spontaneous Bleed needing hospitalization or transfusion in past 6months

Minor Criteria:

  1. Age > 75y/o
  2. Mod CKD (eGFR 30-59)
  3. Hg 11-12.9 / 11-11.9
  4. Spontaneous Bleed needing hospitalization or transfusion in past 12months
  5. Long term oral NSAIDs/steroids
  6. Any ischaemic stroke

If high bleeding risk: consider stopping P2Y12i after 3months

19
Q

What are some of the criteria for extending therapy? (technically FYI) What will the duration be?

A

Criteria for Extended Therapy >12months (becos higher risk of clotting):
**High thrombogenic risk **
–> Complex CAD + at least 1 criteria
DM
MI
Multivessel/polyvascular/premature or accelerated CAD
Continuous systemic inflammatory disease e.g. HIV, SLE, chronic arthritis
CKD 15-59
3 stents
3 lesions treated
stent >60mm
Complex revascularization
History of stent thrombosis on ATP therapy

Moderate thrombotic risk :
Non-complex CAD + at least 1 criteria
DM
MI
Poly-vascular CAD
CKD 15-59

20
Q

If patient has AMI and has PCI, and has high bleeding risk, what i the duration of therapy?

A

*If high bleeding risk: consider stopping P2Y12i after 3months

21
Q

What is the follow up for AMI?

A

Follow Up:

  1. Duration of APT – Aspirin lifelong, P2Y12i depends on (12m for ACS/ 6m for CCS)
  2. Monitor & TCU – bleeding, FBC, dypsnea (tica)
  3. Counselling
    a. Explain thrombogenicity of cardiac stents (as explained below^)
    b. DAPT complementary, why need to be adherence
    c. Duration of DAPT, aspirin usually lifelong
    d. When have invasive procedures required (usually small surgery don’t need to stop, e.g. dental extraction)
  4. Manage CV RF (secondary prevention of CVD and ASCVD)
    a. HTN< 130/80mmHg
    b. DM < 7%
    c. Cholesterol, give statins
    d. Exercise, 150mins of moderate exercise /week
    e. Diet
    f. Smoking cessation
    g. Low dose Aspirin (if pri prevention, only for atherosclerosis)

^Types of stents:
1. Bare metal stent (BMS) – hardly used now
2. 1st gen Drug eluting stent (DES)
a. Paclitaxel, sirolimus
b. More thrombogenic
3. 2nd gen DES
a. Everolimus, zotarolimus
b. Less thrombogenic

Impt to give DAPT while on stent becos:
1. In stent thrombosis (IST)
2. In stent restenosis (ISR)

22
Q

WRT CYP2C19 polymorphism and clopidogrel:
What if patient has *2 or *3 alleles, what metabolizers do they have and what are they at risk of?
What should you do if they have these alleles (in terms of the drugs given)?

A

Polymorphism CYP2C19 and Clopidogrel
*2 and *3 (loss of function) –> intermediate metabolizers or poor metabolizers
- Higher risk of MACCE following PCI/stroke/TIA
- Thus give ticagrelor or prasugrel –> since they are potent agents but not activated by CYP2C19
*17 (gain of function) –> ultra-rapid metabolizers (have no adv)

3154 Haematology (8 decks)

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