Acute Coronary Syndrome (ACS) Summary Slides HL

What is the acronym for ACS treatment?

MONA3B2

Morphine

O2

NTG

ASA + ADP Rec Antag + Anticoag

BB + IIB/IIIA + Statin

When do we use morphine for ACS treatment?

analgesia and vasodilation

What are some precautions to morphine use?

can slow down absorption and peak for anti-platelet therapy

True or False: IIb/3a therapy may be considered when using morphine

True

When do we use O2 for ACS treatment?

decrease angina pain caused by hypoxia if O2 sats < 90% and in respiratory distress

When do we use NTG for ACS treatment?

vasodilation for persistent ischemic chest pain, HF, and HTN

How long can we use IV NTG for?

48 hours

Should we use BB, ACE, or NTG first?

BB or ACE above NTG

What are C/I of NTG?

sildenafil, vardenafil (within 24 hours), tadalafil (within 48 hours)

HR < 50

HR > 100 (without HF)

What is the MOA of ASA?

inhibits platelet activation

When do we use ASA for ACS treatment?

reduces mortality and recurrent MI

What dosage form of ASA is used for ACS treatment?

chew and swallow NON-enteric coated 162-325mg for 1 dose

What is a C/I of ASA?

allergy (use clopidogrel instead)

What is the MOA/purpose of BB?

decrease myocardial ischemia, re-infarction, and frequency of dysrhythmias

Why are BB used for ACS treatment?

increases long time survival

What BBs are used if patient has HFrEF?

metoprolol succinate, carvedilol, bisoprolol

When should BBs be started during ACS treatment?

within 24 hours

What are C/I of BBs?

HF

Low output state

High risk of cardiogenic shock

Heart block

Active asthma

Reactive airway disease

What is included in a TIMI score for an NSTEMI?

+1 point for all of the following

Age 65+

3+ RF for CAD (Lipids, HTN, DM, Smoking)

FH of premature CHD

Known CAD (w/ 50% stenosis)

ASA use within 7 days

ST-depression

2+ episodes of chest discomfort within 24 hours

Biomarkers

What are treatment routes for NSTEMIs?

selective invasion or routine invasion

What are benefits of selective invasive NSTEMI treatment?

avoids early invasive procedures

better for low risk patients

may be preferred by patients

What medications are used for selective invasive NSTEMI treatment?

ACS = MONAB

P2Y12: ticagrelor or clopidogrel

Anticoags: IV hep, enoxaparin, fondaparinux

What is the purpose of routine invasive NSTEMI treatment?

angiography for revascularization and has less of the following: UA, re-hospitalization, MI, death

What are C/I of routine invasive NSTEMI treatment?

Hepatic failure

Renal failure

Pulmonary failure

Cancer

+ other high-risk patients

What medications are used in routine invasive NSTEMI treatment?

ACS = MONAB

P2Y12: ticagrelor, clopidogrel, or prasugrel

Anticoagulants: IV hep, enoxaparin, bivalirudin

What is the MOA of P2Y12 inhibitors?

inhibit ADP on the platelet to limit platelet activation (AKA ADP antagonists)

When is ticagrelor used?

with ASA 81mg

When is ticagrelor C/I?

hx of intracranial hemorrhage

What are precautions of ticagrelor?

monitor hyperuricemia or gout

What is a benefit of prasurgrel?

fewest drug-drug interactions

When is prasurgrel C/I?

CVA

kinda C/I in age 75+ and those with increased bleeding risk (BBW)

What are precautions of clopidogrel?

Avoid 2C19 inhibitors (i.e., omeprazole, esomeprazole, fluconazole)

Can be less potent and effective for carriers of reduced fxn allele of 2C19

True or False: IV heparin infusion depends on renal fxn

False

What are risks of heparin?

bleeding, thrombocytopenia, HIT

What are monitoring parameters for heparin?

PTT or Anti-Xa

Hgb/Hct

Platelets

What are monitoring parameters for enoxaparin SQ, fondaparinux SQ, and bialirudin IV?

Hgb/Hct

Platelets

SCr

What is the MOA of fondaparinux SQ?

factor Xa inhibitor

What is the MOA of bivalrudin?

direct thrombin inhibitor

Which anticoagulant's dose depends on PCI?

bivalirudin

What are treatment goals for STEMI?

Restore patency of affected artery

Prevent death or arrhythmias

Control chest pain

What is the treatment route used for STEMI patients?

immediate reperfusion

What are immediate reperfusion options?

CABG, PCI, or fibrinolysis/thrombolysis

When do we perform CABG for STEMI treatment?

lesions that cannot be stented or global disease

When do we perform PCI for STEMI treatment?

if it can be performed within 120 minutes, patient is stable, and if there's a C/I to thrombolytics (FIRST LINE/PREFERRED)

When do we perform fibrinolysis for STEMI treatment?

if PCI unavailable and can be performed within 30 minutes and patient is presenting within 12 hours of the onset of symptoms

What are options for fibrinolysis?

tPA, tenecteplase, reteplase

What are ABSOLUTE C/I to fibronolysis?

Active internal bleeding

Previous intracranial hemorrhage or stroke of unknown origin at any time

Previous ischemic stroke within 3 months

Intracranial or intraspinal surgery in prior 2 months

Severe uncontrolled HTN (SBP > 180 or DBP > 110)

What are RELATIVE C/I to fibrinolysis?

Hx of ischemic stroke > 3 months prior

Refractory HTN

Oral anticoagulant therapy

Active peptic ulcer

Prolonged (10+ min) or traumatic CPR

Recent internal bleeding within 2-4 weeks

Major surgery within 3 weeks prior

Noncompressible vascular punctures

Dementia

Pregnancy

Which medications are used in STEMI treatment?

ACS = MONAB

P2Y12: ticagrelor, prasurgrel > clopidogrel

Anticoagulants: IV hep or bivalirudin

SOMETIMES: GP iib/3a

When do we use GP IIb/3a medications for STEMI treatment?

Before OR w/ procedure

Add in high risk patients (elevated biomarkers, diabetes, undergoing revascularization)

Those who do not receive P2Y12 pretreatment

Those with large volume thrombosis

Not routinely used in PCI due to lack of benefit in major adverse CV events and increase in bleeding vs clopidogrel

What is an ADR of IIb/3a meds?

increase bleeding risk

What are monitoring parameters of IIb/3a meds?

Hgb/Hct

Platelets

What is the acronym for secondary ppx with ACS treatment?

ABCD Headline NewS

ASA/DAPT + ACE/ARB + MRA

BB

Cholesterol (statin)

Diet/DM

HTN

Nitrates

Smoking cessation

+ vaccines and cardio rehab

How long do we use DAPT therapy with ACS treatment?

12+ months when PCI, BUT evaluate risk of bleed vs ischemia to determine length

When are ACE inhibitors indicated for secondary ppx?

PVEF < 40%, HTN, DM, stable CKD

What are C/I to ACE inhibitors?

Hypotension

Pregnancy

Bilateral renal stenosis

Consider ARB is ACE is C/I

When are MRAs used for secondary ppx?

if patient is on an ACE + BB after MI and LVEF < 40% and S/S HF or DM

What are C/I to MRAs?

Hyperkalemia

CrCl < 30mL/min

SCr > 2.5 (men) or 2.0 (women)

When are BBs used for secondary ppx?

ALWAYS unless C/I

When are statins used for secondary ppx?

high intensity to LDL goal < 70mg/dL

True or False: consider adding ezetimibe or PCSK9 inhibitors if at high risk

True

What is the strategy when someone has Afib + ACS?

depends! ACS medical management vs stenting

First Line: Bare Metal Stent (BMS)

Alternative: Drug Eluting Stent (DES)

What is the indication of a DES?

Shortened need for DAPT

What CHA2DS-VASc score indicates just DAPT therapy?

0-1

What are double therapy options for CHA2DS-VASc?

Warfarin + Clopidogrel/Ticagrelor

Rivoroxaban (low dose 15mg QD) + Clopidogrel

Dabigatran (150mg BID) + Clopidogrel

What is the triple therapy option for CHA2DS-VASc?

Warfarin + ASA + Clopidogrel >> Ticagrelor/Prasugrel

can transition to double therapy after 4-6 weeks