ACS (UA/NSTEMI & STEMI)

Anti-platelet Therapy

Clopidogrel (Plavix) 300-600mg

Aspirin 81mg

GP IIb/IIIa inhibitors

Anticoagulant Therapy

UFH

Enoxaparin

Bivalirudin

Fondaparinux

Anti-Ischemic Therapy

SL NTG

IV NTG

IV Morphine 1-5 mg

beta-blocker

non DHP-CCB

ACEI

Aldosterone Antagonist

definite ACS

ST elevation

NO ST elevation

Evaluate for Reperfusion

UA/NSTEMI Guidelines

  • STEMI pt ≠ eligible for reperfusion
  • SAME drug therapy for UA/NSTEMI

genreal treatment

ASA, BB, anticoagulant, nitrates, statin, P2Y12 inh

  • MOA: irreversible ADP (P2Y12 receptor) antagonist
  • SE: GI upset, rash, bleeding; slow onset due to pro-drug
  • 300-600mg LD followed by 75mg/day once daily
  • polymorphism, CYP2C19, affect clopidogrel activity
  • high levels of residual platelet activity while receiving clopidogrel associated with worse outcomes
  • continue in all patients with ACS
  • increased risk of bleeding with higher dose
  • 81-162 mg/day MD

combo with

PPI - Omeprazole - potent CYP2C19 inhibitor

  • reduce the risk of GI bleeding and Plavix PK
  • increase risk of adverse CV outcomes
  • 🚫 AVOID omeprazole concomitantly or 12hrs apart
  • consider other acid-reducing agent
    with less CYP2C19 inhibitory activity
  • higher Plavix dose concomitantly administered with omeprazole = increase antiplatelet response

PPI - Prasugrel 60mg

  • Thienopyridine agent, inhibits P2Y12 receptor, prodrug
  • ❌ NO PCI = ❌ NO Prasugrel
  • Prasugrel has more efficient active metabolites formation than Clopidogrel = greater platelet inhibition
  • 60mg LD and 10mg MD once daily
  • duration therapy after PCI is same as Clopidogrel

approved for treating

ACS (UA/NSTEMI & STEMI) in patient with PCI

❌ CI active bleeding or h/o TIA or stroke

🚫 AVOID pre-cath; 75+yo or <60kg, or concomitant med that increase bleeding risk (warfarin)

when Prasugrel >>> Clopidogrel ?

  • ACS patients undergo stent implantation
  • NO h/o stroke or TIA
  • NOT at high risk of bleeding

PPI - Ticagrelor 180mg

PO reversible P2Y12 antagonist; ❎ prodrug

indicate

  • reduce the risk of CV events in patients with ACS
  • small reduction in combo of CV death, MI or stroke compared to Clopidogrel
  • reduces risks of stent thrombosis in PCI patients

SE

bleeding, dyspnea, bradycardia, increase serum uric acid and creatine

when Ticagrelo >>> Clopidogrel ?

patients with ACS treated with DAPT after stent implantation

🚫 AVOID strong CYP3A4 inhibitors (-azole, clarithromycin, ritonavir)
🚫 AVOID Simvastatin and Lovastatin > 40mg

180mg LD followed by 90mg 2x/day; no renal impairment dose adjustment

Abciximab

Eptifibatide

Tirofiban

  • monoclonal antibody, binds to platele >15 days
  • reversible with platelet transfusion
  • peptide, reversible antagonist
  • dose adjustment with ClCr <50 ml/min
  • non-peptide, reversible antagonist
  • dose adjustment with renal insufficiency

60units/kg LD, 12 units/kg/hr IV

  • 1 mg/kg SQ Q12H or 1mg/kg SQ Q24H if ClCr <30ml/min
  • can give 30mg IV LD

d/c 24hr prior to CABG to reduce bleeding risk

direct thrombin inhibitor

IVB 0.75mg/kg LD followed by infusion of 1.75 mg/kg/hr

according to ACC/AHA, d/c &after PCI*

for patients with ACS undergoing an invasive management

UFH, enoxaparin, bivalirudin

❌ CI HIT

🚫 AVOID stage 4 CKD

0.4mg Q5min 3x dose

NO significant benefit on mortality

🚫 AVOID patients with SBP <90 mmHg,
🚫 AVOID suspected RV infarction

SE

HA and hypotension

start infusion at 5-10 mcg/min and titrate to desired effect

keep SBP ≥ 100-110 mmHg

patients with ACS may increase the risk of death and/or MI

MOA

decrease myocardial oxygen demand
decrease risk of ventricular wall rupture

increase ventricular fibrillation threshold

for patients with CI to beta-blockers

do NOT improved survival

🚫 AVOID patients with LV dysfunction (EF<40%) and HF

for patients with EF ≤40% with HTN, DM, stable CKD

SBP should be ≥ 100mmHg

for post-MI patients without significant renal dysfunction

(creatinine >2.5 mg/dl in 👨🏻, >2.0 in 👩🏻)

an add-on with ACEI/ARB, BB, EF <40%, DM, HF