5 - ACS Part 2 Flashcards by Sam Myers

What is DAPT?

dual anti platelet therapy

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2 options for treating a STEMI?

1) fibrinolytics

2) primary PCI

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2 options for treating a UA/NSTEMI?

**assess risks
THEN either:

1) early invasive strategy (surgery)
2) ischemia guided strategy (medicine)

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What is the initial treatment once ACS is suspected but we don’t know which type (UA, STEMI or NSTEMI)?

MONA

morphine
oxygen
nitrates
ASA 325 mg

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Describe what points are given for to determine a patient’s TIMI Risk Score

1 point is given for each of the following:

> 65 yo
> 3 risk factors for CAD
prior coronary stenosis > 50%
ST deviation on ECG
> 2 anginal events in prior 24 hours
use of aspirin in prior 7 days
elevated cardiac biomarkers

**see slide 10

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If they have a TIMI score >2, what should happen?

they should be considered for early invasive strategy (surgery)

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If they have a TIMI score of 0 or 1, what should happen?

they would be considered for ischemia guided strategy (medicine)

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What is entailed in early invasive strategy?

Angiography +/- revascularization (PCI) within 24 hours

- Indicated for high risk patients (TIMI risk score > 2, or presence or other high risk characteristics)

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What is entailed in ischemia-guided strategy?

medical management
patients with low risk features
may be referred for revascularization if schema worsens or if new high risk features occur

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Who is a CABG indicated for?

-high risk patients with multi vessel disease may be referred for CABG (hold DAPT 5-7 days prior to surgery if possible)

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Antiplatelets:

Options?

ASA
Ticagrelor
Clopidogrel
Prasugrel

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ASA:

Initial dose

160-325 mg STAT (chewed)

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ASA:

Maintenance dose

80-325 mg daily

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Ticagrelor:

Initial dose

180 mg LD

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Ticagrelor:

Maintenance dose

90 mg BID

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Clopidogrel:

Initial dose

150-300 mg LD

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Clopidogrel:

Maintenance dose

75 mg daily

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Prasugrel:

Initial dose

60 mg LD

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Prasugrel:

Maintenance dose

10 mg daily

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Who is DAPT indicated for?

UA/NSTEMI patients who underwent early invasive strategy with PCI should receive DAPT as outlined for STEMI patients
For patients with ischemia-guided strategy (medical management), current guidelines recommend DAPT with ASA plus ticagrelor or clopidogrel

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How long is DAPT indicated for?

for 1 year in all ACS patients whether they are treated medically, with PCI or CABG

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MOA of GP 2b/3a inhibitors

block binding of fibrinogen to GP 2b/3a receptor on platelet surface, therefore inhibit platelet aggregation

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What are examples of GP 2b/3a inhibitors

abciximab
eptifibatide
tirofiban

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What is the dose of enoxaparin?

1mg/kg SC Q12H (max 100 mg) until PCI or hospital discharge shown to decrease risk of death, MI and stroke

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Advantage of enoxaparin?

easier to give, no monitoring, lower incidence of HIT ?, similar cost to UFH

Dose of UFH?

60 units/kg LD then 12 units/kg/hr infusion - titrate to APTT 1.2-2x control - until PCI or 48 hrs

What is the standard heparin?

LMWH = standard *if it's someone who is morbidly obese and we can't dose properly or they are known to have chronic failure - switch to UFH

Describe fondaparinux

indirect-acting factor Xa inhibitor

Dose of Fondaparinux?

2.5mg SC once daily (until PCI or hospital discharge)

What advantage does fondaparinux have over enoxparin?

lower rate of major bleeding

Goals of adjunct therapy

- reduce the risk of short term and long term complications associated with ACS - slow progression of coronary heart disease and minimize the risk of future cardiovascular events and other morbidities - improve mortality and restore QOL

List 4 ACS complications

- heart failure - cardiogenic shock - arrhythmias - pericarditis

Describe how heart failure could occur after an ACS

LV myocardium may be ischemic, stunned, hibernating or irrevocably injured after MI

Describe how cardiogenic shock could occur after an ACS

- Decreased cardiac output & evidence of tissue hypoxia in presence of adequate intravascular volume - Often due to extensive LV infarction

Describe how arrhythmias could occur after an ACS

-arrhythmias may occur post MI due to ischemia and severe HF

Describe pericarditis after an ACS

- uncommon and usually presents within 72 hour post MI | - symptoms usually resolve within 3-4 days

What is the treatment for pericarditis?

ASA 650 mg po QID or NSAIDs

Why are BB used in ACS?

- prevent extension of infarction by reducing oxygen demand | - decrease cardiovascular mortality, recurrent nonfatal MI and all-cause mortality

When should BB be initiated after an MI?

within 24 hours after onset of MI unless contraindicated

BB: | Start at low dose and titrate to maintain resting HR of ____ bpm

55-60

What conditions would make someone contraindicated to get a BB?

- hypotension - bradycardia - acute heart failure - cardiogenic shock - asthma - 2nd or 3rd degree AV block

Metoprolol: | Initial dose

25mg BID

Metoprolol: | Max dose

100mg BID

Atenolol: | Initial dose

12.5-25 mg daily

Atenolol: | Max dose

100 mg daily

Carvedilol: | Initial dose

3.125 mg BID

Carvedilol: | Max dose

25 mg BID

Why are ACEi used in ACS?

-minimize ventricular remodelling, reduce oxygen demand and myocardial wall stress by reducing after load or preload

When should someone start an ACEi after MI?

within 24 hour of MI once BP has been stabilized unless CI

What types of patients should we use ACEi with caution?

those with renal impairment and hyperkalemia

What do we monitor for BB?

- BP - HR - signs/symptoms of HF

What do we monitor for ACEi?

- SCr - electrolytes - watch for hyperkalemia (K > 5.5)

Ramipril: | Initial dose

1.25 - 2.5 mg daily

Ramipril: | Target dose

10mg/day

Enalapril: | Initial dose

2.5mg BID

Enalapril: | Target dose

10-20 mg BID

Lisinopril: | Initial dose

2.5-5 mg daily

Lisinopril: | Target dose

40 mg daily

Captopril: | Initial dose

6.25 TID

Captopril: | Target dose

25-50 mg TID

Who are ARBs indicated for?

People who cannot tolerate ACEi

Monitoring of an ARB is the same as an ____

ACEi

Candesartan: | Initial dose

4 mg daily

Candesartan: | Target dose

32 mg daily

Telmisartan: | Initial dose

40 mg daily

Telmisartan: | Target dose

80 mg daily

Valsartan: | Initial dose

20 mg BID

Valsartan: | Target dose

160 mg BID

Statins: If not at max dose already, titrate to achieve _____% reduction in LDL

50-60

Monitoring for statins?

- Lipid panel (LDL-C, chol, HDL-C) - LFTs - CK - signs and symptoms of myopathy and rhabdomyolysis

Atorvastatin doses

20-80 mg daily

Fluvastatin doses

20-80 mg daily

Pravastatin doses

20-40 mg daily

Lovastatin doses

20-80 mg daily

Simvastatin doses

20-80 mg daily

Rosuvastatin doses

5-40 mg daily

What types of patients should get an MRA (mineralocorticoid receptor antagonist)?

for consideration in patients with significant LV dysfunction (EF < 40%)

Should caution MRAs in what types of patients?

CrCl < 30 | K > 5

When should K+ be monitored when on an MRA

at baseline and then within 1 week of initiation

Spironolactone: | Initial dose

12.5 mg daily

Spironolactone: | Target dose

25 mg daily

Eplerenone: | Initial dose

25 mg daily

Eplerenone: | Target dose

50 mg daily

What are some modifiable CHD risk factors?

- smoking cessation - hypertension - dyslipidemia - obesity - sedentary lifestyle - stress

List some non-pharm therapies

- weight management - physical exercise - smoking cessation - ICD (implantable cardioverter defibrillator) - stress management/depression screening

Goals for weight management?

- BMI 18.5 - 25 - Waist circumference (<100 cm males & < 90 cm in females) - Goal of 5-10% weight reduction

Goals for exercise?

30-60 mins of moderate-vigorous physical exercise 3-5x per week *This may change based on each individual's starting exercise habits

How much does smoking cessation lower risk of recurrent MI after 2 years?

by half !!!!

Are omega 3 fatty acids beneficial for preventing cardiovascular disease?

No evidence, but don't tell patients to stop taking them

Are antioxidants such as vitamins A, C, E and beta carotene beneficial for preventing cardiovascular disease?

How about folic acid with/without vitamin B6 of B12? Is it good for preventing cardiovascular disease?

NOPE

Why is hormonal therapy not indicated in post menopausal women post MI?

may increase CV risk

Post MI patients need to avoid _____

NSAIDs, including selective COX2 inhibitors

Post MI: For active, ongoing users of cocaine and meth, ____ ________ should be avoided due to risk of potentiating coronary spasm

beta blockers