DUNN Anticoagulant Options & Statins for Ischemia - Exam 4 Study

post-ACS:

ASA for how long??

P2Y12 inhibitor for how long??

beta blockers for how long?? what if concomitant HFrEF??

NTG??

ASA indefinite

P2Y12 inhibitor for at least 12 months

beta blocker for 3 years or indefinitely if HFrEF

SL NTG prescription

what medications can slow down or reverse ventricular remodeling to prevent HF

ACE inhibitors (or ARBs)

BBs

MRAs

does ACE inhibitor or BB supersede to slow development of HF post-ACS

ACE inhibitor

how quickly should an oral ACE inhibitor be started post-ACS

within 24 hours

in what patient populations should an ACE inhibitor be continued indefinitely post-ACS

HFrEF, HTN, DM, CKD

what are AE of ACE inhibitors

cough, hypotension, angioedema, hyperkalemia, renal insufficiency

what are two contraindications to ACE inhibitors

bilateral renal artery stenosis and pregnancy

what should be monitored with ACE inhibitors

SCr, K, BP within 2 weeks

in what time frame should MRAs be considered following MI in certain patients

1-2 weeks post-MI

in what patient populations should MRAs be considered within 1-2 weeks after MI

those already receiving an ACEi with EF < 40% (HFrEF) and HF sx or DM

what should be monitored with MRAs

potassium, especially in those with renal dysfunction (Follow up in 1 week, then 2 weeks, then monthly for 3 months, then quarterly for 1 year, then every 6 months with potassium, SCr, & BP)

which MRA can cause gynecomastia, sexual dysfunction, and menstrual irregularities

spironolactone

who should receive statin post-ACS

everyone should receive high intensity statin post-ACS

when should lipid panel be reassessed after statin initiation and what is goal with high intensity statin

Reassess in 4-6 weeks with goal LDL reduction of 50%

T/F: Post-ACS patients benefit from statins due to reduced mortality, MI, and stroke alongside the pleiotropic effects of anti-inflammatory and antithrombotic properties

true

post-ACS: who can be considered for moderate intensity statin instead of high intensity statin

> 75 years or those at high risk of ADE (such as with drug interactions)

when can we consider adding zetia to statin therapy post-ACS

Consider adding if LDL ≥ 70 after NSTEMI/UA despite max tolerated statin

when can we consider adding PCSK9 inhibitor to statin therapy post-ACS

Consider adding to maximally tolerated statin for very high risk patients and elevated LDL > 70

what are treatment options for arrhythmias

beta blockers - prevention

antiarrhythmics such as amiodarone - present arrhythmia

internal cardiac defibrillator - life-threating

what should secondary prevention (post-ACS) antiplatelet therapy be

ASA 81mg/day indefinitely

P2Y12 inhibitor for at least 12 months post ACS or PCI

when should ACE inhibitor be used for secondary prevention post-ACS

LVEF < 40%, HTN, DM, or CKD

who should receive MRA for secondary prevention (post-ACS)

post-MI patients with LVEF < 40% and DM or HF

Start beta blocker post-ACS and continue for ________ in all patients with normal LV function

3 years

Start beta blocker post-ACS and continue indefinitely in patients with ___________

reduced EF ≤ 40%

when using beta blockers for patients with HFrEF which ones are used

carvedilol, bisoprolol, and metoprolol succinate

what are the high intensity statins

Atorvastatin 40-80 mg

Rosuvastatin 20-40 mg

what two vaccines should be recommended with secondary prevention post-ACS

influenza vaccine

pneumococcal vaccine (≥ 65 and in high risk patients with CVD)

should post-ACS patients take NSAIDs? why or why not?

shouldn't, NSAIDs increase bleeding risk, increase BP, impact kidneys, double the risk of future MI, and increase the risk of HF

what should post-ACS patients take instead of NSAIDs

try tylenol first -> then try nonacetylated salicylates -> then tramadol -> then small doses of narcotics for short period

if all non-NSAID options exhausted, what can be used

nonselective NSAIDs such as naproxen - lowest effective dose and for shortest possible time

should fibrinolytics be used in NSTEMI/UA

no

why does clopidogrel see inter patient variability

CYP2C19 variations

Continuation of P2Y12 inhibitor > 12 months may be considered in patients with what type of stent?

DES

P2Y12 inhibitor, _______ or __________, + ASA should be administered for at least 12 months to all patients with NSTEMI/UA without contraindications who are treated with EITHER an early invasive or ischemia-guided - but reasonable to prefer _________

clopidogrel or ticagrelor; ticagrelor

Reasonable to choose P2Y12 inhibitor __________ in patients with NSTEMI/UA who undergo PCI who are not at high risk of bleeding complications

prasugrel

what does triple therapy involve

anticoagulant + DAPT (ASA + P2Y12)

which P2Y12 inhibitor often used in triple therapy and why

clopidogrel due to lowest bleeding risk

triple therapy does what to bleeding risk vs DAPT alone

increases bleeding risk 3x

in what patients may triple therapy be used post-ACS

in AFib, VTE or mechanical valve + ACS with PCI

Duration of triple therapy with vitamin K antagonist + ASA + P2Y12 inhibitor in patients with NSTEMI/UA should be __________ to extent possible to limit risk of bleeding

minimized

what should be prescribed to NSTEMI/UA patients that get triple therapy

PPI

Target oral anticoagulant therapy to __________ INR reasonable in patients with NSTEMI/UA managed with ASA + P2Y12 inhibitor

lower INR (of 2-2.5)

with which stent type is anticoagulant + clopidogrel an option vs triple therapy

BMS

which P2Y12 not recommended for triple therapy

prasugrel

what is the drug interaction seen with triple therapy and co-prescribing a certain drug to prevent GI bleed

PPIs and clopidogrel --> omeprazole especially will decrease clopidogrel's efficacy by inhibiting CYP2C19 thus keeping clopidogrel from being activated

with ischemia guided strategy of NSTEMI/UA, when is fondaparinux preferred as anticoagulant

patients at high risk of bleeding

with ischemia guided strategy of NSTEMI/UA, when is fondaparinux contraindicated

if CrCl < 30mL/min

with ischemia guided strategy of NSTEMI/UA, what is LMWH preferred over

UFH

with ischemia guided strategy of NSTEMI/UA, when do we use caution with LMWH

renal insufficiency and elderly

with ischemia guided strategy of NSTEMI/UA, when is UFH preferred

renal dysfunction

are GP IIb/IIIa inhibitors used in fibrinolysis (STEMI)

no

what P2Y12 inhibitor used with fibrinolysis (STEMI)

clopidogrel

what are anticoagulant options with STEMI PCI

UFH, LMWH, bivalirudin

what are anticoagulant options with STEMI fibrinolysis

UFH, LMWH, fondaparinux

what are P2Y12 inhibitor options for ischemia guided management of NSTEMI/UA

clopidogrel or ticagrelor

what are anticoagulant options for ischemia guided management of NSTEMI/UA

UFH, LMWH, fondaparinux

what are P2Y12 inhibitor options for early invasive approach (unsure if PCI or CABG) in NSTEMI/UA

clopidogrel or ticagrelor

what are anticoagulant options for early invasive approach (unsure if PCI or CABG) in NSTEMI/UA

UFH, LMWH, fondaparunix, or bivalirudin

if doing PCI (not CABG) in NSTEMI/UA what are P2Y12 inhibitor options

clopidogrel, prasugrel, or ticagrelor

what are anticoagulant options if doing PCI (not CABG) in NSTEMI/UA

UFH, LMWH, bivalirudin

when are GP IIb/IIIa inhibitors used in early invasive approach for NSTEMI/UA? and which ones if upstream

high risk patients (TIMI 5-7) - refractory angina pain, evolving EKG changes, increasing cardiac enzymes, hemodynamically unstable --> use if not using bivalirudin

-eptifibatide or tirofiban (no abciximab)