Cardio: ACS Treatment Strategy and Drug Selection

Skilled PCI Facility within 90mins?

Yesss: PCI

Noooo: Fibrinolysis

What is PCI?

When Door to balloon time < 90 minutes…

-Lower mortality rate

-Opens > 90% occluded coronary arteries

-Lower risks of stroke/ICH & major bleed

When is PCI used?

if contraindicated to fibrinolytics

Fibrinolytics

-Higher mortality rate

-Opens < 60% occluded coronary arteries

-High risk of stroke, ICH & major bleed

When are fibrinolytics used?

-PCI not an option

-Vascular access difficulties

-Prolonged transport time

Medications for PCI?

Clopidogrel 600 mg OR prasugrel 60 mg OR ticagrelor 180 mg OR cangrelor IV AND UFH +/- GPI

OR

bivalirudin

What is shown on ECG only in fibrinolytics?

ST segment elevation

When does ST segment elevation occur?

< or = 12 hours from symptom onset (out to 24 hours)

• Invasive strategy is not an option

Door to needle time for fibrinolytic?

<30 min (ACC?AHA guidelines and quality performance measure)

Are there any contraindications for fibrinolytics?

Noooo

What is the biggest fear with lytic?

What are non-fibrin specific?

Streptokinase

What is fibrin specific?

• Recommended by ACC/AHA

• Opens greater % arteries than non-fibrin (greater decreases in mortality)

What are the fibrin specific agents?

• Alteplase

• Tenecteplase

• Reteplase

  • Short half-life

  • Dosing varies

What are recommended agents for fibrinolysis?

Clopidogrel 300 mg if ≤ 75 YO (NO loading dose if > 75 YO) AND UFH OR enoxaparin OR  fondaparinux

How to determine for NSTEMI a person’s risk score?

TIMI risk score

What is the TIMI Risk Score consist of?

Age ≥ 65 yrs

≥ 3 CHD risk factors: smoking, hypercholesterolemia, HTN, DM, fam hx premature CHD death/events

Known CAD (50% stenosis of ≥ one major coronary artery on angiogram)

ASA use w/in past 7 days

2 or more episodes of chest discomfort within past 24 hrs

ST segment depression of ≥ 0.5mm

Positive biochemical marker for infarction

Low risk

0-2 points

Moderate r

High risk

5-7 points

If high-moderate risk=

Invasive strategy=PCI

What is invasive strategy=PCI?

• Similar to PCI with STEMI but wider time window for PCI

What does the wider time window for PCI allow?

Ensure the following are added: Antiplatelet and antithrombotic

What are medications recommended for high-moderate risk?

Clopidogrel OR

prasugrel OR

ticagrelor OR

 cangrelor AND

UFH +/- GPI

OR

Enoxaparin +/- GPI

OR

Bivalirudin

OR

Fondaparinux WITH UFH or bivalirudin

What is recommended for low risk TIMI Score?

• Ischemic guided medical management

• Nooo cash lab, treated with medications only

When is low risk TIMI score strategy used?

•Lower risk

•Comorbidities

•Life expectancy

•Known CAD not amenable to revascularization (not surgical candidate)

•Contraindications to antithrombotics- dAPT

What are medications recommended for low risk?

Clopidogrel OR ticagrelor

AND

UFH

OR

Enoxaparin

OR

Fondaparinux