IC6- ASCVD and stroke Flashcards
What is needed for diagnosis of ACS? (3)
- Classical MI SSx
- ECG changes (ST elevation/ depression)
- Elevated troponin levels
What do you do for ACS?
Suspected ACS → 💊 load aspirin 100/300mg → if pt meets 3 criteria for diagnosis of MI → send the pt for primary angioplasty/ PCI; meanwhile load pt on 💊ticegrelor 180mg/ clopidogrel 600mg.
If needed, other medications: IV bolus UFH (most commonly used)/ LMWH, IV bolus GPIIb/IIIa [Eptifibatide] f/b infusion, IV cangrelor (P2Y12i), IV fibrinolytics (hardly used today)
What are the follow-up plans after ACS Tx? (3)
- Tx: Aspirin lifelong, P2Y12i according to indication
- Monitoring 📈: bleeding, FBC, dyspnoea (ticagrelor)
- Pt counselling
- Emphasize on importance of adherence in the 12m
- Using a soft bristled toothbrush to prevent gum bleeding
- Watch out for 🚩red flags like GI bleeding (black, tarry stools)
- Work on other CVD risk factors: Cholesterol, high BP, physical activity, aspirin use (low-dose for high-risk pts), T2DM, diet, tobacco
What is the function of DAPT after coronary stenting?
To prevent in-stent thrombosis
How do PPIs help with bleeding risk?
What kind of pts can you give them to?
PPIs help to reduce incidences of GI bleeding, hence can be given to pts who esp have Hx of GI bleeding
What is the Tx and duration for STEMI after PCI?
What is the dosing?
Aspirin 100mg (usually lifelong) + ticagrelor load 180mg then 90mg BD up to 12m to prevent in-stent thrombosis
What is the Tx and duration for NSTEMI?
What is the follow-up Tx?
Pt with NSTEMI already initiated on aspirin:
1. Ischemia-guided strategy: ticagrelor, clopidogrel
2. Early coronary angiography/ early invasive strategy: ticagrelor (1st choice), clopidogrel (3rd choice)
Follow-up Tx:
- Continue aspirin indefinitely
- Discontinue ticagrelor or clopidogrel 5 days before CABG for pts undergoing revascularisation
- Ticegrelor/ prasugrel (or clopidogrel 2nd choice) for 12m
What is the most important thing to look at when determining DAPT duration?
Bleeding risk
When is extended DAPT Tx (30 months) needed?
Usually for recurrent ischaemia
How many major and minor criterion must the patient fulfil to have a HBR?
If the pt meets 1 MAJOR criterion OR 2 MINOR criterion
What happens to DAPT Tx duration if patient has HBR?
May want to shorten duration of DAPT to 3m (but can keep aspirin lifelong)
What are the major criterion for HBR? (13)
- Anticipated use of long-term anticoagulation
- Severe/ ESCKD (eGFR < 30 mL/min)
- Hb < 11g/dL
- Spontaneous bleeding req hospitalisation or transfusion in past 6 months or any time (if recurrent)
- Moderate or severe baseline thrombocytopenia (platelet count < 100 x 109/L)
- Chronic bleeding diathesis
- Liver cirrhosis with portal HTN
- Active malignancy (excluding nonmelanoma skin cancer) within past 12m
- Previous spontaneous ICH
- Presence of a bAVM
- Moderate or severe ischemic stroke within past 6m
- Nondeferrable major surgery on DAPT
- Recent major surgery or major trauma within 30d before PCI
What are the minor criterion for HBR? (7)
- Age ≥75 y/o
- Moderate CKD (eGFR 30-59 mL/min)
- Hb 11-12.9 g/dL for men
- Hb 11-11.9 g/dL for women
- Spontaneous bleeding requiring hospitalisation or transfusion within past 12m (not meeting major criterion)
- Long term use of PO NSAIDs or steroids
- Any ischemic stroke at any time (not meeting major criterion)
In what situations would you extend DAPT Tx? (3)
- Low bleeding risk
- High ischaemic risk
- Recurrent MI despite adequate Tx
In what situations would you shorten DAPT Tx? (1)
High bleeding risk
Following the ischaemic risk assessment, what are the factors favouring DAPT escalation? (Clopidogrel → Ticagrelor) (6)
- Prior stent thrombosis on adequate antiplatelet Tx
- Stenting of the last remaining patent coronary artery
- Diffuse multivessel disease (esp in pts with diabetes) implanted ≥ 3 stents
- Bifurcation with 2 stents implanted (esp left main coronary artery)
- Total stent length > 60mm
- Tx of chronic total occlusion
Following the ischaemic risk assessment, what are the factors favouring DAPT de-escalation? (Ticagrelor → Clopidogrel) (3)
- Prior major bleeding/ major hemorrhage
- Anemia
- Clinically significant bleeding on dual anti-thrombotic Tx
How does LOF carriers of CYP2C19 affect Clopidogrel metabolism?
How does ticagrelor compare to clopidogrel in LOF carriers?
Loss-of-function carriers of CYP2C19 may impair the conversion of clopidogrel into its active form → higher risk of Tx failure and adverse cardiovascular events → hence ticagrelor is superior to clopidogrel
How does ticagrelor compare to clopidogrel in non-LOF carriers?
For loss-of-function non-carriers of CYP2C19, clopidogrel non-inferior to ticagrelor
What are all the allele combinations that code for poor CYP2C19 metabolisers of clopidogrel?
Intermediate metabolisers (still poorer than normal metabolisers):
- 1/2
- 1/3
Poor metabolisers:
- 2/2
- 2/3
- 3/3
What is the Tx and duration for SHID?
Aspirin + clopidogrel for 6m
- Followed by aspirin monoTx lifelong
What is the loading dose of clopidogrel used? (ACS)
Which is more common? And what are their onset times?
Clopidogrel dosing: load 300mg/ 600mg (more common) then 75g OM
Note: onset time is > 6h for 300mg, whereas 2h for 600mg
What are the 2 different types of stroke?
Which is the one where antithrombotics are contraindicated?
- Ischaemic stroke → blocked artery
- Hemorrhagic stroke → ruptured artery (antithrombotics C/I!)
What does the NIHSS scale tell us?
Does it help to tell us whether thrombolytics can be used?
Severity of the stroke
Also assesses eligibility for rTPA (thrombolytics)
Moderate - High NIHSS scores → ✅ thrombolysis
What is the NIHSS score considered major stroke?
Major: NIHSS ≥ 5
What does the ABCD2 score tell us?
Can be used to estimate risk of ischaemic stroke in first 2 days after TIA
What are the ABCD2 score risk factors? And subsequent points?
Age
- ≥60 y/o → 1 point
- < 60 y/o → 0 points
Blood pressure after TIA
- SBP ≥140 mmHg or DBP ≥ 90 mmHg → 1 point
- SBP < 140 mmHg and DBP < 90 mmHg → 0 points
Clinical features
- Unilateral weakness → 2 points
- Isolated speech disturbance → 1 point
Duration of TIA SSx
- ≥60 min → 2 points
- 10-59 min → 1 point
- < 10 mins → 0 points
Diabetes
- Present → 1 point
- Absent → 0 points
For a patient with new-onset AIS who is not on antithrombotic Tx, what are the factors you consider for eligibility of rTPA?
- Major stroke NIHSS ≥ 5 (if NIHSS < 5 then don’t need to start rTPA)
- Presenting within 3h of SSx onset (up to 4.5h with additional criteria)
- Disabling stroke SSx
- BP < 185/110 mmHg, blood glucose > 2.8 mmol/L
- CT brain changes
For a patient with new-onset AIS who is not on antithrombotic Tx and is eligible for rTPA, what are your next steps?
- Start SAPT after 24h (within 48h of thrombolytic)
- Evaluate stroke mechanism
- MRI brain
- 24 Holter
- TTE
- US carotids
- Lipid panel, TFTs, HbA1c
What must you monitor after thrombolysis? For how long? (v impt!)
Monitor BP for 24h
For a patient with new-onset AIS who is not on antithrombotic Tx and is NOT eligible for rTPA, what are your next steps?
- Minor stroke (NIHSS 0-3) or high risk TIA (ABCD2 ≥ 4): start DAPT asap x 21d
OR
Not minor stroke or high risk TIA: start SAPT asap - Evaluate stroke mechanism
- MRI brain
- 24 Holter
- TTE
- US carotids
- Lipid panel, TFTs, HbA1c
After assessing stroke mechanism, if it’s a cardioembolic stroke, what do you do?
Stop antiplatelet Tx and start OAC (do not start within 24h of rTPA)
** DON’T FORGET:
Also tart high-intensity statin if no contraindications
- Atorvastatin 40-80 mg OD
- Rosuvastatin 20-40 mg OD
For stroke mechanism, which 3 main arteries do severe major ICAS (intracranial arthero stenosis stroke) refer to?
- Anterior cerebral artery
- Middle cerebral artery
- Posterior cerebral artery
After assessing stroke mechanism, if it’s a non-cardioembolic stroke, severe major ICAS, what do you do?
May be reasonable to add clopidogrel to ASA x 90d, followed by lifelong SAPT
** DON’T FORGET:
Also tart high-intensity statin if no contraindications
- Atorvastatin 40-80 mg OD
- Rosuvastatin 20-40 mg OD
After assessing stroke mechanism, if it’s a non-cardioembolic stroke, non-severe major ICAS, what do you do?
Lifelong SAPT
** DON’T FORGET:
Also tart high-intensity statin if no contraindications
- Atorvastatin 40-80 mg OD
- Rosuvastatin 20-40 mg OD
For stroke, what are the 2 antiplatelets used for SAPT and DAPT? What are their doses?
ASA (100mg) and clopidogrel (75mg OM)
For stroke pts, due to their immobilisation in bed, what must you consider?
What drug do you give and when?
VTEp!!!
Can give LMWH within 48h but AFTER 24h if rTPA is used
How long before surgery do we stop clopidogrel and ticagrelor?
Clopidogrel → MINIMUM 5 days before surgery
Ticagrelor → 2-3 days
