Ischemic Heart Disease (CCD, ACS, PAD) Flashcards
P2Y12 inhibitor that is reversible
Ticagrelor
Oral P2Y12 inhibitors with the quickest onset of action (2)
Ticagrelor, Prasugrel
Primary metabolism pathway for Ticagrelor
3A4
P2Y12 inhibitors that are prodrugs (2)
Clopidogrel, Prasugrel
P2Y12 inhibitors that are irreversible
Clopidogrel, Prasugrel
Clopidogrel and Prasugrel bind at what receptor
ADP-binding
Absolute contraindication for prasugrel
history of stroke/TIA
Absolute contraindication for ticagrelor
history of cerebral bleed and severe liver disease
Clopidogrel is metabolized by
a 2-step process involving 2C19
When should you discontinue clopidogrel before surgery?
5 days before
When should you discontinue prasugrel before surgery?
7 days before
Clopidogrel loading dose
300-600 mg
Clopidogrel loading dose with lytic
/< 75 years: 300 mg
> 75 years: 75 mg
What is the maintenance dose of Clopidogrel?
75mg daily
Ticagrelor loading dose
180 mg
Ticagrelor maintenance dose
90 mg twice daily
Prasugrel loading dose
60 mg
Prasugrel maintenance dose
10 mg daily
Prasugrel relative contraindications
< 60 kg, > 75 years of age
O (acute treatment)
Oxygen- provide if O2 sat <90%
S (acute/chronic treatment)
Statin- start or continue a high intensity statin (Atorvastatin 40-80 mg or Rosuvastatin 20-40 mg)
N (acute/chronic treatment)
Acute - Nitroglycerin- SL NTG every 5 minutes for 3 times and if chest pain is still ongoing then we can consider IV NTG
Chronic - send home with Rx for sublingual nitroglycerin
A (acute/chronic treatment)
Aspirin- loading dose of 162-325 mg should be given in a chewable non-enteric coated tablet
A (acute ONLY treatment)
Anticoagulant- IV unfractionated heparin for 48 hours or until PCI can be performed or SQ Enoxaparin for the duration of hospitalization or until PCI is performed
P (acute/chronic treatment)
P2Y12 inhibitor LOAD (acute)- Ticagrelor (180 mg), Prasugrel (60 mg), Clopidogrel (300-600 mg) are given as loading doses in acute treatment
P2Y12 inhibitor MAINTENANCE (chronic) - ticagrelor 90 mg twice daily, prasugrel 10 mg daily, or clopidogrel 75 mg daily
B (chronic treatment)
Beta Blockers (Longterm Treatment) Patient on Beta Blocker at least 3 years/Indefinitely
All beta blockers are okay
Heart Failure With reduced Ejection Fraction: Metoprolol Succinate, Carvedilol, Bisoprolol
A (chronic treatment)
ACE/ARB (Longterm Treatment): Patient is on indefinitely
If possible, all patients
Patients with LVEF <40%
Patients with HTN, DM, stable CKD
M (chronic treatment)
Mineralocorticoid Receptor Antagonist (Longterm Treatment): Should be on indefinitely
Drugs: Spironolactone or Eplerenone
Patients with EF <40% (on ACE and Beta Blocker)
Contraindications: Serum Creatine: >2.5 mg/dl men and women >2.0 mg/dL-Potassium: >5mEq/L
Medications with Cardiovascular and Diabetes benefit
GLP1 Agonists
SGLT2 inhibitors
Chronic coronary disease includes what patients?
- Patients with stable angina
- Patients discharged after ACS
- Patients with atherosclerosis diagnosed via screening
What is the goal of therapy for patients diagnosed with CCD?
Prevent development of major adverse cardiovascular event (MACE) like a myocardial infarction (ACS), stroke, or death due to cardiovascular causes
What non-pharmacological management should occur for patients with CCD?
- Multidisciplinary approach
- Individualized education
- Assessment of SDOH
- Diet and physical activity
- Tobacco cessation
- Alcohol limitations
- Attempt to avoid - cocaine, methampheatmines, opioids, marijuana
What lipid therapy should occur for patients with CCD not at very high risk?
- High intensity statin, LDL-C reduction at least 50%
- If high-intensity is not tolerate, moderate intensity is recommended
- Max statin and LDL-C > 70 > add ezetimibe
- On max tolerated statin and LDL-C < 100 mg/dL with fasting TG 150-499 mg/dL, add icosapent ethyl
What lipid therapy should occur for patients with CCD at very high risk?
- High intensity statin, LDL-C reduction at least 50%
- Max statin and LDL-C > 70 > add ezetimibe
- On max tolerated statin and LDL-C < 100 mg/dL with fasting TG 150-499 mg/dL, add icosapent ethyl
- If on max LDL-C lowering therapy and LDL-C 70 or greater or non-HDL above 100, a PCSK9 inhibitor can be beneficial
What antiplatelet therapy should a patient with CCD and no history of PCI receive?
Aspirin 81 mg daily
What antiplatelet therapy should a patient with CCD and a PCI receive?
DAPT for 1-6 months, then SAPT
What antiplatelet therapy should a patient with CCD and a CABG receive?
DAPT
Use this for intermittent anginal symptoms
SL Nitroglycerin
How do Beta-blockers work to decrease anginal pain?
Decreases HR and contractility, which results in a decrease in O2 demand (GOAL: HR: 50-60bpm; exercise HR: 100bpm)
Antiarrhythmic and slow progression of plaque
Beta-blockers adverse effects
bradycardia, heart block, worsening HF, bronchospasm, cold extremities, fatigue, depression, reduced exercise tolerance, decreased libido, insomnia, impotence
Beta-blocker pearls
Must be tapered upon discontinuation
Mortality benefit in HFrEF: bisoprolol, metoprolol succinate, carvediol
Do not initiate while a heart failure exacerbation
Reduce dose if pt experiencing exacerbation (try not to discontinue)
How to CCBs work for anginal symptoms?
Both DHP and non-DHP work
Non-DHP: decreased HR and contractility → decreased O2 demand
DHP: decreased afterload → decrease O2 demand
Avoid Non-DHP CCB in these scenarios
Concomitant beta-blocker, Severe LV dysfunction
When do you use ranolazine for angina?
Add on therapy or Patients who need an anti-anginal that has no impact on HR/BP
Ranolazine MOA
MOA: inhibits persistent/late inward Na+ current in the ventricles; also has anti-ischemic activity related to reduced accumulation of intracellular calcium.
Ranolazine adverse effect
QT prolongation
Ranolazine metabolism
CYP3A4, 2D6, pGp
How do we diagnose PAD?
ABI (ankle brachial index) -> ratio of blood pressure in ankles:arms < 0.9
When is Cilostazol recommended in PAD?
To manage symptoms and improve walking distance
What are the adverse effects of cilostazol? Why does this happen?
Headache GI upset/diarrhea= lots of vasodilation
How long does Cilostazol take to work
2-4 weeks or up to 12 weeks.
Cilostazol BBW
Contraindicated in patients with heart failure
For long-term treatment of PAD what drugs should be given to ALL patients?
- Statin
- BP control (ACEI/ARB preferred)
When is DAPT recommended in PAD?
After revascularization (aspirin + clopidogrel)
What medication should be given to all patients with acute limb ischemia?
Heparin
