SIHD antiplatelet

Question 1

what drugs are used to prevent ACS and death?

Answer 1

anti-thrombotic therapy
statins
ACEi/ARBs
colchicine?
beta-blockers

Question 2

what is the moa of aspirin?

Answer 2

acetylation and irreversible inactivation of platelet COX-1

Question 3

how does aspirin lead to anti platelet activity?

Answer 3

blocking TXA2 synthesis with interferes with platelet aggregation thus prolonging bleeding time and blocking the formation of arterial thrombi formation

Question 4

why does it matter if a pt with CHD is using celecoxib for pain management?

Answer 4

celecoxib inhibits COX2 which leads to decrease production of prostacyclin PGI2 leading to higher thrombotic risk

Question 5

what does prostacyclin PGI2 do in relation to coxibs and CHD?

Answer 5

has protective anti-coagulative effect
when blocked, leads to platelet aggregation and higher thrombotic risk as a result

Question 6

when is aspirin beneficial?

Answer 6

at low dose
detrimental at higher dose

Question 7

what is the loading dose of aspirin?

Answer 7

162 to 325mg

Question 8

what is the maintenance dose of aspirin?

Answer 8

75-162mg daily

Question 9

what drugs are P2Y12 inhibitors?

Answer 9

clopidogrel (plavix)
prasugrel (effient)
ticagrelor (brilinta)
cangrelor

Question 10

what is the dosing of clopidogrel (plavix)?

Answer 10

loading: 300 to 600mg
maintenance: 75mg daily

Question 11

what is the dosing of prasugrel (effient)?

Answer 11

loading: 60mg
maintenance: 10mg daily

Question 12

what is the dosing of ticagrelor (brilinta)?

Answer 12

loading: 180mg
maintenance: 90mg BID

Question 13

what is unique about cangrelor?

Answer 13

it is the only P2Y12 that is IV only

Question 14

what is the moa of P2Y12 inhibitors?

Answer 14

selectively inhibit adenosine diphosphate induced platelet aggregation with no direct effect on TXA2

Question 15

what are the AE of aspirin?

Answer 15

GI and hematologic bleeding
hypersensitivity

Question 16

how long does it take for clopidogrel to reach peak inhibition?

Answer 16

4-5h if 300mg
2-3h if 600mg

Question 17

what P2Y12 inhibitors are prodrugs?

Answer 17

clopidogrel
prasugrel

Question 18

what are the AE of clopidogrel and prasugrel?

Answer 18

bleeding, diarrhea, rash

Question 19

what are the AE of ticagrelor?

Answer 19

bleeding, bradycardia, heart block, dyspnea

Question 20

what type of treatment is favored in CCD with no history of stent (aka secondary prevention)?

Answer 20

SAPT
DAPT may be beneficial in certain high risk patients, but usually not as effective as ASA to reduce MACE

Question 21

how is SAPT handled in CCD?

Answer 21

aspirin 75-100mg/day (preference of 81mg)
if CI or intolerant, clopidogrel 75mg/day

Question 22

what are the two types of intracoronary artery stents?

Answer 22

bare metal stents (uncommon)
drug eluting stents

Question 23

what is a drug eluting stent?

Answer 23

an intracoronary artery that releases anti-proliferative agents that help prevent inflammation at the site of implementation

Question 24

when an elective PCI and drug eluting stent is scheduled to be put in, what should happen before the procedure?

Answer 24

loading dosing of aspirin or P2Y12 inhibitor

Question 25

after an elective PCI and drug eluting stent, how should a person with a low risk of bleeding be treated?

Answer 25

DAPT - minimum of 6 months SAPT - indefinitely (aspirin)

Question 26

after an elective PCI and drug eluting stent, how should a person with a high risk of bleeding/overt bleeding be treated?

Answer 26

DAPT - 1 to 3 months may be reasonable (would like to push towards 6 months) SAPT - P2Y12i until 12 months SAPT - ASA indefinitely

Question 27

for a patient who has a PCI/stent and an emergent CABG, how should their SIHD be treated?

Answer 27

restart therapy after CABG and continue duration similar to after elective PCI

Question 28

What should a patient with an elective CABG be treated with?

Answer 28

DAPT - 12 months of aspirin 81 and clopidogrel 75 (some controversy) SAPT - aspirin indefinitely

Question 29

when used in combination with ticagrelor, what must the aspirin dose be below?

Answer 29

under 100mg due to increased risk of brain bleed going up

Question 30

when is prasugrel contraindicated?

Answer 30

history of transient ischemic attack, ICH, or stroke

Question 31

should PPI therapy be used with DAPT?

Answer 31

yes especially in elderly patients - has shown recent to reduce GI bleeding risk

Question 32

for a patient on anti-platelet therapy, how should a non-emergent surgery (like hip/knee replacement) be treated?

Answer 32

try to finsih year of anti-platelet therapy then surgery if cant wait, hold drugs 5-7 days prior to procedure to decrease risk of bleeding - this may increase risk of developing thrombosis at site of stent

Question 33

what is the benefit of using RAS inhibitors in CHD?

Answer 33

stabilizes plaque improved ET function inhibition of VSM cell growth decrease macrophage migration anti-ox properties??

Question 34

do RAS inhibitors help with symptoms?

Answer 34

no focuses on stabilization and prevent inflammation

Question 35

when should RAS inhibitors be considered?

Answer 35

in all patients with CCD especially in patients with LVEF under 40%, HTN, DM, or CKD

Question 36

when is colchicine contraindicated?

Answer 36

severe renal and hepatic disease

Question 37

when is colchicine indicated?

Answer 37

for reducing the risk of myocardial infarction, stroke, coronary revascularization, and CV deaths in adults with established ASCVD or multiple risk factors