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PR3154 > IC6- ASCVD and stroke > Flashcards

IC6- ASCVD and stroke Flashcards

1
Q

What is needed for diagnosis of ACS? (3)

A
  1. Classical MI SSx
  2. ECG changes (ST elevation/ depression)
  3. Elevated troponin levels
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2
Q

What do you do for ACS?

A

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)

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3
Q

What are the follow-up plans after ACS Tx? (3)

A
  1. Tx: Aspirin lifelong, P2Y12i according to indication
  2. Monitoring 📈: bleeding, FBC, dyspnoea (ticagrelor)
  3. 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
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4
Q

What is the function of DAPT after coronary stenting?

A

To prevent in-stent thrombosis

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5
Q

How do PPIs help with bleeding risk?

What kind of pts can you give them to?

A

PPIs help to reduce incidences of GI bleeding, hence can be given to pts who esp have Hx of GI bleeding

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6
Q

What is the Tx and duration for STEMI after PCI?

What is the dosing?

A

Aspirin 100mg (usually lifelong) + ticagrelor load 180mg then 90mg BD up to 12m to prevent in-stent thrombosis

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7
Q

What is the Tx and duration for NSTEMI?

What is the follow-up Tx?

A

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

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8
Q

What is the most important thing to look at when determining DAPT duration?

A

Bleeding risk

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9
Q

When is extended DAPT Tx (30 months) needed?

A

Usually for recurrent ischaemia

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10
Q

How many major and minor criterion must the patient fulfil to have a HBR?

A

If the pt meets 1 MAJOR criterion OR 2 MINOR criterion

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11
Q

What happens to DAPT Tx duration if patient has HBR?

A

May want to shorten duration of DAPT to 3m (but can keep aspirin lifelong)

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12
Q

What are the major criterion for HBR? (13)

A
  • 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
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13
Q

What are the minor criterion for HBR? (7)

A
  • 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)
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14
Q

In what situations would you extend DAPT Tx? (3)

A
  • Low bleeding risk
  • High ischaemic risk
  • Recurrent MI despite adequate Tx
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15
Q

In what situations would you shorten DAPT Tx? (1)

A

High bleeding risk

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16
Q

Following the ischaemic risk assessment, what are the factors favouring DAPT escalation? (Clopidogrel → Ticagrelor) (6)

A
  • 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
17
Q

Following the ischaemic risk assessment, what are the factors favouring DAPT de-escalation? (Ticagrelor → Clopidogrel) (3)

A
  • Prior major bleeding/ major hemorrhage
  • Anemia
  • Clinically significant bleeding on dual anti-thrombotic Tx
18
Q

How does LOF carriers of CYP2C19 affect Clopidogrel metabolism?

How does ticagrelor compare to clopidogrel in LOF carriers?

A

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

19
Q

How does ticagrelor compare to clopidogrel in non-LOF carriers?

A

For loss-of-function non-carriers of CYP2C19, clopidogrel non-inferior to ticagrelor

20
Q

What are all the allele combinations that code for poor CYP2C19 metabolisers of clopidogrel?

A

Intermediate metabolisers (still poorer than normal metabolisers):
- 1/2
- 1/3

Poor metabolisers:
- 2/2
- 2/3
- 3/3

21
Q

What is the Tx and duration for SHID?

A

Aspirin + clopidogrel for 6m

  • Followed by aspirin monoTx lifelong
22
Q

What is the loading dose of clopidogrel used? (ACS)

Which is more common? And what are their onset times?

A

Clopidogrel dosing: load 300mg/ 600mg (more common) then 75g OM

Note: onset time is > 6h for 300mg, whereas 2h for 600mg

23
Q

What are the 2 different types of stroke?

Which is the one where antithrombotics are contraindicated?

A
  1. Ischaemic stroke → blocked artery
  2. Hemorrhagic stroke → ruptured artery (antithrombotics C/I!)
24
Q

What does the NIHSS scale tell us?

Does it help to tell us whether thrombolytics can be used?

A

Severity of the stroke

Also assesses eligibility for rTPA (thrombolytics)

Moderate - High NIHSS scores → ✅ thrombolysis

25
Q

What is the NIHSS score considered major stroke?

A

Major: NIHSS ≥ 5

26
Q

What does the ABCD2 score tell us?

A

Can be used to estimate risk of ischaemic stroke in first 2 days after TIA

27
Q

What are the ABCD2 score risk factors? And subsequent points?

A

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

28
Q

For a patient with new-onset AIS who is not on antithrombotic Tx, what are the factors you consider for eligibility of rTPA?

A
  • 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
29
Q

For a patient with new-onset AIS who is not on antithrombotic Tx and is eligible for rTPA, what are your next steps?

A
  1. Start SAPT after 24h (within 48h of thrombolytic)
  2. Evaluate stroke mechanism
    - MRI brain
    - 24 Holter
    - TTE
    - US carotids
    - Lipid panel, TFTs, HbA1c
30
Q

What must you monitor after thrombolysis? For how long? (v impt!)

A

Monitor BP for 24h

31
Q

For a patient with new-onset AIS who is not on antithrombotic Tx and is NOT eligible for rTPA, what are your next steps?

A
  1. 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
  2. Evaluate stroke mechanism
    - MRI brain
    - 24 Holter
    - TTE
    - US carotids
    - Lipid panel, TFTs, HbA1c
32
Q

After assessing stroke mechanism, if it’s a cardioembolic stroke, what do you do?

A

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

33
Q

For stroke mechanism, which 3 main arteries do severe major ICAS (intracranial arthero stenosis stroke) refer to?

A
  • Anterior cerebral artery
  • Middle cerebral artery
  • Posterior cerebral artery
34
Q

After assessing stroke mechanism, if it’s a non-cardioembolic stroke, severe major ICAS, what do you do?

A

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

35
Q

After assessing stroke mechanism, if it’s a non-cardioembolic stroke, non-severe major ICAS, what do you do?

A

Lifelong SAPT

** DON’T FORGET:
Also tart high-intensity statin if no contraindications
- Atorvastatin 40-80 mg OD
- Rosuvastatin 20-40 mg OD

36
Q

For stroke, what are the 2 antiplatelets used for SAPT and DAPT? What are their doses?

A

ASA (100mg) and clopidogrel (75mg OM)

37
Q

For stroke pts, due to their immobilisation in bed, what must you consider?

What drug do you give and when?

A

VTEp!!!

Can give LMWH within 48h but AFTER 24h if rTPA is used

38
Q

How long before surgery do we stop clopidogrel and ticagrelor?

A

Clopidogrel → MINIMUM 5 days before surgery
Ticagrelor → 2-3 days

PR3154 (11 decks)

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