Cardio: ACS Late Hospital Care/Secondary Prevention

What are Late Hospital Care/Secondary Prevention

• Aspirin 81 mg indefinitely

• P2Y12 inhibitor

• Beta blocker within 24 hours if no CI

• High intensity statin ASAP

• ACEI/ARB

• Evaluate for aldosterone antagonist

For STEMI or NSTE-ACS, what is used to treat?

• All treatment strategis

• Continue oral dual anti platelet therapy

What dual oral antiplatelet therapies?

Aspirin 81 mg + P2Y12 inhibitor

• Clopidogrel 75 mg once daily

• Prasugrel 10 mg (or 5 mg) po once daily

• Ticagrelor 90 mg po twice daily

How long is DAPT for?

At least 12 months (IA) 

When is therapy more than 12 months reasonable?

• Bleeding vs. ischemic risks

• (if ticagrelor > 12 mos after MI- dose 60 mg BID)

What does DAPT decrease?

Death/MI over 1 year post MI

What are PCI related complications at 24 hours?

• Acute stent thrombosis 

Acute stent thrombosis

• 1-2% of patients

• Incomplete stent expansion and vessel dissection

What are PCI related complications at 30 days?

Subacute stent thrombosis

Subacute stent thrombosis

• 1% of patients

• Incomplete platelet activation

• Resembles vessel closure but worse prognosis

• >80% have large MI and 20 day mortality is 25%

What is the PCI related complications at 90 days?

restenosis

What is restenosis?

• 20% pts: BMS vs. <10% pts: DES

• Gradual renarrowing with > 50% stenosis severity

• Pts. present with ischemia

• Determinant of event free survival after PCI

What is the PCI related complication at 180 days > >?

Late stent thrombosis

Late stent thrombosis

• Stent occlusion occurring >30 days or >6 months

• Usually results in STEMI or death

What is re-endothelialization?

• Varies based on stent type

What are the types of stents present?

• Bare metal stent

• Drug eluting stent

What are drug eluting stents?

1st and 2nd Generation

1st generation

• Sirolimus (Cypher)

• Paclitaxel (Taxus)

2nd Generation

• Everolimus (Xience)

• Zotarolimus (Endeavor)

What should be monitored for dual anti platelet therapy?

• Bleeding

• GI effects

• Costs

• Adherence

What are major GI effects?

• Gastroduodenal ulcers leading to GI bleed, perforation, death

  • PPIs used in pts with h/o GIB d/t DAPT

What are minor GI effects?

Dyspepsia

Adherence for dual anti platelet therapy?

Beware of abrupt discontinuation= stent closure= mortality

Management of preoperative?

Delay elective non-cardiac surgery for 30 days s/p BMS; at least 6 months after DES

CABG surgery

• Continue ASA
  Stop clopidogrel or ticagrelor 5 days before

• Stop prasugrel 7 days before

Combined oral Anticoagulatant therapy with dAPT?

• If on oral anticoagulant for ANOTHER indication

• Increase bleeding complications

What should be minimized with combined oral anticoagulant therapy with dAPT?

• Minimize duration as possible

• Reasonable to drop the ASA in select patients. Consider tart 2-2.5 if warfarin

• Clopidogrel is DOC

How long to use UFH?

x 48 hours

How long to use Enoxaparin?

48 hours to 8 days/discharge

How long to use fondaparinux?

48 hours to 8 days/discharge

How long to use bivalirudin?

Discontinued after catherization

How are anticoagulants used?

Acute use only unless patient has another indication for Anticoagulation

Why are statins given of sub-acute ACS management?

• Pleiotropic effects

• Reduce rate of recurrent MI, IHD mortality, revascularization, and stroke

What has statins been proven to reduce the rate of recurrence?

Prove-IT TIMI 22 and MIRACL trials

Why type of statin is initiated or continued in ACS?

High intensity statin:

• Rosuvastatin (Crestor) 20-40 mg

• Atorvastatin (Lipitor) 80 mg

How much does high intensity statin reduce LDL cholesterol?

50% reduction in LDL cholesterol

What should be added before hospital discharge (unless CI)?

ASAP

How long are statins used for?

Indefinitely

What should be maintained?

Blood glucose < 180 mg/dL while admitted

When is maintaining blood glucose recommended?

Within 1st 24-48 hours (decreases mortality rate, infarct size, infection)

What are secondary prevention goals?

• Prevent recurrent ACS, stroke, death

• Prevent LV remodeling and development of HF

• Control modifiable risk factors

What are medications used to prevent LV remodeling and HF-post-ACS?

• Beta blockers

• ACE-I

• Aldosterone antagonists

When are Beta blockers initiated?

Initiated acutely and continued at least 3 years in pts with normal LVEF

What does BB prevents?

Recurrent ACS, stroke and death

When is ACE-I initiated?

Within first 24 hours

Who should use ACE-I?

• Considered in all ACS patients 

• Particularly use if EF < or = 40%, HTN, DM, or CKD

What kind of effect is it?

Class effect (all agents)

When can ARB be used?

If intolerant to ACEI

What are aldosterone antagonists considered?

In 1st 2 weeks post-MI- IF on ACEI and BB and EF < or = 40% and clinical evidence of HF

Which aldosterone antagonists are used?

Spirinoloactone or eplerenone

What are patient counseling to be provided?

• Adherence! (Do NOT stop therapy without talking with provider)

• Watch for bleeding

• Beta-blocker may cause “crummy feeling”

• SL NTG counseling

What are performance measures provided for ACS National Quality Measures?

• Aspirin within 24 hours & at discharge

• Beta-blocker within 24 hours & at discharge

• LDL cholesterol assessment

• Statin at discharge

• ACEI/ARB for LVSD at discharge

• Time to reperfusion for PCI AND fibrinolytic

• Smoking cessation advice counseling