IHD/ACS II Flashcards
Overview: Diagnosis
ACS: Sx/Signs
-Chest pain: dull, 15-30 min, radiates to jaw/arm/back
-Dyspnea
-Nausea
-Diaphoresis
-Palpitations
-Pallor
-Anxiety
Desired Outcomes of ACS Treatment
Short-term
-Restoration of blood flow
-Prevent death/complications
-Prevent coronary artery reocclusion
-Relief chest pain
Long-term
-Control CV risks
-Prevent CV events
-Improve QOL
General Treatment Measures
- Admit to ICU
- Oxygenation
- ECG monitoring
- Glycemic control
- Vitals monitoring
- Pain relief
- Stool softeners
STEMI TX: 1 = MONA
MONA
- Morphine: 1-5 mg IV bolus PRN
-Avoid in lethargy, hypotension, bradycardia
-Caution: CLOP + MORPH = DDI - Oxygen: 2-4 lpm nasally
-If O2 < 90, HF, dyspnea - NTG SL
-0.4 mg every 5 min x 3 doses
-Do not use if SBP < 90 or < 30 below baseline - ASA/Clop
-325 mg
STEMI TX = 2 AC
Heparin
-Could use LMWH or fondaparinux for STEMI but for primary PCI we clinically only use UFH
FIBRINOLYSIS
= 60 u/k bolus (max 4,000)
= 12 u/k IV (max 1000 u/hr)
PRIMARY PCI
= 60 u/k IV bolus (max 5,000)
= 12 u/k IV (max 1000 u/hr)
MED MAN
= 60 u/k IV bolus (max 5,000)
= 12 u/k IV (max 1000 u/hr)
BB: Metoprolol Tartrate
-within 12 hr
-5 mg IV q 5 min (up to 3 doses)
-Avoid in: 70+, brady < 60, SBP < 120, PR > 0.24, heart block 2-3, asthma
Heparin Nomogram for ACS at UCSDH
Goal aPTT 50-70 seconds or anti-Xa 0.3-0.6 IU/mL
Reversing Heparin
protamine dose = 1 mg for every 100 units of circulating heparin (t 1⁄2 = 60-120 min)
Reperfusion Therapy
Goal: TIMI-3 flow = normal epicardial and myocardial
perfusion
Time Windows:
– Door-2-Balloon: 90 minutes (primary PCI)
– Door-2-Needle: 30 minutes (thrombolysis)
Fibrinolysis Indications
Key goal would be to achieve TIMI-3 flow
- Sx of ACS with an onset within 12hours of first medical contact
- ST-segment elevation of at least 1mm in height in 2 or more contiguous leads, or new or presumed new left bundle branch block
- Anticipated that primary PCI cannot be performed within 120 minutes of first medical contact
Characteristics of patients w/ increased risk of ICH
Intracranial hemorrhage (ICH) remain biggest concern w/ fibrinolytics
– female gender
– age >75 years old
– known cerebral vascular disease
– elevated DBP and/or SBP
– HTN
Same CI as other fibrinolytic card: VCAT BIHH
Tenecteplase dosing
Single IV bolus over 5 seconds
- <60 kg: 30mg
- 60-69 kg: 35 mg
- 70-79 kg: 40 mg
- 80-89 kg: 45 mg
- > 90kg: 50mg
Fibrinolysis Monitoring + successful tx def
– Blood pressure
– Bleeding (hematocrit, hemoglobin, hematuria, hematemesis, etc)
– Mental status (r/o ICH)
– Allergic reactions
Consider fibrinolysis successful if:
1. > 50% reduction in ST segments of the ECG
2. relief of chest pain
3. appearance of reperfusion arrhythmias
Primary PCI - Cath Lab
- Heparin already started
- Angiogram
- Anti-thrombotics (BCBCHH)
-Continue heparin as monotherapy
-Continue heparin and add Cangrelor
-Stop heparin, start Bivalirudin
-Stop heparin, start Bivalirudin and Cangrelor
-Salvage: Glycoprotein IIb/IIa (rare)
Bivalirudin dosing in Primary PCI
- Loading dose: 0.75 mg/kg IV bolus
- Maintenance dose: 1.75 mg/kg/hr IV
Caution: reduce dose with significant renal disease
-Discontinue at the end of PCI or may continue at 1.75 mg/kg/hr x 4 hours and then 0.2 mg/kg/hr (up to 20 hours post PCI)
ADP Receptor Blockers: Primary PCI
– Thienopyridines
– P2Y12 receptor inhibitors
– ED or Cath lab
= Clopidogrel, Prasugrel, Ticagrelor, Cangrelor
Clop = LD 300 mg for fibrinolysis, LD 300-600 otherwise
Clopidogrel (Plavix®)
For MED MAN ACS (no pcis)
DDI:
-Avoid omeprazole or esomeprazole (PPIs),use pantoprazole or H2RAs
-Use PPIs only if high risk of GI bleed
Genetics:
-CYP2C192 allele and lesser extent CYP2C193 allele
Requires 2 step activation by CYP enzymes
Less bleeding compared to others
Platelet reactivity units (PRU) of ____ is the suggested “target” or “goal” to reduce ischemic risk
< 230
Prasugrel (Effient®)
*indicated for ACS being managed with PCI
At risk pts for use of Prasugrel:
- age 75+
- <60 kg body weight
- stroke/TIA hx (CONTRA)*
Higher rates of bleeding, hold drug 7 days prior to CABG, no DDIs/genetics
Ticagrelor (Brilinta®)
*indicated for ACS (PCI or non-invasive medical management)
DDI:
-CYP 3A4/5, PGP, aspirin
CI:
-ICH hx
(Nonintracranial fatal bleeding profile favors ticagrelor, Intracranial fatal bleeding profile favors clopidogrel)
-Caution in LD/COPD
AE:
-dyspnea
LDIC
Comparison of ORAL thienopyridines in “at risk” populations
- MI/Diabetes/CYP PM: PT
- 75+/Stoke/TIA: CT
- A/COPD/LD/ADH: CP
- DDI: P
Cangrelor (Kengreal®)
-Adjunct to PCI to reduce periprocedural MI, repeat coronary revasc and stent thrombosis (who have not been treated with a P2Y12 or GP IIb/IIIa inhibitor)
-Dose: 30 mcg/kg IV bolus
-AE: bleeding
Cangrelor – Transitioning to oral P2Y12
- Ticagrelor 180 mg at any time during cangrelor infusion or immediately after
- Prasugrel 60 mg immediately after discontinuation of cangrelor
- Clopidogrel 600 mg immediately after discontinuation of cangrelor
Tirofiban, Eptifibatide (Glycoprotein IIb/lla inhibitors)
AE: bleeding, thrombocytopenia
Indications for ACE Inhibitors: ICU
- AMI
– use within first 24 hours of a suspected anterior wall MI or STEMI associated with clinical heart failure and those with an LVEF ≤ 40% in patients with no contraindications
– use after first 24 hours for hypertension, LVEF ≥ 40%, DM, CKD
NSTE-ACS: TX
NSTE-ACS = unstable angina or NSTEMI
Early pharmacotherapy for NSTE-ACS is similar to STEMI except:
– Don’t use fibrinolytics
– MONA, heparin (BB, P2Y12i, statin)
NSTE-ACS: ED TX
- Heparin
-Early invasive, ischemia
= 60 u/k IV bolus (max 5,000)
= 12 u/k IV (max 1000 u/hr) - Enoxaparin
-Ischemia
= 1 mg/kg SQ
-Avoid in < 20 CRCL - Fondaparinux
-Ischemia
= 2.5 mg SC daily (up to 8 days)
-Avoid in < 30 CRCL
Other Early Pharm TX for NSTE-ACS
- Antiplatelets
= PCI = CTPC
= Med Man = CT only - CCB
= sub for BB
= diltiazem more useful
= don’t use in LV dys or pulm edema - Glycoprotein IIb/IIa
= consider if high TIMI score, ongoing chest pain and medium score
= caution, bleeding af
Secondary Prevention after MI
RAR C BAS
- Control modifiable risk factors
* Smoking, BP, lipids, diabetes, physical activity, weight management, diet, stress - Aspirin 81-162 mg QD
-Use < 100 if in combo with ticagrelor - Rivaroxaban 2.5 mg BID
-wait until DAPT complete then add to aspirin if needed - Clop, Pras, Tica
- BB (give for at least 1 year for all pts, indefinitely in LV < 40%
-Metoprolol, carvedilol - ACEI/ARB
= all pts with LVEF < 40%, CKD, DIA, HTN, anterior wall MI
= avoid in hypotension, RF, hyperkalemia - Spironolactone, Eplernone
= first 2 weeks post MI in patients already receiving an ACEI with EF ≤ 40% and HF sx and diabetes
= 25 mg PO QD
