Therapeutics - ACS Part 2 Flashcards
true or false
anticoagulant therapy should be given to ALL ACS patients
TRUE
to decrease intracoronary and catheter thrombosis
which anticoagulants are preferred in a patient getting a PCI
unfractionated heparin (UFH) or bivalrudin
state which anticoagulant the patient should get:
NSTEMI:
-Ischemia guided
-invasive
ischemia guided - UFH, lovenox, or fondaparinux
invasive - UFH, lovenox, bivalrudin
which anticoagulant(s) can be given to a patient who is given a fibrinolytic for STEMI
UFH, lovenox, fondaparinux
true or false
bivalrudin can be given with a fibrinolytic
NO – INCREASED RISK OF BLEEDING
When is anticoagulant therapy discontinued?
usually after the PCI
only time bivalrudin can be given as an anticoagulant
when pt is getting PCI (invasive)
NOT WHEN GETTING FIBRINOLYTIC!!!!!
bivalrudin class
direct thrombin inhibitor
UFH concerns
bleeding (monitor Hgb and hematocrit), aPTT/active clotting time, HIT (platelets
how long is UFH used
up to 48 hours
or after PCI is done
true or false
anti-Xa does NOT need to be monitored for enoxaparin
true
is dose adjustment needed ever for enoxaparin?
yes - if CrCl less than 30
how long to use enoxaparin
until the PCI or until out of hosptial (up to 8 days)
true or false
bivalrudin does not need a dose adjustment in renal failure
fals e- it does
can bivalrudin be given if pt has history of HIT?
YES - it’s a direct thrombin inhibitor!
how long to give bivalrudin
until PCI - up to 4 hours post PCI
monitoring paramters for fondaparinux
does anti Xa need to be monitored?
bleeding, spinal or epidural hematoma, platelets
dose adjust CRCL less than 30
no anti xa
true or false
fondaparinux needs renal dose adjustment in CrCl less than 30
FALSE - IT’S CONTRAINDICATED! NO DOSE ADJUSTMENT JUST CANT USE
can fondaparinux be given if the patient had a history of HIT
yes
when to d/c fondaparinux
until PCI or until out of hospital
true or false
fondaparinux is not used alone in PCI
true
true or false
fondaparinux is a 1st line anticoagulant if pt is going for a PCI
FALSE
1ST line is UFH or bivalrudin
****very important - in which STEMI patients can fibrinolytics not be given
IF SYMPTOM ONSET HAS BEEN LONGER THAN 12 HOURS - NE BENEFIT ONLY BLEEDING RISK
explain in which scenario fibrinolytics would be given
only in STEMI patients whose symptoms started less than 12 hours ago, and their PCI cant be performed within 120 mins of symptom onset
imp to note that fibrinolytics dont open the artery all the way - just buys time to get to cath lab
true or false
when fibrinolytics are used, they are used alone
FALSE - used with other anticoagulant like UFH, enoxaparin, or fondaparinux
as mentioned, fibrinolytics are combined with another anticoagulant like UFH, enoxaparin, or fondaparinux
how long is this anticoagulant continued
for at least 48 hours
whole hospitalization (up to 8 days)
or up until the pt gets revascularized
4 things to monitor in a patient getting a fibrinolytic
bleeding
ECG
chest pain releif
allergies ( for older ones like strptokinase)
**preferred reperfusion strategy
PCI
if it has been less than 12 hours since symptom onset, what are the reperfusion options
what about over 12 hours?
less than 12 hours - PCI or fibrinolytics
more than 12 hours - PCI/CABG ONLY - cannot use lytics
name some post PCI complications
bleeding
rupture
stent thrombosis (clot)
arrrhythmia
mechanical complications
CIN (contast induced nephropathy)
as mentioned, stent thrombosis is a PCI complication
what can be done to prevent
caused by premature discontinuation - counsel!!!!!
increase DAPT duration (MD aspirin + MD P2Y12 antagonist) for at least 12 months
**duration of DAPT as medical therapy with NO intervention being scheduled
at least 12 months
**duration of DAPT if pt got lytics
at least 14 days - up to 12 months
**duration of DAPT if pt got PCI
at least 12 months
**duration of DAPT if pt got CABG
1 year
is DAPT ever continued for longer than 12 months?
yes - can find DAPT score
if 2 or more - prolong dap for around 15 months
if less than 2 - do not continue beyond 12 months. at 12 months, stop P2Y12 and ccontinue aspirin indefinitely
true or false
women have higher rates of in-hospital and long-term complications
true
Name 4 classes of drugs that are for secondary prevention and DISCHARGE MEDS — that the pt actually goes home with
beta blocker (or CCB if BB C/I)
renin antagonist (if Hfref - aldosterone antagonist)
DAPT (duration varies)
high intensity statin
what med may be beneficial to a discharged patient
PPI - decreased risk of stomach ulcers
true or false
pts being discharged from ACS should avoid NSAIDS
true - can prevent normal scars from forming
pt has STEMI and needs emergency reperfusion
what is initial therapy?
MONA
morphine (if needed)
oxygen (if needed)
aspirin 162-325mg chewed STAT
+ oral P2Y12 clopidogrel 300-600mg (if lytic given - only 300mg) or ticagrelor 180mg
nitroglycerin
3 options for fibrinolytics
what must they be given with and for how long
alteplase
reteplase
tenectaplase
with UFH or LMWH for 48 hours
true or false
lytic can be given with bivalrudin
FALSE
pt is NSTEMI
what therapy is given initially (risk assessment not made yet)
MONA
aspirin LD chewed + P2Y12 (ticagrelor 180mg or clopidogrel 300-600mg)
morphine maybe
o2 maybe
nitroglycerin
pt has UA
what is initial therapy given (risk assessment not made yet)
MONA
pt has UA or NSTEMI and determined to follow ischemia-guided approach
name 5 therapies to start stat
- chewed aspirin LD (if not started yet)
- oral P2Y12 (clopidogrel or ticagrelor - if not given yet)
- anticoagulant (UFH FOR 48 HRS, LOVENOX 7 days or d/c , OR FONDAPARINUX 7 days or d/c)
- atorvastatin 40-80mg
- depending on BP and stability - BB and ace inhibitor potentially
name the 6 potential CHRONIC discharge meds for secondary prevention
low dose aspirin
P2Y12 antagonist
high potency statin REGARDLESS LDL
b blocker low dose
ACEI/ARB
aldisterone antagonist if EF less than 40%
if patient is in respiratory distress and O2 sat is normal - do we give O2?
yes - bc in respiratory distress
*loading dose clopidogrel if getting fibrinolytic
300mg
when may the efficacy of ticagrelor be decreased
in patients getting aspirin doses over 300mg
only give less than 100mg!
true or false
a loading dose of a P2Y12 receptor antagonist should be given before a PCI
true
interaction between cangrelor and the oral P2Y12 inhibitors
onset of action of clopidogrel and prasugrel is delayed with cangrelor coadmin.
therefore, clopidogrel and prasugral shold not be started until cangrelor infucion is done
no interaction with ticagrelor tho!!!!!!!!
true or false
eptifibatide and tirofiban are preferred GpIIb/IIIa antagonists
true - just have to d/c to reverse the effect
abciximab needs platelet transfusions to reverse
