MT2_10_Acute Coronary Syndrome Flashcards
What are the main causes of ACS?
- atherosclerotic rupture
- narrowing after PCS
- vasopasms
- coronary artery dissection
What happens with a plaque ruptures?
- collagen: activates platelet aggregation
- tissue factor: coagulation cascade for thrombus formation (activates factor 10) over platelets
EKG: T Wave Inversion
- ischemia
- UA/NSTEMI
ST Depression
- subendocardial ischemia
- UA/STEMI
ST Elevation
- ACUTE infarct
- revertive damage/injury
- STEMI
Q Waves
- transmural infarct, prior MI
- dead myocardial tissue, not reversible
When does analgesics come into play when it comes to therapy? What is the DOC? Why? monitor?
What if the patient is hemodynamically unstable?
- if NTG does not work
- morphine: releases histamine, vasodilation, anxiolytic
- monitor decrease in BP, HR, RR, caution in RV infarction
- fentanyl (due to less histamine release)
How much O2 to give to a patient?
2-4 L/min
MOA of Nitro?
- Dose?
- Monitor?
- AE
- CI
muscle relaxant and vasodilator, decrease in preload and after load
- 0.4mg tab q5min 3x
- AE/monitor: headache, hypo, tacky
- CI: use with PDE5inhibitor, RV infarction, SBP less than 90
For aspirin, monitor for___and CI in____
- bleeding, CBC
- aspirin allergy (use clopidogrel)
For a bare metal stent, when is it indicated?
- pts with compliance issues
- high bleed risk
- larger arteries
For a drug eluting stent, what is it for?
- to prevent tissue growth, and narrower vessels (DM patients)
Comparing BMS and DES
- risk of restenosis (tissue grows over stent)
- stent thrombosis (formation of blood clot)
- antiplatelet therapy
- long-term mortality benefit
- higher for BMS
- higher DES
- longer for DES
- same mortality benefit
- DES has reduction in target lesion revasc.
What is the indication for fibrinolytic therapy? In a STEMI patient? The do we not use it?
- delay in primary PCI within 2 hours of onset, onset of symptoms was less than 12 hours ago
- if the symptoms happened 12-24 hours ago and there is evidence of ongoing ischemia (ECG) and there is a large area myocardium at risk
- do not use if ST depression
What is the MOA of fibrinolytic?
- catalyze plasminogen to plasmin which breaks down fibrin
Absolute CI of fibrinolytic?
- prior brain bleed, current bleeds, brain lesions, brain tumors
- stroke within 3 months, except acs within 4.5 hours
- aortic dissection
- uncontrolled HTN
- head/facial trauma within 3 months
- intracranial or spinal surgery
-steptokinase use 6 months prior
For TPA, what is the dose?
- 15mg bolus
- .75mg/kg 30 min (max 50)
- .5 mg/kg in one hour
If the fibrinolytic doesn’t work, when should you consider a PCI?
- if there is no relief of chest pain
- no resolution of ST elevation greater than 70%
- lack of reperfusion arrhythmias
What to monitor for when giving a fibrinolytic? (4)
- blleding
- CBC
- INR
- aPTT (with heparin)
Class I indication for fibrinolytic therapy is a STEMI pt presents within __ hours of symptom onset and time of delay to PCI greater than __min
- 12
- 120
After STEMI or fibrinolytic, what to you do? With what agents?q
- prevent clot expansion
- (anti platelet) aspirin, P2y12 inhibitor, (GP2B3A inhibitor), and an anticoagulant
When is ASA indicated, monitor for…? Dose
- ALL ACS patients
- monitor for bleeding and CBC
- 165-325 loading, then 81 QD
For dual anti platelet therapy, what are the indications?
- in all ACS patients for 12 months
- PCI w stent to prevent thrombosis
Indication of clopidogrel
Dosing
Hold
BBW
What if patient is on a PPI?
- ALL patients with ACS, alternative to aspirin
- LD: 300mg, 600 for stent, no LD if greater than 75, less than 75 300
- all MD is 75mg
Hold 5 days prior surgery
- BBW: variant 2C19 alleles, reduce conversion to active metabolite
- weigh risk vs benefits, pantoprazole> omeprazole, which inhibits 2C19 the most
For prasugrel, what is the indication?
- why is it “better” than clopidogrel
- Dose
- Hold
- CI
BBW
- ACS w PCI ONLY
- faster inhibition of platelets bc only one single CYP conversion
- LD 60mg, 10mg PO QD 1Y (less than 60, 5mg)
- hold 7 days
- CI: hx of stroke or TIA
- BBW: greater than 75 years old
Compared to Plavix, how does ticagrelor work?
- Dose
- Hold
- CI
- BBW
- similar, but it is reversible so you can recover platelets if need be, NOT a prodrug
- 180 mg, 90mg BID 1year, 60mg BID after
- hold 5 days before
- CI: hepatic impairment, brain bleeds
- use w aspirin less than 100
For cangrelor, what is the main indication?
- adjunct to PCI, in patients not treated with other P2y12 inhibitors of GP2B3A inhibitors
- reversible! inhibition happens within 2 minutes, platelet function returns in one hour
Indication for Vorapaxar?
Dose
CI
- hx of MI or PAD
- 2.08 mg PO daily w aspirin and/or clopidogrel
- CI: stroke, TIA, intracranial bleeding
- DO NOT USE in ACS or prior to PCI
How long should patients on a DAPT?
- drug eluting stent: at least 3-6months - 12 years
- bare metal stent: at least 1 month, for one year
- non invasive ticagrelor or clopidogrel up to 12 months
all with aspirin
When risk stratifying ACS NSTEMI, what has to be present? (just one is needed)
- prolonged chest pain
- hemodynamic instability
- dynamic ST changes on EKG
- Heart failure symptoms
- new/worsening regurgitation mitral
What are the GP2B3A inhibitors, and what is their indication? Why do we use these agents?
- Can it be used in PCI?
- What if pt is getting CABG
- MUST BE
- Monitor
- CI
- Abciximab, Eptifibatide, Tirofiban
- binds to the GP receptors on activated platelets to prevent fibrinogen cross linking, therefore no platelets
- only use if patients are at high risk, unable to get a PCI right away
- yes
- can get these drugs, if scheduled within 5-7 days
- given with another anti platelet
- monitor: bleeding
- CI: active bleeding within 30 days, hx of stroke in 30 days, severe HTN (>200/110), major surgery within 6 weeks
For Abciximab (Reopro), what is the indication, and is adjustment needed?
- PCI ONLY
- ab binds to receptor, causing hinderance
- no renal adjustment is needed
For Eptifibatide, what is the indication?adjust?
- ACS w.wo PCI
- synthetic peptide that blocks the inhibitor
- adjust if clearance is less than 50, to 1mcg/kg/min
For tirofiban, indication?really adjust?
- ACS w/wo PCI
- renal adjust, clearance is less than 60, 0.075 mcg/kg/min
For anticoagulation therapy, what can be used?
Heparin: UFH, LMWH
DTI: bivalirudin, argatroban
Factor 10a inhibitor: fonda
When is UFH indicated?Dosing?Monitoring?
all patients with ACS
- LD: 60U, MD12U /kg
- titrate to 1.5-2x baseline aPTT
- monitor bleeding, CBC, ACT,/aPTT
For LMWH, when is it indicated?
- all patents with ACS, more affinity to 10a
- enox: less than 75, 30mg IV bolus, then 1mg.kg SQ Q12
- BBW: spinal/epidermal hematomas
- monitor: bleeding, CBC, CrCl, anti-10a sometimes
When are DTI indicated?
Monitor?
What are the drugs?
- alternative to UFH, LMWH in patents with HIT and antithrombin III deficiency
- monitor bleed, CBC, ACT/aPTT
bivalirudin, agatriban, fonda
What is the dose for bivalirudin?
0.75 mg/kg/hr, then 1.75 until end of infusion
if CrCL is less than 30, 1mg/kg/hr
Dosing for agatriban?
When to avoid?
350 mcg/kg bolus 3-5 min
AST/ALT greater than 3x normal
falsely elevated INR
if needed for post PCI, 2-10 mcg/kg/min, closely monitor aPTT
