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Pharm 2 Exam 2 > Thrombolytics + extra (STEMI/NSTEMI/UA) > Flashcards

Thrombolytics + extra (STEMI/NSTEMI/UA) Flashcards

1
Q

Thrombolytics

A

Alteplase
Reteplase
Tenecteplase

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2
Q

Thrombolytics Indications

A

PCI within 90 minutes door to balloon time

Lytics within 30 minutes if PCI within 90 minutes is impossible-door to needle time

Hemodynamically compromised pts (cardiogenic shock, pulm edema, congestion) receiving lytics to receive angiography and PCI

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3
Q

Thrombolytics MOA

A

lytics dissolve pathologic thrombus and fibrin at sites of vascular injury:

  • endogenous tissue plasminogen activator (t-PA) released from endothelium
  • plasminogen converted to plasmin
  • plasmin digests clot bound fibrin
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4
Q

Lytics can be used in ____ but not ___ or __

A

use lytics in STEMI ONLY***!!!!!

DO NOT USE IN UA/NSTEMI

  • NOT better when added to ASA, clopidogrel, anticoag, and GP IIB/IIIA inhibitors
  • actually will increase risk of MI and other serious hemorrhagic events ☹
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5
Q

Lytics Considerations

A

New and improved lytics are based on endogenous t-PA

structures make each unique: Finger and Kringle pieces an effect fibrin specificity, potency, clearance etc

alteplase is more like tenecteplase but overall all 3 have same efficacy!

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6
Q

Lytics reversal?

A

Lytics CAN be reversed with AMINOCAPROIC ACID ☺

  • binds to lysine on plasminogen and plasmin
  • prevents interaction with fibrin
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7
Q

Alteplase MOA

A

Serine protease cleaves Arg-Val bond in plasminogen and converts it to plasmin
*Requires fibrin as cofactor for activation of plasminogen
-enhanced proteolysis in presence of clot fibrin, highly specific for clot bound fibrin
No direct antiplatelet effects

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8
Q

Alteplase indication

A

Given with UFH or enoxaparin

LESS active on systemically circulating plasminogen

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9
Q

Alteplase Metabolism

A

Non antigenic

  • moderate degree of fibrin depletion and D dimmer accumulation
  • peak thrombolytic effects within 30-60 minutes, IV infusion required to maintain lysis

75% achieve patency within 90 minutes
>50% achieve TIMI grade 3 flow

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10
Q

Alteplase clearance

A

Degraded into component amino acids in liver
-50% of alteplase cleared within 5 minutes of stoping infusion, 80% in 10 minutes

half life 27-46 minutes

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11
Q

Alteplase CI/ Precautions

A 
CI:
-bleeding
-uncontrolled htn*****
-av malformation or aneurysm
-HX/evidence of hemorrhagic stroke
-SAH
-Platelets less than 100,000
Heparin w/in 48 hours 
precautions: recent trauma, high bleed risk, recent punctures
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12
Q

Alteplase considerations

A

Replaced streptokinase bc of fibrin secificty

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13
Q

Recteplase MOA

A

Catalyzes conversion of plasminogen to plasmin and enhances thrombolysis

Early platelet inhibition within 6 hrs with rebound platelet aggregation at 24 hrs with increased GP IIb/IIIa expression

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14
Q

Recteplase indications

A

Given with UFG, enoxaparin

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15
Q

Recteplase Metabolism

A 
Peak response within 30-90 min of IV
-60-70% achieve patency by 90 minutes
-60% with TIMI grade 3 flow
inactivated in blood by:
-C1 inactivator
-a-1 antitrypsin
-a-2 antiplasmin
RENAL clearance
Half life 13-16 minutes
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16
Q

Recteplase CI/precautions

A

CI:

  • bleeding
  • av malformation or aneurysm
  • recent surgery/trauma
  • hx of CVA; **uncontrolled HTN
    precautions:
  • recent punctures, surgery, trauma, antiplatelet tx
  • recent GI/GU bleeding
  • Advanced age; high bp
17
Q

Recteplase considerations

A

Recombinant deletion mutant of wild type tissue plasminogen activator

  • does not have kringle-1, finger, GF domains
  • decreased fibrin specificity, higher potency, shorter half life
18
Q

Tenecteplase MOA

A

Plasma inactivation via PAI-1

19
Q

Tenecteplase Indications

A

Used with UFH, enoxaparin

20
Q

Tenecteplase Metabolism

A

Extensive inactivation in the liver

Half life: biphasic—24 minutes then 115 minutes ****
75% achieve patency at 90 minutes
60% TIMI 3 flow

21
Q

Tenecteplase CI/precautions

A

CI:

  • bleeding
  • av malformation or aneurysm
  • recent surgery/trauma
  • hx of CVA; uncontrolled HTN**
    precautions:
  • recent punctures, surgery, trauma, antiplatelet tx
  • recent GI/GU bleeding
  • Advanced age; high bp >180/110
22
Q

Tenecteplase SE

A

Increased half life
Increased fibrin specificity
Reduced inactivation by plasminogen activation inhibitor 1 (PAI-1)

 decrease risk by lowering infusion rate!! **

23
Q

Tenecteplase considerations

A

Genetically reengineered alteplase ()
-has 2 AA substitutes and 4 alanine substitutes

produced in Chinese hamster ovary cells

24
Q

Pathogenesis to MI

A

Plaque disruption/fissure/erosion
thrombosis formation
Non ST elevation ACS or ST elevation ACS

25
Q

What % pts with ACS have >= 2 plaques

A

50%

26
Q

TIMI Risk Score

A 
more increased needs a more aggressive TX
Age >/= 65
>/= 3CAD risk factors
Prior Coronary Stenosis >50%
ST deviation
>/=2 Anginal events in  less than 24 hours
ASA last 7 days
elevated cardiac markers
27
Q

Class 1 agents for NSTE-ACS

A

-Aspirin
Clopidogrel if allerigic
Or use with clopidogrel if invasive approach is not planned
Stop clopidogrel 5-7 days before CABG or surgery
-Use GP IIb/IIIa inhibitor if cardiac cath and PCI is planned- max tx 8 days

28
Q

Class 2a Agents for NSTE-ACS

A

Use GP IIb/IIIa inhibitor in pts RECEIVING CLOPIDOGREL if cardiac cath and PCI planned
Use GP IIb/IIIa inhibitor in high risk pts if invasive strategy is not planned

29
Q

Antiplatelet tx functions to

A

prevent thrombosis from plaque rupture in ACS

30
Q

Dual or Tripple antiplatelet therapy can reduce odds of vascular caused death, MI or stroke by

A

22%

31
Q

What anti platelet combos are there?

A

ASA + Clopidogrel (one or both)
option to add GP IIb/IIIa inhibitors

caution because increase risk to bleed

Pharm 2 Exam 2 (10 decks)

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