Acute coronary syndrome meds

Question 1

List all meds used in acute MIs

Answer 1

Oxygen
Nitrates (anti-ischemics)
Analgesia
BB
CCB
Cholesterol lowering agents
RAAS inhibitors
Anti-platelet agents
Parenteral anticoagulation
Other anti-ischemics

Question 2

When do you give O2 to AMI pts?

Answer 2

O2 sat < 90%
Respiratory distress
Other high risk features of hypoxemia

Question 3

When might O2 have negative effects in coronary pts?

Answer 3

Increased coronary vascular resistance
Reduced coronary blood flow
Increased risk of mortality
Significantly larger infarct sizes than those w/o O2 therapy

Question 4

What do nitrates do for AMI?

Answer 4

Dilate capacitance vessels which decreases preload

Question 5

For what do you administer nigtoglycerin and how do you give it?

Answer 5

Continued pain

SL

Question 6

How do you dose SL nitro?

Answer 6

0.3-0.4 mg q 5 minutes x3

Question 7

After the q5 dosing, then what do you do with nitro?

Answer 7

Evaluate for need for IV nitro

Question 8

When do you NOT give nitro?

Why?

Answer 8

If on phosphodiesterase inhibitor
(If taken sildenafil in last 24 hours, or tedalafil in last 48 hours)
Decrease in BP

Question 9

What is a common analgesia given to AMI pts for continued CP? How is it administered?

Answer 9

Morphine sulfate

IVP

Question 10

Why do you give morphine sulfate for continued cp?

Answer 10

If pt is already on max tolerated nitro

Question 11

What is another analgesia combo that is actually not given to AMI pts?

Answer 11

NSAIDS (not asprin) + COX2 inhibitors

Question 12

Why are NSAIDS + COX2 inhibitors not given to AMI pts?

Answer 12

Enhances platelet aggregation by inhibiting PG synthesis

Question 13

What NSAID can be used for its anti-platelet effects?

Answer 13

Aspirin

Question 14

When do you begin BB for AMI pts?

Answer 14

WIthin 24 hours

Question 15

Are there some exceptions to starting BB in AMI pts?

Answer 15

Yes

signs of HF, low output state, etc.

Question 16

What BB should AMI pts w/ stable HF be continued on?

Answer 16

Metorpolol succinate
Carvedilol
Bisoprolol

Question 17

Why do we avoid IV BBs in AMI pts?

Answer 17

May increase risk of shock

Question 18

When do you give CCB?

Answer 18

Ischemic/continued pain pts with:
Contraindications to BBs
Unacceptable side-effects from BBs
Continued pain after appropriate use of BBs and nitrates

Question 19

Which non-dihydropyridine CCBs are used as initial therapy for AMI pts?

Answer 19

Verapamil (PO)

Diltiazem (PO)

Question 20

What CCB shouldnt be used for AMI pts? Why?

Answer 20

Imediate release nifedipine

Causes a dose-related increase in mortality in CAD and harm in ACS pts

Question 21

What antianginal with minimal effects on HR and BP do we have for AMI pts?

Answer 21

Ranolazine

Question 22

What are the AEs of ranolazine?

Answer 22

Constipation

Dose related QTc prolongation

Question 23

What must you start AMI pts on?

Answer 23

Benign high-intensity statin therapy

Question 24

Give the two high intensity statins that we give AMI pts and their dosing

Answer 24

Atorvastatin titrate 10-80 mg po once daily

Rosuvastatin titrate 5-40 mg po once daily

Question 25

When do you start AMI pts on ACEI? How long do you keep them on this?

Answer 25

When LVEF < 40% | Indefinitely

Question 26

What ACEI do you start AMI pts on in the hospital? When do you switch to a long acting ACEI?

Answer 26

Catopril (tid) or enalaprin (bid) Switch to long acting @ max dose

Question 27

What do you use in AMI pts intolerant to ACEIs?

Answer 27

ARBs

Question 28

What do you add to pharmacotherapy for AMI pts who are on therapeutic doses of ACEIs and BB?

Answer 28

ARA

Question 29

What two drugs do you never combine for heart pts?

Answer 29

ACEI and ARB

Question 30

What is your acute anti-platelet agent? What is the dose?

Answer 30

Non-enteric-coated chewable aspirin | 162-324 mg

Question 31

Why do you not order enteric coated ASA acutely?

Answer 31

It delays absorption

Question 32

Does 325 mg ASA = 324 mg ASA in the computerized dispensing systems?

Answer 32

No

Question 33

What do you give to pts who are allergic or intolerant to aspirin?

Answer 33

Clopidogrel

Question 34

What is the chronic dosing of aspirin for anti-platelet therapy for AMI pts?

Answer 34

81-325 mg indefinitely

Question 35

What else do you add to anti-platelet therapy for AMI pts? For how long?

Answer 35

P2Y12 aspirin receptor inhibitor 12 months

Question 36

What are the two P2Y12 aspirin agents used post AMI? How often are they dosed

Answer 36

Clopidogrel: daily Ticegralor: bid

Question 37

Why is pasugrel not recommended for chronic anti-platelet therapy?

Answer 37

Increased risk of spontaneous, life-threatening, and fatal bleeding

Question 38

What other category of therapy related to blood is recommended in addition to antiplatelet therapy for all AMI pts?

Answer 38

Anticoagulation

Question 39

What LMWH is preferred for ACS?

Answer 39

Enoxaparin

Question 40

What is the dosing of enoxaparin for pts with CrCl > 30 mL/min for ACS?

Answer 40

1 mg/kg SC q 12 hours | *actual body weight*

Question 41

What is the dosing of enoxaparin for pts with CrCl < 30 mL/min for ACS?

Answer 41

1 mg/kg SC q 24 hours | *actual body weight*

Question 42

When do you avoid giving LMWH?

Answer 42

In dialysis pts w/ ACS

Question 43

Where is anticoagulant bivalrudin often used?

Answer 43

Cath labs

Question 44

What are the two advantages of bivalrudin over UFH or LMWH?

Answer 44

Will bind to clot bound thrombin (unlike heparin) | No significant protein binding (more predicatble anticoagulant response)

Question 45

What kind of drug is fondaparinux?

Answer 45

A synthetic pentasaccharide | selective factor Xa inhibitor

Question 46

Is there a risk of HITT with fondaparinux?

Answer 46

Minimal if any

Question 47

When is fondaparinux contraindicated? Why?

Answer 47

CrCl < 30 mL/min | Increased risk of bleeding

Question 48

When do you use fondaparinux with caution?

Answer 48

CrCl 30-50 mL/min

Question 49

Is the half life of unfractionated heparin (UFH) long or short?

Answer 49

Short | 1.5 hours

Question 50

Can you simply d/c IV UFH or do you need to taper it in urgent interventions?

Answer 50

Just d/c it

Question 51

How do you indicate to the pharmacist how much UFH you need?

Answer 51

You specify the indication (DVT, PE, NSTEMI, STEMI, PCI)

Question 52

What is the initial bolus max dose of weight based UFH regimens?

Answer 52

4000 units

Question 53

What is the initial maintenance infusion max dose for weight based UFH regimens?

Answer 53

1000 units/hour

Question 54

When do we use the anticoagulant argatroban for ACS pts?

Answer 54

In pts w/ h/o HITT undergoing PCI