Lecture 3 - Acute Coronary Symptoms Flashcards by Patryk Lasiuk

cause of ACS?

rupture of atherosclerotic plaque with subsequent platelet adherence, activation, and aggregation, and the activation of the clotting cascade.

Ultimately, clot forms composed of fibrin and platelets

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Unstable Angina vs NSTEMI

UA = not positive for cardiac enzymes, no cell death, ischemia (not infarction)

NSTEMI = positive for cardiac enzymes, death of myocardium (infarction), no ST elevation

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STEMI will be…

occlusive thrombus
Fibrin rich

want drugs to dissolve fibrin

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UA/NSTEMI

Mural Thrombus

mostly platelets, use anti-platelet drugs

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TIMI Risk score NSTEMI

Low = 0-2
Medium = 3-4
High = 5-7

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ACS Non-pharmacologic therapy

EKG
Oxygen (O2 < 90%)
Cardiac Enzymes
Bed Rest

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ACS Pharmacologic Therapy

Aspirin 325mg non-ec
Nitrates
Morphine??
Anti-coagulant
Anti-platelet
Statin

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Class I recommendation: Nitroglycerin

SL = 0.4mg q5min for 3 doses

IV = 5-10mcg/min, titrate up to 75-100 mcg/min

Avoid in pt with hypotension ( SBP < 90) or right ventricular infarcts

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Class I recommendation: Morphine

2-4mg IV q5-15min until pain relief or ADR

may worsen outcomes in NSTEMI

Monitor BP,HR, RR, naloxone present

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Class I recommendation: Beta-Blockers

All pts w/o CI in 1st 24hrs

Oral > IV preferred

CI: Signs of HF, low output state (HR <60, SBP <90)

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CCBs

generally 2nd line

wary of SL short acting nifedipine = reflex tachycardia leading to MI

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Plavix is…

clopidogrel

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Effient is…

Prasugrel

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Brilinta is…

ticagrelor

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Aspirin info

Decreases morbidity/mortality,
DOESNT IMPACT CHEST PAIN

Dosing: 325 mg qd
MOA: irreversibly inhibit COX, inhibiting platelet aggregation

don’t use EC, 81 mg dose preferred for maintenance

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Clopidogrel Dosing

Dosing: 300-600 mg loading, higher = faster inhibition
Maintenance: 75mg qd

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Clopidogrel interactions

Pro drug, CYP450 metabolism

PPIs inhibit CYP450, so co-admin appress to increase risk of reinfarction

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Prasugrel info

more potent irreversible platelet inhib compared to clopidogrel

approved for pt managed with PCI

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Prasugrel Dosing

60mg loading dose, continue 10 mg once daily w or w/o food

consider 5mg once daily for pt <60kg

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Prasugrel considerations

don’t start in….

> 75 yr old
previous history of TIA or stroke
likely to undergo CABG, start after
BW < 60kg

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Ticagrelor MOA

reversibly binds to ADP receptor P2Y12

Ticagrelor Dosing

Loading: 180 mg once w/ Aspirin 325

Maintenance dose: 90 mg bid w/ 81mg aspirin

if on for longer than 12 months, can possibly reduce to 60mg BID

Ticagrelor Drug Interactions

Carbamazepine,Phenytoin

Ticagrelor Adverse effects

Dyspnea, dissipates in 2-4 weeks

bleeding

Cangrelor (Kengreal) MOA

reversibly binds to ADP

Cangrelor Dosing

Loading: 30mcg/kg IV bolus Maintenance Dose: 4mcg/kg/min IV for duration of PCI or 2hrs Doesn't interact with Ticagrelor, but does with Prasugrel or clopidogrel (load after stoping infusion not during)***

GP IIB and IIIA inhibitors are used....

adjunctive anti platelet in some cases *usually*

Integrilin (Eptifibatide)

Dose has to be loaded, and given by infusion. Has renal dosing Discontinue infusion with OD

Aggrastat (Tirofiban)

Dose has to be loaded, and given by infusion. Has renal dosing Discontinue infusion with OD

Xa inhibitor

Fondaparinux (Arixtra)

Direct thrombin inhibitor

Bivalirudin (angiomax) | Dabigatran (Pradaxa)

Low molecular weight heparin

Enoxaparin (Lovenox) | Dalteparin (Fragmin)

Enoxaparin (Lovenox) Dosing

1mg/kg q12h (CrCl > 30/min) 1mg/kg q24h (CrCl <30/min) Usually round to next syringe or next 10mg

what to monitor Enoxaparin

Scr Platelets Anti-factor Xa lvls

Fondaparinux (arixtra) info

Class 3 rec Avoid using as solo in PCI, used w/ Heparin

Fondaparinux (arixtra) Dosing

STEMI: 2.5mg IV Day 1, then 2.5mg subcut q24h NSTEMI: 2.5mg SQ once daily caution CrCl 30-50ml/min **Don't use if CrCl < 30ml/min Monitor: Scr, Anti-factor Xa lvls

Bivalirudin (Angiomax) info

Dosing: IV bolus + IV infusion Monitor: Scr, can monitor aPTT Dose adjustment for severe Renal failure

NSAID use in ACS?

Black box warning increased risk of mortality, reinfarction, HTN, etc

Unstable Angina Clinical Presentation

1. Typical rise and gradual fall (troponin) or more rapid rise/fall (CK-MB) with at least one of the following.... - Ischemic Symptoms - Development of Q waves on ECG - ECG changes indicative of ischemia - Imaging of myocardium abnormality

CK-creatinine phosphokinase info

peak at 24 hrs, normalizes in 2 days

Troponins info

Elevations may persist up to 2 weeks

Treating pt presenting with ACS

1. Triage 2. Asses risk of CV death/ recurrent ischemia 3. General care (ASA, NTG, Statin...consider O2/BB/Morphine) 4. Choose invasive or non-invasive initial strategy 5. select second antiplatelet to add to ASA 6. choose an anticoagulant agent

Statins use

High-intensity statin during hospital care Atorva 40-80* or Rosa 20*-40 consider moderate intensity if >75yr old or not candidate for high intensity

Irreversible, nonselective COX-1 Inhib

Aspirin

Irreversible P2Y12 antagonist

Clopidogrel | Prasugrel

Reversible P2Y12 antagonist

Ticagrelor | Cangrelor

GPIIb/IIIa inhibitors

Abciximab Eptifibatide Tirofiban

PAR-1 Antagonist

Vorapaxar

Enoxaparin Advantage and Disadvantage

Advantage: Lower incidence of HIT Less monitoring Twice Daily dosing instead of continuous infusion ``` Disadvantage: unsure dosing in obese/renal impairment longer duration not always wanted harder to reverse only in certain syringe sizes ```

Fondaparinux Advantage and Disadvantage

Advantage: once daily dose No incidence of HIT ``` Disadvantage: Lack of reversibility Catheter thrombosis Longer duration of action unsure of universal dosing for all pt renal dosing CrCL < 30 ml/min ```

Bivalirudin Advantage and Disadvantage

Advantages: no incidence of HIT may req less use of GPIIb/IIIa inhib Disadvantages: lack of reversibility continuous infusion not studied in ACS pts w/ conservative management strategy