________ results from plaque build up in the coronary arteries (coronary atherosclerosis)
Acute Coronary syndrome (ACS)
what causes an imbalance between myocardial oxygen supply and demand?
1) plaque can rupture2) leading to clot (thrombus) formation3) reduced blood flow (ischemia) to the heart
List some risk factors that can lead to plaque build up that causes an ACS (10)
1) age men > 45 yr, women > 55 yr2) 1st degree relative with coronary event before 55 yr men, 65 yr women3) smoking4) HTN5) known CAD6) HLD7) DM8) Chronic angina9) lack of exercise10) excessive alcohol
Classic symptoms of ACS
1) chest pain - discomfort, pressure, squeezing lasting > 10 min2) severe dyspnea3) diaphresis4) syncope/presyncope5) palpitations6) radiating pain - arms, back, neck, jaw, epigastric region
what are the types of ACS?
1) NSTE-ACS2) STEMI3) UA4) NSTEMI
what is used to diagnose ACS?
12-lead ECG within 10 min at the site of 1st medical contact
what labs and when do you need them for ACS?
1) Cardiac troponin I & T (TnI and TnT) - 3-6 hrs2) CK-MB
What type of ACS is this?1) chest pain2) cardiac enzymes - negative3) no ST elevation4) partial blockage
UA
What type of ACS is this?1) chest pain2) cardiac enzymes - positive3) no ST elevation4) partial blockage
NSTEMI
What type of ACS is this?1) chest pain2) cardiac enzymes - positive3) ST elevation4) complete blockage
STEMI
what is the coronary revascularization procedure that involves inflating a small ballon inside a coronary artery to widen it and improve blood flow? This is where a metal mesh, stent, is placed in the artery and afterward to keep the artery open
PCI
Tx for STEMI:_____ is preferred but if it cannot be done in a reasonable time frame ______ should be given
1) PCI2) fibrinolytic
patient may go directly to urgent _________ if there is significant multi-vessel disease within the coronary arteries
coronary artery bypass graft (CABG) surgery
what drug class decreases myocardial oxygen (O2) demand or increase myocardial O2 supply (blood flow) to relieve ischemia?
Anti-anginals - morphine, nitrates, BB
what drug class inhibits platelet aggregation to prevent clot formation/growth?
antiplatelets - aspirin, P2Y12 inhibitors, glycoprotein (GP) IIb/IIIa inhibitors
what drug class inhibits clotting factors to prevent clot formation/growth?
anticoagulants - UFH, LMWH, bivalirudin
what does MONA-GAP-BA stand for?
M - MorphineO - OxygenN - NitratesA - AspirinG - GPIIb/IIIa antagonistsA - AnticoagulantsP - P2Y12 inhibitorsB - BBA - ACE
what's the Tx for NSTE-ACS?
MONA-GAP-BA +/- PCI
what's the Tx for STEMI?
MONA-GAP-BA + PCI or fibrinolytic (PCI preferred)
what are given immediately (as needed) in ACS?
M - MorphineO - O2N - NitratesA - Aspirin
what drug?Clinical benefit 1) Antianginal produces arterial & venous dilation (decreases preload & after load)2) provides pain relief
Morphine
what drug?Clinical benefit 1) Antianginal - dilate coronary arteries and improve collateral blood flow; decrease preload and after load; reduces chest pain
Nitrates
what is the dosing for morphine?
2-5 mg IV repeated at 5-30 minute intervals prn
what is the dose for nitrates? formulation?
0.3-0.4 mg, sublingual
when should you not use IV NTG?
1) SBP < 902) HR < 503) pt experiencing a right ventricular infarction
what is contraindicated in use with nitrates?
PDE-5 inhibitors
________ aspirin ______mg should be given to all patients immediately
non-enteric-coated chewable, 162-325 mg
what is the maintenance aspirin dose that should be continued indefinitely?
81-162 mg daily
what are the 3 GPIIb/IIIa receptor antagonists?
1) abciximab2) eptifibatide3) tirofiban
what drug class?clinical benefit: inhibit clotting factors and can reduce infarct size
anticoagulants
anticoagulants for ACS include?
1) LMWH (enoxaprin, dalteparin2) UFH3) bivalirudin
what P2Y12 inhibitors are used in ACS?
1) clopidogrel2) prasugrel3) ticagrelor
what drug classes are given within 24 hours (as needed) and may be continued outpatient?
1) BB2) ACE
what drug class?clinical benefit: antianginal - 1) decrease BP, HR and contractility2) decrease ischemia, reinfarction and arrhythmias3) prevent cardiac remodeling4) increase long-term survival
BB
what type of BB is preferred in ACS?
an oral low dose, beta-1 selective blocker w/o intrinsic sympathomimetic activity preferred should be started within the first 24 hours
when is a beta-1 selective BB contraindicated in an ACS pt?
1) decompensated HF2) cariogenic shock3) HR < 45 bpm
what BB should you choose if the pt has a concomitant HFrER that is stable?
1) bisoprolol2) metoprolol succinate3) carvedilol
what can be used as an alternate for BB in ACS?
long-acting Non-DHP CCB such as1) Verapamil2) Diltiazem
what drug class?clinical benefit: Inhibit angiotensin converting enzyme and block the production of angiotensin II; prevent cardiac remodeling; decrease preload and after load
ACE
what type of ACE should you not start within the 1st 24 hrs?
IV
what should not be given to an ACS pt due to increased risk of mortality, reinfarction, HTN, cardiac rupture, renal insufficiency, and HF?
NSAIDs
what should not be given in ACS due to increased risk of mortality?
IR Nifedipine
what drug?inhibits platelet aggregation/clot formation by inhibiting production of thromboxane A2 (TXA2) via irreversible COX1 & COX2 inhibition
Aspirin
What drug class?bind to the adenosine diphosphate (ADP) P2Y12 receptor
P2Y12 inhibitors
what drug class?block the platelet glycoprotein IIb/IIIa receptor
GPIIb/IIIa receptor antagonists
What drug?protease-activated receptor-1 (PAR-1) antagonist that reversibly binds to the PAR-1
Vorapaxar
______ & _____ are structurally similar and are classified as thienopyridines
1) clopidogrel2) prasugrel
which P2Y12 inhibitor is not a prodrug?
Icagrelor
what is the maintenance dose for clopidogrel (placix)?
75 mg PO daily
what is indicated for ACS managed with PCI?
Prasugrel (Effient)
Pharm class of Prasugrel (Effient)
P2Y12 inhibitor
Pharm class of Ticagrelor (Brillinta)
P2Y12 inhibitor
Generic for Effient
Prasugrel
Pharm class of Cangrelor (Kengreal)
P2Y12 inhibitor
Generic for Brillinta
Ticagrelor
Generic for Kengreal
Cangrelor
what is the ONLY injection P2Y12 inhibitor?
Cangrelor (Kengreal)
what P2Y12 inhibitor?1) give dose promptly, no later than 1 hour2) Boxed warning - bleeding, not recommended for > 75 yr unless DM, MI), Do not initiate if CABG likely, stop at least 7 days prior to elective surgery3) Contraindication - serious bleeding, HX of TIA / STROKE4) warning - Bleeding risk, TTP5) side effects - bleeding
Prasugrel (Effient)
what Is the maintenance dose for Ticagrelor (Brilinta)?
90 mg PO BID for 1 year, then 60 mg BID
what P2Y12 inhibitor?1) after the initial aspirin dose of 162-325 mg, DO NOT exceed aspirin 100 mg for maintenance dose2) Boxed warning - avoid use in CABG, stop 5 days before any surgery3) Contraindication - serious bleeding4) warning - bleeding risk, TTP5) side effects - Bleeding, dyspnea
Ticagrelor (Brilinta)
what P2Y12 inhibitor?1) effects are gone after 1 hr2) Contraindication - serious bleeding3) transition to one of the orals after PCI4) indicated as an adjunct to PCI in patients who are P2Y12 naive and not receiving GP inhibitor
Cangrelor (Kengreal)
what drugs should you avoid with P2Y12 inhibitor use that can increase risk of bleeding?
1) NSAIDs2) warfarin3) SSRis4) SNRIs
what should you consider with Ticagrelor?
1) STATINS - it is a CYP3A4 so AVOID doses greater than 40 mg/day with simvastatin & lovastatin2) DIGOXIN
__________ increases the effects of Repaglinide, which can cause hypoglycemia
Clopidogrel
which are the REVERSIBLE GP receptor antagonists?
1) Eptifiatide2) Tirofiban
which GP receptor antagonist is IRreversible? and is indicated for PCI +/- stent and can be given with heparin?
Abciximab
Pharm class of Abciximab (ReoPro)
GP receptor Antagonist
Generic for ReoPro
Abciximab
Pharm class of Tirfiban (Aggrastat)
GP receptor Antagonist
Generic for Integrilin
Eptifibatide
Pharm class of Eptifibatide (Integrilin)
GP receptor Antagonist
Generic for Aggrastat
Tirfiban
side effects for GP receptor antagonists?
1) bleeding2) thrombocytopenia
what drug is not recommended for medical management (NSTE-ACS without PCI)?
Abciximab (ReoPro)
Pharm class of Vorapaxar (Zontivity)
Protease-Activated Receptor-1 Antagonist
Generic for Zontivity
Vorapaxar
what drug class cause fibrinolysis (clot breakdown) by binding to fibrin and converting plasminogen to plasmin?
Fibrinolytics
what drug class is only used for STEMI?
Fibrinolytics
when should a PCI be performed?
1) within 90 min (optimal door-to-ballon time2) within 120 min of the first medical contact
if PCI is not possible within 120 minutes of first medical contact, fibrinolytic therapy is recommended and should be given within?
30 min (door-to-needle)
when PCI is not available, fibrinolytic therapy is reasonable for a pt with STEMI if?
the pt is still symptomatic within 12-24 hours of symptom onset
pharm class of alteplase (Activase)
Fibrinolytics
Generic for Activase
alteplase
pharm class of Tenecteplase (TNKase)
Fibrinolytics
Generic of TNKase
Tenecteplase
pharm class of Reteplase (Retavase)
Fibrinolytics
Generic of Retavase
Reteplase
what drug is a recombinant tissue plasminogen activator (tPA, rTPA)?
Alteplase (Activase)
Generic for Cathflo Activase?
Alteplase
Contraindications for fibrinolytics
1) active internal bleeding2) Hx of recent stroke3) uncontrolled HTN
Side effects of fibrinolytics
bleeding (including ICH)
Monitoring for fibrinolytics
1) Hgb2) Hct3) s/sx of bleeding
alteplase contraindications and ______ when used for ischemic stroke
dosing differ
duration for aspirin
indefinitely
duration of P2Y12 inhibitor patients who received fibrinolytics?
12 months
duration of P2Y12 inhibitor patients who received PCI?
12 months
duration of NTG?
indefinitely
duration of BB
3 years *indefinitely if HF or tx for HTN
duration of ACE
indefinitely if EF < 40%, HTN, CKD, or DM, MI
aldosterone antagonist duration
indefinitely if EF < 40% HF or DM
when is aldosterone antagonist contraindicated?
1) SCr > 2.5 men, >2 women2) hyperkalemia K > 5
duration of statins
indefinitely with a high intensity statins
what drugs can you consider for pain relief?
1) APAP2) nonacetylate salicylates3) tramadol4) small dose of narcotics5) NAPROXEN
what type of NSAIDS should be avoided in ACS?
COX-2 selective - high CV risk
Tx for ACS + Afib
1) dual or triple therapy for short duration (4-6 wk)2) PPI for pt with hx of GIB + triple therapy
what life counseling should be made with ACS pts?
1) smoking cessation2) manage HTN or DM3) avoid excessive OH4) encourage physical activity5) healthy diet