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CardioPulm II > ACS > Flashcards

Flashcards in ACS Deck (183):
1

Clopidogrel

Plavix®

2

Prasugrel

Effient®

3

Ticagrelor

Brilinta

4

Unfractionated Heparin

UFH

5

Fondaparinux

Arixtra®

6

Bivalirudin

Angiomax®

7

Tirofiban

Aggrastat®

8

Eptifibatide

Integrilin®

9

Abciximab

Reopro®

10

Ticlopidine

Ticlid®

11

Omeprazole

Prilosec®

12

Metoprolol tartrate

Lopressor®

13

Metoprolol succinate

Toprol XL®

14

Atenolol

Tenormin®

15

Carvedilol

Coreg®

16

Ischemia

Reduction of blood supply or increase in oxygen demand of myocardium

17

Infarction

Interruption of blood flow that leads to necrosis of myocardium

18

What is ACS?

Spectrum of conditions that result from myocardial ischemia and/or infarction

19

Atherothrombosis

-Disruption of an atherosclerotic plaque
-Results in thrombosis
-Reduced myocardial perfusion → infarction (death

20

STEMI

Complete artery occlusion by the thrombus

21

UA/NSTEMI

Incomplete artery occlusion by the thrombus

22

Risk factors of ACS: Modifiable

Physical Inactivity

Obesity - (especially abdominal)

Smoking- counsel

HTN

Hyperlipidemia

23

Risk Factors for ACS: Non-modifiable

Age

Male gender <55

Family history of premature CHD

History of CAD, including MI

DM

24

Clinical Presentation: Classic


-Chest discomfort, squeezing sensation

-Chest pressure can radiate to shoulder, left arm, back or jaw

25

Clinical Presentation: Rest

occurs at rest and lasts > 20 min

26

Clinical Presentation: New-onset

severe (marked limitation of physical activity)

27

Clinical Presentation: Increasing

more frequent, longer in duration or higher intensity

28

Clinical Presentation: Atypical

Epigastric pain
Nausea and vomiting
Diaphoresis
Shortness of breath
Light-headedness, syncope
Weakness

Atypical sx more common in women, elderly (≥ 75 yo) & pts with DM, CKD, dementia

29

Diagnosis: ACS

Electrocardiogram changes (EKG, ECG)

Positive cardiac biomarkers (measured x 3)
->Creatinine Kinase (CK)
->Creatinine Kinase – MB isoenzyme (CK-MB)
->Troponin I/T – Biomarker of CHOICE

30

Diagnosis: ACS : Gold standard

Cardiac Catheterization
-->Gold standard for diagnosis

31

Diagnosis: ACS: Biomarker of choice

Troponin I/T

(measured x 3)

32

Classification of ACS: STEMI

No different in the extent of symptoms- Chest Pain or Severe Chest Paint.

Symptoms: Present
EKG Change: ST Elevation
Biomarkers: High

33

Classification of ACS: NSTEMI

No different in the extent of symptoms- Chest Pain or Severe Chest Paint.

Symptoms: Present

EKG Changes:
ST segment depression or T wave inversion

Biomarkers Medium

34

Classification of ACS: UA

No different in the extent of symptoms- Chest Pain or Severe Chest Paint.

Symptoms: Present
EKG Changes: ST segment depression or T wave inversion
Biomarkers: No Elevation

35

Initial Therapy: STEMI

Aspirin
Nitroglycerin
UFH/LMWH
+/-Beta-blocker (IV)
+/-Morphine

36

Initial Therapy: STEMI

acronym

M – Morphine (+/-)
O – Oxygen (+/-)
N – Nitroglycerin
A – Aspirin
A - Anticoagulant

37

Initial Therapy: Asprin

First dose 162-325 mg chewed

Not EC

38

Initial Therapy: Nitroglycerin (NTG)

Outside Hospital

Call EMS if angina not relieved 5 min after 1 dose (0.4 mg sublingual)

39

Initial Therapy: Nitroglycerin (NTG)

In Hoptial

EVERYONE GETS AN ORDER FOR NTG AND RX

Sublingual NTG can be repeated q 5 min x 3 doses
Consider IV NTG if angina not relieved

40

Initial Therapy: Anticoagulation

Unfractionated heparin (UFH) – preferred

Enoxaparin as alternative to UFH

41

Reperfusion Therapy

Goal: re-open partially or completely occluded coronary artery

Re-establish blood flow

Improve perfusion to the affected myocardial tissue

42

Initial Therapy: Beta-blocker (+/-)

IV beta-blockers upon presentation in pts who are hypertensive or ongoing ischemia and do NOT have:

1.Signs of HF
2.PR interval > 0.24 seconds
3.Heart block
4.Active asthma/COPD

43

Initial Therapy: Morphine (+/-)


Dosing and indication

For continued chest pain***
Dose: 2-4 mg IV repeated q 5-15 min prn

44

Reperfusion Therapy: Non-Pharmacologic

Percutaneous Coronary Intervention (PCI)

--Invasive procedure – NOT surgery
--Mechanical revascularization - dilation of the coronary artery – “stenting”

45

Reperfusion Therapy: Pharmacologic

Fibrinolytic Therapy—NON PREFERRED - BREAK CLOT

46

Timing of Reperfusion Therapy: Door to Balloon Time

Door to Balloon Time”: < 90 min
Target time from hospital presentation to PCI
HAVE 90MIN TO GET THEM TO CATH LAB

47

Timing of Reperfusion Therapy: Door to Needle Time

Door to Needle Time”: < 30 min
Target time from hospital presentation to fibrinolytic

48

WHY PCI preferred over fibrinolytics?

↓ Mortality rate
↓ Risk of stroke (ICH) & major bleeding

49

Fibrinolytic Therapy

STEPTOKINANCE IS NOT FIBRIN SPECIFIT—INCREASES SYSTEMIC BLEEDING

50

Fibrinolytic Therapy: Indications

STEMI patients with:
Symptom onset within 12 hrs AND
ST-elevation in at least 2 contiguous EKG leads

Indicated for STEMI patients at non-PCI hospitals
Age < 75 (controversial)

51

When shouldn't Fibrinolytic therapy be used?

Fibrinolytic therapy NOT recommended in UA/NSTEMI patients!!

52

Absolute Contraindications – to Fibrinolytic therapy

Previous intracranial hemorrhage (at ANY time)***

Ischemic stroke within 3 months**

53

Relative Contraindications – more than one Relative ContraIND is Absolute—Risk for Intracranial Hemorrhage

Fibrinolytic therapy

Uncontrolled HTN (SBP > 180 or DBP >110 mmHg)
History of stroke > 3 months
Current use of anticoagulants
Age > 75

54

Fibrin-Specific Agents

Alteplase (tPA): Activase ®
Reteplase (rPA): Retavase ®
Tenecteplase (TNK-tPA):TNKase ®

55

Alteplase (tPA): Activase ®

Dosage*****

15 mg IV bolus followed by
0.75 mg/kg (max 50 mg) IV infusion over 30 min followed by 0.5 mg/kg (max 35 mg) IV over 1 hr (100 mg TOTAL)

56

Choice of Fibrinolytic Agent

Fibrin-specific agents more effective
Alteplase, reteplase, tenecteplase
---Preferred agents as per ACC/AHA guidelines

57

Fibrinolytic Agent: Risk of bleeding

ICH risk higher with fibrin-specific agents

Systemic bleeding higher with streptokinase

58

Fibrinolytic Agent : ADR or Side Effects

SE:

Bleeding: Intracranial hemorrhage (ICH): largest risk

Reperfusion arrhythmia: usually self limiting

59

Antiplatelet Therapy with Fibrinolytics:

Loading Dose

Aspirin 162-325 mg X 1 AND

Clopidogrel
Pts ≤ 75 yo: 300 mg x 1
Pts > 75 yo: no LD, give 75 mg

60

Antiplatelet Therapy with Fibrinolytics:

Maintenance Dose

Aspirin 81 to 325 mg po daily indefinitely
-->81 mg dose preferred ( hiegher doses are not more effective)

Clopidogrel 75 mg po daily for at least 14 days and up to 1 year

61

Anticoagulation with Fibrinolytics: Indications

Anticoagulant tx for a min of 48 hrs and preferably for the duration of hospitalization or up to 8 days

If anticoagulant tx continued > 48 hrs, therapies other than UFH recommended due to risk of HIT**

**Enoxaparin** is preferred anticoagulant in patients receiving fibrinolytic therapy**

62

Anticoagulation with Fibrinolytics

**Enoxaparin (Lovenox®)**

Unfractionated heparin
(UFH)

Fondaparinux (Arixtra®)

63

**Enoxaparin (Lovenox®)**- Preferred

Dosing for anticoagulation

30 mg IV bolus followed immediately by 1 mg/kg sub cut q12h***

Age ≥ 75 yo, no bolus, 0.75 mg/kg subcut q12h

CrCl < 30 ml/min: 1 mg/kg subcut q24h- when to RENAL DOSE

64

Unfractionated heparin
(UFH)

Dosing for anticoagulation

60 units/kg IV bolus (max 4000 Units) followed by 12 units/kg/hr (max 1000 Units/hr)

Adjusted to maintain aPTT 1.5 - 2 X control

65

Fondaparinux (Arixtra®)

2.5 mg IV, then 2.5 mg subcut daily in 24 hrs

Contraindicated if CrCl < 30 ml/min– Can give in HISTORY OF HIT

66

Stenting "PCI"

Bare metal stent (BMS)

Drug-eluting stents (DES)
-Paclitaxel
-Sirolimus
-Everolimus
-Zotarolimus

67

Restenosis

blood vessel grow over the stent and cause a blockage.

68

PCI indications

Don't know

69

Primary PCI:

Decreases Chance of Intracranial hemorrhage.

70

PCI timing

should be performed if immediately available (within 90 min of hospital presentation)

Should be performed within 12 hrs of symptom onset

71

Complications of PCI:

Contrast - Induced nephropathy
PCI = IV dye administration

High risk patients:
1.Advanced age >75 years!!!
2.Chronic kidney disease (CKD)
3.DM
4.Heart failure

72

How to prevent In-stent restenosis & rethrombosis?

Prevent with dual antiplatelet therapy (DAPT)

73

Prevention of Contrast-induced Nephropathy

*************
1. Risk stratification & monitoring
BUN/SrCr daily after PCI

2. Hydration (NSS) pre- and post-procedure (#1 way to prevent contrast neuropathy)

+/- N-acetylcysteine (Mucomyst®)
+/- Sodium bicarbonate

3. Concomitant medication assessment
->Hold metformin at time of PCI, then x 48 hrs
->Nephrotoxic drugs (ACE-I, ARBS, diuretics

74

Dual Antiplatelet Therapy with PCI

Clopidogrel (Plavix®)
600 mg-PCI LOADING DOSE!!!

75

Anticoagulants with PCI

Unfractionated Heparin (UFH)

Unfractionated Heparin (UFH)
Inhibits factors Xa & IIa (thrombin

76

Anticoagulants with PCI

Fondaparinux (Arixtra®)

Fondaparinux (Arixtra®) –Hx of HIT ok**
Pentasaccharide that inhibits factor Xa only

77

Anticoagulants with PCI

Bivalirudin (Angiomax®)

Bivalirudin (Angiomax®) – Hx of HIT ok**

Direct thrombin inhibitor that inhibits factor IIa
Has anticoagulant & antiplatelet activity
“2 for 1” drug

78

Anticoagulants with PCI

Recommendations

Preferred agents: UFH (need GP too) or bivalirudin (decrease risk of bleeding-preferred) -CLASS I


Bivalirudin for pts at high risk of bleeding in PCI


D/c UFH & bivalirudin after successful PCI

79

Anticoagulants with PCI

Unfractionated heparin (UFH)

IV GPI planned: 50-70 U/kg IV bolus

No IV GPI planned: 70-100 U/kg IV bolus

Supplemental IV bolus to target ACT

80

Anticoagulants with PCI

Bivalirudin (Angiomax®)

0.75 mg/kg IV bolus
Infusion:
1.75 mg/kg/hr


RENALLY DOSE(need to reduce dose) CrCl < 30 ml/min: 1 mg/kg/hr

81

Anticoagulants with PCI

Fondaparinux (Arixtra®)

Not recommended as the sole anticoagulant for PCI due to risk of catheter thrombosis

82

Anticoagulants with PCI

Contraindications/Precautions

History of HIT (UFH/LMWH)

CrCl < 30 ml/min
---↓ Bivalirudin infusion to 1 mg/kg/hr
---Fondaparinux contraindicated

83

Glycoprotein IIb/IIIa Inhibitors


Glyo- sugar

Tirofiban (Aggrastat®)
Eptifibatide (Integrilin®)
Abciximab (Reopro)

TEA

84

Glycoprotein IIb/IIIa Inhibitors

Benefits

Clinical Benefits:

Maintain patency of coronary artery during PCI

↓ Thrombosis & mortality following PCI**

85

should Glycoprotein IIb/IIIa Inhibitors be recommended with fibrinolytic therapy?

NEVER recommended with fibrinolytic therapy
(↑ bleeding risk)

86

Whats the preferred Glycoprotein IIb/IIIa Inhibitors?

Abciximab (Reopro®)

PREFERRED

87

When are Glycoprotein IIb/IIIa recommended?

Recommended at the time of PCI (downstream)

In STEMI pts undergoing primary PCI, it is reasonable to administer a GP IIb/IIIa inhibitor

88

Glycoprotein IIb/IIIa dosing??

Don't do that

89

What type of elimination is
Tirofiban and Eptifibatide?

What must you do to counter it?

Reduce dose.


Tirofiban (Aggrastat®)
Renal
CrCl < 30 ml/min:
↓ infusion by 50%


Eptifibatide (Integrilin®)
Renal
CrCl < 50 ml/min:
↓ infusion by 50%
Avoid in HD pts

90

GP IIb/IIIa Inhibitors:

Contraindications?

Active bleeding

Thrombocytopenia

Prior stroke

91

Secondary prevention

Nice SAAB

N – NTG (SL)
S – Statin
A – Aspirin
A – Antiplatelet
B – Beta-blocker

92

Secondary prevention:
Who gets aspirin?

All STEMI patients: ASA should be administered ASAP and continued indefinitely

93

Secondary prevention:
Aspirin dosing?

Initial dose
162 – 325 mg (chewed ASAP) _HIGHDOSE!!!

Maintenance Dose
81 – 325 mg po daily indefinitely

94

Secondary prevention:

Thienopyridines

Ticlopidine (Ticlid®) – risk of neutrapenia—Inhbiti P2Y12

Clopidogrel (Plavix®)

Prasugrel (Effient®)

95

Secondary prevention:

Cyclopentyltriazolopyrimidine

Ticagrelor (Brilinta®)-Reversible inhibitor, shorter T1/2 too

96

Secondary prevention:

Benefits of Antiplatelet Therapy:P2Y12 Inhibitors

Clinical Benefit:

↓ Restenosis/rethrombosis s/p STEMI

97

Secondary prevention:

Prasugrel & ticagrelor warnings?

More potent anti-platelet effects

Higher bleeding risk (WHY PLAVIX is still around

98

Secondary prevention:

Who gets Clopidogrel (Plavix®)?

How long?

Alternative for patients with true ASA allergy
Continue indefinitely

Duration:
Continue for at least 12 months

99

Secondary prevention:

Clopidogrel (Plavix®) dosing?

Loading dose: 600 mg po x 1 (standard for PCI)

Maintenance dose: 75 mg po daily

Discontinue 5 days prior to surgery (ie, CABG)

100

is Clopidogrel (Plavix®) a produrg?

Yes,Metabolized by CYP2C19 to active metabolite

101

Clopidogrel (Plavix®) boxed warning?

Genetic polymorphisms and ↓ CYP2C19 activity

Clopidogrel may have ↓ antiplatelet effects

102

Clopidogrel and PPIs

PPIs inhibit CYP2C19; risk of stent thrombosis.

Omeprazole (Prilosec®): greatest risk

103

COGENT Trial

Pts on ASA + clopidogrel randomized to receive omeprazole vs. placebo

No difference in CV events, only ↓ GI bleeding

104

PPI+ clopidogrel mangagment?

History of GI bleed

Patients at high risk for GI bleed -Advanced age, concomitant warfarin, steroids, NSAIDS

Choose alternative PPI (ie, pantoprazole) or H2 blocker (ie, famotidine, ranitidine)

105

Prasugrel (Effient®)
Recommendations?

addition to ASA in STEMI patients undergoing PCI only***

106

Prasugrel (Effient®)
Duration

Continue for at least 12 months

107

Prasugrel (Effient®)
Dosing

Loading dose: 60 mg po x 1

Maintenance Dose: 10 mg po daily

D/C 7 days prior to surgery (ie, CABG

108

Prasugrel (Effient®)

Black box warning?

Black Box Warning: may cause significant or fatal bleeding

109

Prasugrel (Effient®)

contraindication?

History of TIA or stroke!

110

Prasugrel (Effient®)


precaution

Age > 75 years

Weight < 60 kg: (↓ MD to 5mg daily)

111

Ticagrelor (Brilinta®)

addition to aspirin in STEMI patients
*** undergoing PCI or medical management***

112

Ticagrelor (Brilinta®)
Duration

Continue for at least 12 months

113

Ticagrelor (Brilinta®)
Dosing:

Loading dose: 180 mg

Maintenance dose: 90 mg po BID** (compliance)

D/C at least 5 days prior to surgery

114

Ticagrelor (Brilinta®)
Contraindication?

Severe hepatic impairment

115

Ticagrelor & Aspirin Dose

What's the proper maintence aspirin dose?

Maintenance ASA dose should be 75-100 mg daily with ticagrelor

116

Ticagrelor: Drug Interactions?

Avoid strong CYP3A4 inducers
Rifampin, dexamethasone, phenytoin, carbamazepine, phenobarbital

Avoid strong CYP3A4 inhibitors
Ketoconazole, itraconazole, voriconazole, clarithromycin, ritonavir, indinavir, atazanavir


Limit simvastatin & lovastatin to 40 mg daily

Monitor digoxin levels closely

117

Monitoring: P2Y12 Inhibitors

All:
S/sx of ischemia
Bleeding, Hg/Hct
N/V/D


Ticagrelor
Dyspnea (usually transient)
Bradycardia

118

Ticagrelor & Adenosine

Looks the same: chemical structure.

119

Beta-Blockers:

indications

Initiate oral beta-blocker therapy in ALL PATIENTS in 1st 24 hours!

IV beta-blocker may be administered at presentation in pts who are hypertensive or have ongoing ischemia

120

Beta-Blockers:

Contraindications/Precautions

Bradycardia (HR < 60)
Hypotension (SBP < 90)

Signs of HF
Active asthma or COPD (wheezing)

121

Beta-Blockers

Dosing

Titrate beta-blockers by doubling the dose to goal HR

Titrate to goal resting HR 50 – 60!!

Avoid beta-blockers with intrinsic sympathomimetic activity (ISA) - ie, acebutolol

122

Choice of Beta-Blocker

EF ≥ 40%:
May use any b-blocker without ISA

EF < 40%: (stabilized HF)
Metoprolol succinate, carvedilol or bisoprolol

123

What beta blockers to use?

EF < 40%: (stabilized HF)

EF < 40%: (stabilized HF)
Metoprolol succinate, carvedilol or bisoprolol

124

What beta blockers to use?

EF ≥ 40%:

May use any b-blocker without ISA

125

Beta-Blockers

Metoprolol tartrate (Lopressor®)

Dosing

Acute: 5 mg slow IV push (over 1-2 min)

q 5 min x 3, then 25 – 50 mg po q6hrs

Maintenance: 25 – 100 mg po BID

126

Metoprolol succinate
(Toprol XL®)

Dosing

25 – 200 mg po daily

127

Nitrates:

Clinical Benefits

No effect on overall mortality – relief of CP only

128

Nitrates:
Indications

Take ONE dose of SL nitroglycerin.

If symptoms worsen or do not improve, call 9-1-1 immediately

129

Nitrates:

Contraindications

Do not administer within 24 hrs of phosphodiesterase inhibitors (sildenafil or vardenafil) or 48 hrs for tadalafil

130

Nitrates:
Sublingual

0.4 mg SL q 5 min x 3 doses

131

Nitrates:
IV infusion

5 - 10 mcg/min IV, titrated to 75 - 100 mcg/min IV

until relief of symptoms or limiting SE’s (HA)

132

Nitrates
Oral

Depends on formulation
Isosorbide mononitrate or Isosorbide dinitrate

133

Nitrates
Duration

Continue nitrates for (up to) 24 hrs after ischemia is relieved

134

Nitrates
Contraindications:

Hypotension (SBP < 90 or > 30% below baseline)

Bradycardia (HR < 50)

Tachycardia (HR > 100)

Right ventricular infarction

135

who gets Nitroglycerin?

doses?

NTG Rx for ALL patients with ACS!

NTG 0.4 (1/150 gr) mg SL prn CP

NTG spray, 1-2 sprays onto/under tongue prn CP
May repeat q 5min x 3 doses TOTAL

136

Counseling:

Nitroglycerin

Call 911 if no relief after 5 min

May cause HA, dizziness, tingling (sit down)

Store in a cool, dry place

137

Lipid-Lowering Agents:

Decrease morbidity & mortality s/p MI

High-intensity or moderate-intensity statin based on patient factors

138

High-intensity Statins?

Atorvastatin (40*)-80 mg
Rosuvastatin 20 (40) mg

139

Consider a moderate-intensity statin

Serious comorbidities
Renal or hepatic dysfunction

History of statin intolerance/muscle disorders

Unexplained ALT elevations > 3X ULN

Drug interactions affecting statin metabolism

> 75 years of age

140

Moderate intensity Statins?

Atorvastatin 10 (20) mg
Rosuvastatin (5) 10 mg
Simvastatin 20-40 mg
Pravastatin 40 (80) mg

141

Statin follow up?

Lipid panel in 4-8 weeks
To assess adherence & patient’s response

142

ACEI and ARBs

Mortality?

Reduce overall mortality!

143

ACEI and ARBs

Indications

ARBs for pts who cannot tolerate ACEI (ie, cough)

ACEI within 24 hrs & continue indefinitely in pts with:

LVEF < 40%
HTN
DM
CKD

Class IIb
ACEI for ALL patients

144

Lisinopril (Zestril®)
Enalapril (Vasotec®)
Ramipril (Altace®)
Captopril (Capoten®)


Initial Dosing

Lisinopril (Zestril®)
Enalapril (Vasotec®)
Ramipril (Altace®)
Captopril (Capoten®)

5 mg po daily
2.5 mg po po BID
1.25 – 2.5 mg po daily
6.25 – 12.5 mg po TID

145

Lisinopril (Zestril®)
Enalapril (Vasotec®)
Ramipril (Altace®)
Captopril (Capoten®)


Target Dose

Lisinopril (Zestril®)
Enalapril (Vasotec®)
Ramipril (Altace®)
Captopril (Capoten®)

20-40 mg po daily
10 mg po BID
10 mg po daily
50 mg po TID

146

ARBs?

Valsartan (Diovan®)
Candesartan (Atacand®)
Losartan (Cozaar®)

Valsartan (Diovan®)
Candesartan (Atacand®)
Losartan (Cozaar®)

Initial Dose
20 mg po BID
4 mg po daily
12.5-25 mg po daily


Target Dose
160 mg po BID
32 mg po daily
150 mg po daily

147

ACEI and ARBs

contraindications?

Hypotension (SBP < 100 mmHg)

Renal dysfunction (SrCr > 2.5)

Hyperkalemia (K > 5.5 mEq/L)

Bilateral renal artery stenosis

Pregnancy (category D

148

Aldosterone Antagonists

mortality?

Decreases morbidity & mortality

149

Aldosterone Antagonists

Indication

Indications

For ACS pts on ACEI & B-blocker with:
-LVEF < 40%, DM or HF

Continue indefinitely

150

Aldosterone Antagonists

Spironolactone (Aldactone®)

Initial
12.5 mg po daily

Target
25 – 50 mg po daily


151

Aldosterone Antagonists

Eplerenone (Inspra®)

Initial
25 mg po daily

Target
50 mg po daily

152

Calcium Channel Blockers

Indications:


Verapamil or diltiazem when beta-blockers are ineffective or contraindicated for relief of ongoing ischemia

153

Calcium Channel Blockers

Drug of Choice

(avoid beta-blockers):

Cocaine-induced ACS
Variant (Prinzmetal angina)
-->Cause coronary vasodilation

154

Glycemic Control:

BG < 180 mg/dL s/p STEMI

insulin-based regimen to achieve BG < 180 mg/dL s/p STEMI

155

ACS Blood pressure guidelines?

Goal BP < 140/90

156

Recommendation to all with STEMI?

Smoking cessation

Goal BP < 140/90

Goal Resting HR 50-60

Exercise

Weight loss (diet control)
-↓ Body weight by 10% from baseline
-BMI < 30 kg/m2
-Waist < 40 inches for men & < 35 inches for women

Influenza & pneumococcal vaccination

VTE prophylaxis

157

Initial therapy: NSTEMI

Aspirin
Nitroglycerin
UFH/LMWH
+/-Beta-blocker (IV)
+/-Morphine

MONAA"

Oxygen?? and no beta blocker??

158

TIMI or GRACE score

Risk assessment tools
-used to identify NSTEMI pts at high risk
-->Thrombolic in Mi

Can aid in treatment decisions
Invasive vs. ischemia-guided strategy

159

TIMI Risk Score: Ranges

High Risk
5 -7 points

Medium Risk
3 - 4 points

Low Risk
0 -2 points

160

Reperfusion:
Fibrinolytic therapy in NSTEMI?

NO, Don't do that.

Only STEMI patient

161

NSTEMI: Invasive strategy

PCI within 24-72 hrs)
High & moderate risk pts

162

NSTEMI:
Ischemia-guided strategy

(medication therapy)
Low risk pts

163

NSTEMI: Antiplatelet Therapy

PCI: Dual antiplatelet therapy (DAPT)

1. ASA on presentation +

2. P2Y12 Inhibitor added to ASA on presentation or at time of PCI:

Clopidogrel (Plavix®)
Ticagrelor (Brilinta®)
Prasugrel (Effient®) -at time of PCI only

164

NSTEMI: Antiplatelet Therapy

PCI: Clopedigrel Loading Dose,

and Maintenance and duration

LD: 600g

MN: 75mg Daily

at least 12 months, all,
P2Y12 Inhibitors: PCI:

Clopidogrel (Plavix®)
Ticagrelor (Brilinta®)
Prasugrel (Effient®

165

Anticoagulants: PCI

Whats the preferred agent for NSTEMI?

Enoxaparin (Lovenox®)

166

Enoxaparin

(Lovenox®)

167

(Lovenox®)

Duration for PCI: NSTEMI

D/C at end of successful PCI!!

168

NSTEMI: GP IIb/IIIa Inhibitors

PCI:

For high risk pts (↑↑ troponin), GP IIb/IIIa Inhibitors may added at time of PCI for :

1.Pts not pretreated with a P2Y12 inhibitor

OR

2. Pts treated with clopidogrel + UFH only

Preferred agents:
Eptibifibitide (Integrilin®) or
Tirofiban (Aggrastat®)

169

NSTEMI: Antiplatelet Therapy

Ischemia-guided strategy

Medical Management
1. ASA on presentation +
2. P2Y12 inhibitor added to ASA as soon as possible after admission

Clopidogrel (Plavix®) or
Ticagrelor (Brilinta®)

170

Ischemia-guided strategy: Dose and medication management.

Clopidogrel (1B)
LD: 300* or 600 mg

Duration Up to
12 months

Ticagrelor (Brilinta®)
Up to 12 months

171

Anticoagulants: Medical Management
Conservative Strategy

Preferred?

Enoxaparin (Lovenox®)

172

Anticoagulants: Medical Management

Enoxaparin
(Lovenox®)

• 1 mg/kg subcut q12 h
• CrCl < 30 ml/min: 1 mg/kg subcut daily***


Unfractionated heparin (UFH
• 60 Units/kg IV LD (max 4000 Units)
• 12 Units/kg/hr IV infusion (max 1000 Units/hr)
• Adjusted to goal aPTT range

Fondaparinux (Arixtra®
• 2.5 mg subcut daily
• CrCl < 30 ml/min: contraindicated severe renal imparment

173

. Prasugrel
(Effient®

Indication?

NSTEMI pts with PCI

174

Dual Antiplatelet Therapy (DAPT)
1. Clopidogrel
(Plavix®)
2. Ticagrelor
(Brilinta®)
3. Prasugrel
(Effient®)
-With aspirin
Duration?

12 months

175

Dual Antiplatelet Therapy (DAPT)

Asprin:Dose & Duration

+ choice of P2Y12 Inhibitor

Indefinitely

81mg

176

Core Measures for ACS

•ACEI or ARB for LVSD at discharge

•Time to fibrinolytic therapy: within 30 min

•Time to PCI: within 90 min

•Smoking cessation counseling

•ASA at arrival


ASA at discharge

•Beta-blocker at discharge

• Statin at discharge

177

NSTEMI:
PCI

DAPT and Anticoagulant Therapy

High Risk:
Invasive Strategy


1. ASA +

2. P2Y12 Inhibitor +
Clopidogrel/ prasugrel/ ticagrelor (LD)

3. Anticoagulant (d/c after PCI)
**Enoxaparin**/ UFH/ fondaparinux/ bivalirudin

GPI + P2Y12 inhibitor in high risk pts

178

NSTEMI:
Medical Management
DAPT and Anticoagulant Therapy

Low Risk:
Ischemia-Guided Therapy

1. ASA +

2. P2Y12 Inhibitor +
Clopidogrel or ticagrelor (LD)

3. Anticoagulant
**Enoxaparin**/ UFH/ fondaparinux

PCI for refractory angina/ischemia

179

Secondary Prevention

Aspirin (indefinitely)
Clopidogrel, prasugrel or ticagrelor (12 months)
Beta-blocker (indefinitely)
Nitroglycerin SL prn
Statin (indefinitely)
+/- ACEI or ARB
+/- Aldosterone antagonist

180

STEMI: Reperfusion therapy

Fibrinolytic Therapy

Fibrinolytic Therapy
Within 30 min of hospital presentation

181

STEMI: Reperfusion therapy
Primary PCI (preferred

Primary PCI (preferred)
Within 90 min of hospital presentation

182


After
STEMI: Reperfusion therapy
Primary PCI (preferred)


DAPT + Anticoagulant Therapy + GPI--Explain

DAPT + Anticoagulant Therapy + GPI

1. ASA +
2. Clopidogrel or Prasugrel or Ticagrelor (LD) +
A. UFH (d/c after PCI) + GP IIb/IIIa Inhibitor
OR
B. Bivalirudin (d/c after PCI)

183

After
STEMI: Reperfusion therapy
Fibrinolytic Therapy

DAPT + Anticoagulant Therapy--explain

1. ASA +
2. Clopidogrel (LD) +
A. UFH (x 48 hrs)
OR
B. LMWH or fondaparinux if tx > 48 hrs