Treatment Approach: CCD, Unstable Angina, NSTEMI, STEMI (Wed AM/PM) Flashcards
goal of therapy for patients with CCD
prevent development of major adverse cardiovascular event (MACE) like a myocardial infarction (ACS), stroke or death due to cardiovascular causes (aka clinical ASCVD)
CCD treatment
non-pharm management
stable angina, diagnosed after acs, ccd diagnosed on screening
- quit smoking (tobacco)
- limit alcohol to 1 or less for women and 2 or less for men
- avoidance in other substances with harmful CV effects (cocaine, meth, opioids, marijuana)
CCD treatment: lipid therapy
not at very high risk
- high intensity statin to lower LDL more than or equal to 50%
- moderate intensity statin if high intensity statin not tolerated
- on max tolerated statin and LDL greater than or equal to 70 mg/dL, add ezetimibe
- on max tolerated statin and LDL less than 100 mg/dL with fasting TG 150-499 mg/dL, add icosapent ethyl
mod int statin
Atorvastatin 10-20 mg
Rosuvastatin 5-10 mg
Simvastatin 20-40 mg
Pravastatin 40-80 mg
Lovastatin 40 mg
Fluvastatin 80 mg
Pitavastatin 2-4 mg
CCD treatment: lipid therapy
very high risk
- high intensity statin to lower LDL more than or equal to 50%
- on max tolerated statin and LDL greater than or equal to 70 mg/dL, add ezetimibe
- on max tolerated statin and LDL lower than 100 mg/dL with fasting TG 150-499 mg/dL, add icosapent ethyl
- on max LDL lowering therapy and LDL more than or equal to 70 mg/dL or non HDL more than or equal to 100 mg/dL, a PCSK-9 can be beneficial
PCSK-9s: praluent (alirocumab), repatha (evolocumab)
CCD treatment: antiplatelet therapy
no PCI
aspirin 81 mg daily
CCD treatment: antiplatelet therapy
directly after PCI
dual antiplatelet therapy (DAPT) for 1-6 months followed by single antiplatelet therapy (SAPT)
SAPT is aspirin or clopidogrel
CCD treatment: antiplatelet therapy
after CABG
dual antiplatelet therapy
SAPT
low dose aspirin or a P2Y12 inhibitor
DAPT
combination of low dose aspirin and a P2Y12 inhibitor
CCD treatment: comorbidity treatment
mental health
targeted discussion and treatment for mental health is reasonable to improve CV outcomes
CCD treatment: comorbidity management
blood pressure
in patients who meet threshold, for BP therapy, ACEI/ARB or beta blockers are recommended first line
CCD treatment: comorbidity management
diabetes
patients with TIIDM should use an SGLT2 inhibitor or GLP1 receptor agonist with proven CV benefit to reduce MACE
anginal chest pain treatment
if attacks are infrequent or prior to activities that cause angina
sublingual nitroglycerin
1. sit down
2. dissolve under tongue
3. take up to 3 doses q 5 mins
store in original container & replace q 6 months
anginal chest pain treatment
decreases HR and contractility (decreased O2 demand)
also antiarrhytmic and may slow progression of plaque
beta blockers
treatment goals: resting HR 50-60 bpm, max exercise HR 100 bpm
anginal chest pain treatment
as effective as beta blockers in preventing anginal symptoms
calcium channel blockers
1. Non-DHP: decreased HR and contractility (avoid w/ beta blockers or severe LV dysfunction)
2. DHP: decreased afterload
anginal chest pain treatment
isosorbide dinitrate or mononitrate
transdermal nitroglycerin patch
long acting nitrate
1.lack of efficacy after consistent exposure
2.provide 10-14 hour nitrate free period (usually during sleep)
anginal chest pain treatment
Inhibits persistent/ late inward Na+ current in the ventricles
ranolazine
1. anti-ischemic activity related to reduced accumulation of intracellular calcium
2. no effect on HR or BP
3. AE: QT prolongation
4. metabolism: 3A4, 2D6, pGp
acute treatment of ACS
unstable angina and NSTEMI
OSNAAP
O of OSNAAP
oxygen
1. if arterial O2 saturation is less than 90%
2. respiratory distress
3. other high risk features of hypoxemia
S of OSNAAP
statin
1. high intensity statin
atorvastatin 40-80 mg
rosuvastatin 20-40 mg
N of OSNAAP
nitroglycerin
1. SL NTG every 5 min × 3 for
continuing ischemic pain and
then assess need for IV NTG
2. Administer IV NTG for
persistent ischemia, HF, or
hypertension
3. Nitrates are contraindicated
with recent use of a phosphodiesterase inhibitor
1st A of OSNAAP
Aspirin
1. loading dose: non-enteric coated, CHEWABLE aspirin ASAP after presentation. (162-325 mg)
2nd A of OSNAAP
anticoagulants
* P2Y12i loading dose of ticagrelor: 180 mg
* maintenance dose for ticagrelor: 90 mg bid for 1-6 mos
* P2Y12i loading dose of clopidogrel: 600 mg
* maintenance dose for clopidogrel: 75 mg qd for 1-6 mos
* P2Y12i loading dose of prasugrel: 60 mg
* maintenance dose for prasugrel: 10 mg qd
ticagrelor preferred
prasugrel only if PCI (stent)
GIIB/IIIA inhibitors
tirofiban (aggrastat), eptifibatide (integrilin), abciximab (reopro)
1. potent antiplatelet agents that block the binding site for fibrinogen
2. used in some catheterization procedures in patients with significant clot burden
Increases bleed risk, especially in combination with aspirin, a P2Y12 inhibitor, and an anticoagulant
acute treatment strategies for STEMI
if time to PCI is more than 90 minutes
fibrinolytic therapy (thrombolytics)
1. work to degrade fibrin clots and restore blood flow (revascularization)
2. only use clopidogrel
3. alteplase (tPA), reteplase, tenecteplase (tNK)
acute treatment of STEMI
just P because everything else is same
P from OSNAAP
P2Y12 Inhibitor (P2Y12i):
* Loading dose:
– Ticagrelor: 180 mg x 1
– Clopidogrel: 600 mg x 1
– With a lytic:
– ≤ 75 years: 300 mg
– > 75 years: 75 mg
– Prasugrel 60 mg x 1 (only
after visualization of coronary
anatomy)
* Maintenance dose: P2Y12i x 1-6
months
– Clopidogrel: 75 mg daily
– Ticagrelor: 90 mg twice daily
– Prasugrel: 10 mg daily
ticagrelor or prasugrel preferred
long term treatment of ACS
unstable angina, NSTEMI, STEMI
SNAP plus BAM
S from SNAPBAM
high intensity statin indefinitely
N from SNAPBAM
send SL PRN rx home with patient
1st A from SNAPBAM
continue maintenance dose of aspirin indefinitely
P from SNAPBAM
continue maintenance dose of P2Y12i for 1-6 mos
B from SNAPBAM
beta blocker for 1 year or indefinitely
1. any beta blocker unless signs of acute HF
2. In patients with reduced EF,
use BB proven to reduce mortality in patients with HF (sustained-release
metoprolol succinate, carvedilol, or bisoprolol)
`
If a patient has a normal EF and low BP and can only tolerate a BB or an ACEI/ARB, usually choose BB
2nd A from SNAPBAM
ACEI/ARB indefinitely
1. ACE inhibitors should be initiated in all patients with LVEF < 40% and in those with hypertension, diabetes mellitus, or stable CKD
2. ARBs are recommended in patients who are ACE inhibitor intolerant
MI caused by vasospasm and vasoconstriction of coronary arteries
cocaine induced myocardial infarction
M from SNAPBAM
Mineralocorticoid Receptor Antagonist
1. Patients with an EF < 40%
who are receiving therapeutic doses of ACE inhibitor and beta blocker
2. Contraindicated:
– Serum creatinine >2.5
mg/dL in men
– Serum creatinine >2.0
mg/dL in women
– Potassium >5.0 mEq/L
sympathomimetic crisis
cocaine inhibits the reuptake of norepinephrine leading to increased norepinephrine concentrations and enhanced alpha 1 mediated vasoconstriction
cocaine induced myocardial infarction
chest pain treatment
aspirin
benzos
cocaine induced myocardial infarction
persistent hypertension treatment
benzos
IV nitroglycerin
cocaine induced myocardial infarction
other acute ACS treatment
possibly avoid acute beta blockers
cocaine induced myocardial infarction
long term ACS treatment
- possibly avoid beta specific beta blockers
- drug abuse counseling
cardiovascular mechanism of NSAID induced cardiotoxicity
- NSAIDs block COX-2
- COX-2 would stimulate vascular vasodilation and decreased platelet aggregation
- physiologic effects of cox inhibition is MI and stroke
intermittent claudication
symptoms and clinical presentation
- pain when walking in the buttocks, thighs or calves
- often relieved with rest
- severe cases will have pain at rest
chronic limb threatening disease
symptoms and clinical presentation
- chronic decreased flow that can lead to ulcerations, gangrene, infections
- patients with diabetes and smokers highest risk
acute limb ischemia
symptoms and clinical presentation
- medical emergency
- requires immediate revascularization to prevent limb loss
PAD treatment
lipid lowering therapy
- High intensity statin
with a goal of lowering LDL ≥ 50% - If LDL ≥ 70 mg/dL after maximally tolerated statin therapy, add PCKS9 inhibitor and/or ezetimibe
PAD treatment
antihypertensive therapy
- PAD and HTN = first line use of ACEI/ARB
- treat to goal < 130/80 mm Hg
PAD treatment
diabetes management and smoking cessation
DM: more detail to come
SC: as before
PAD treatment
preventative foot care
- foot self care education
- foot inspection at every visit clinician
- therapeutic footwear
- referral to foot care specialist
Symptomatic PAD
antiplatelet therapy
dependent on revascularization
if recent revascularization
1. low dose aspirin and rivaroxaban 2.5 mg bid
2. DAPT: aspirin 81 mg qd and P2Y12 inhibitor
if no recent revascularizaation
1. low dose aspirin and rivaroxaban 2.5 mg bid
2. SAPT: clopidogrel 75 mg qd or aspirin 81 mg qd
symptomatic PAD
potential cilostazol therapy
cilostazol helps to improve leg symptoms and improve walking distance
1. inhibits phosphodiesterase III
2. takes 2-4 weeks, may require up to 12 weeks
3. contraindicated in patients with HF
4. AE: headache (~30%), GI upset/diarrhea (~15%)
5. Substrate of: CYP1A2, CYP2C19, CYP2D6, CYP3A4, Weak inhibitor of CYP3A4
symptomatic PAD
structured exercise therapy
- Structured exercise therapy (SET) is recommended to improve walking performance, functional status, and quality of life in all patients with chronic symptomatic PAD
- Can be administered at a rehabilitation facility, clinic, or as
home therapy through consultation with trained personnel
acute limb ischemia
treatment
revascularize immediately
1. immediate admin of systemic heparin in any scenario
2. thrombolytics: local admin to site of occlusion
3. endovascular: balloon +/- stenting, thromboectomy
4. surgical: thromboectomy, bypass surgery, amputation if unable to revascularize
