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ACS (UA/NSTEMI & STEMI) (Anticoagulant Therapy (UFH (60units/kg LD, 12…
ACS (UA/NSTEMI & STEMI)
Anti-platelet Therapy
-
Aspirin 81mg
- continue in all patients with ACS
- increased risk of bleeding with higher dose
- 81-162 mg/day MD
PPI - Prasugrel 60mg
- Thienopyridine agent, inhibits P2Y12 receptor, prodrug
- :red_cross: NO PCI = :red_cross: 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
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:forbidden: AVOID pre-cath; 75+yo or <60kg, or concomitant med that increase bleeding risk (warfarin)
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PPI - Ticagrelor 180mg
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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
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:forbidden: AVOID strong CYP3A4 inhibitors (-azole, clarithromycin, ritonavir)
:forbidden: AVOID Simvastatin and Lovastatin > 40mg
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GP IIb/IIIa inhibitors
Abciximab
- monoclonal antibody, binds to platele >15 days
- reversible with platelet transfusion
Eptifibatide
- peptide, reversible antagonist
- dose adjustment with ClCr <50 ml/min
Tirofiban
- non-peptide, reversible antagonist
- dose adjustment with renal insufficiency
Anticoagulant Therapy
UFH
60units/kg LD, 12 units/kg/hr IV
-
Enoxaparin
- 1 mg/kg SQ Q12H or 1mg/kg SQ Q24H if ClCr <30ml/min
- can give 30mg IV LD
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according to ACC/AHA, d/c &after PCI*
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UFH, enoxaparin, bivalirudin
Anti-Ischemic Therapy
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IV NTG
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:forbidden: AVOID patients with SBP <90 mmHg,
:forbidden: AVOID suspected RV infarction
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ACEI
for patients with EF ≤40% with HTN, DM, stable CKD
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Aldosterone Antagonist
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(creatinine >2.5 mg/dl in :man::skin-tone-2:, >2.0 in :woman::skin-tone-2:)
an add-on with ACEI/ARB, BB, EF <40%, DM, HF
definite ACS
ST elevation
Evaluate for Reperfusion
- STEMI pt ≠ eligible for reperfusion
- SAME drug therapy for UA/NSTEMI
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genreal treatment
ASA, BB, anticoagulant, nitrates, statin, P2Y12 inh