Acute Coronary Syndromes and Myocardial Infarctions

Stable Angina
- Reproducible pain
- Improves with rest (or NTG)
- Last < 10 minutes
- ECG: ___________________
- Cardiac enzymes: ___________________
Unstable Angina/Non ST-Segment Elevation Myocardial Infarction (NSTEMI)
- Pathophysiology of both are the same
o Incomplete blockage of the lumen of the vessel
- Symptoms:
o Occurs with increased frequency or less activity
o May not be relieved with rest (or NGT)
o Last >10 minutes
- ECG: ______________________
- Cardiac enzymes: ______________________
ST-Segment Elevation Myocardial Infarction (STEMI)
- Acute myocardial infarction: AMI
- Complete occlusion resulting in constant pain
o Very little blood flow
- ECG: _____________________________
- Cardiac enzymes: _______________________
Initial therapy
- ECG monitoring
- MONA???
o +/- analgesics


o Oxygen
o +/- nitroglycerin



o Antiplatelets
Nitroglycerin
- Therapeutic goal is to relieve myocardial ischemia via coronary vasodilation
- No reduction in mortality in ACS
- Monitor HR, BP, ECG, chest pain/symptoms
o MAP >65mmHg to maintain coronary perfusion
- ADR: headache (~50%)
o Decrease infusion rate and administer APAP prior to discontinuing NTG
- IV NTG may be beneficial and is recommended in MI patients with HF, pulmonary edema, persistent ischemia, or
hypertension
Antiplatelet
- Therapeutic goal is to limit infarct size reduce recurrent ischemia/infarction and improve survival
- Acute treatment
o ASA 162-325mg chew and swallow
 Clopidogrel 300mg may be used if aspirin allergy is present
o Dual antiplatelet therapy (DAPT)
 Clopidogrel 300-600mg PO X 1
 Prasugrel 60mg PO X 1
 Higher more consistent level of platelet inhibition over clopidogrel
 Reserved for those going to cath lab for PCI
  Should NOT be used in patients with prior history of stroke
 Reasonable to choose prasugrel over clopidogrel for maintenance P2Y12 treatment in ACS
patients who undergo PCI who are not at high risk for bleeding complications
o No decrease in mortality, but increase in bleeding
 Ticagrelor 180mg PO X 1
 Reasonable to choose ticagrelor over clopidogrel for maintenance P2Y12 treatment in ACS
patients treated with an early invasive strategy and/or PCI
o Showed reduction in MI and death with no increase in CABG bleeding
 PLATO trial
 IV cangrelor
 Reserved for patients who aren’t on oral DAPT at time of PCI
 IIb/IIIa Inhibitor (least preferred)
Clopidogrel Prasugrel Ticagrelor
300-600 mg LD 60mg LD 180mg LD
Dose
75mg daily 10mg daily 90mg twice daily
Advantages Generic and established Consistent antiplatelet effect Mortality reduction?
DDIs
Bleeding
DDIs Dyspnea/bradycardia
Disadvantages BBW: Hx of stroke or TIA
Interpatient variability Expensive
Expensive
Twice daily dosing
~40-50% of patients have little/no North America and ASA dosing
5mg daily use in age >75 years and
Controversy response and have high platelet - Less effective in patients
weight <60kg
reactivity taking >100mg ASA
Potential clopidogrel interactions
- CYP3A4
o
- CYPC19
o
- CYP2C9
o
- CYP1A2
o
Potential ticagrelor interactions
- Strong CYP 3A4/5 inhibitors
o Increase ticagrelor exposure; increase bleeding risk
o
- Strong CYP3A4/5 inducers
o Reduce ticagrelor exposure; increase thrombosis risk
o
- ASA
o Dose related
- Simvastatin and lovastatin
o Increase statin concentrations
- Digoxin
o Ticagrelor inhibits P-glycoprotein transporter

Anticoagulant options for ACS

- Unfractionated heparin (continuous infusion)
o K
o Monitor aPTT
o Reversible with __________________
- Low molecular weight heparin (subcutaneous)
o Enoxaparin:
o Dalteparin:
 o Renal elimination
- Fondaparinux
o
o ONLY FOR MEDICAL MANAGEMENT- NOT WITH PCI
o Renal elimination
- Bivalirudin
o Before PCI:

o In lab:

Thrombolytics
- In contrast to anticoagulants, which prevent the propagation of thrombi, plasminogen activators promote thrombolysis
o Break up the clot that already exist, but does not prevent new clot formation
- Promote thrombolysis by hydrolyzing the arginine560-valine561 peptide bond in plasminogen to form the active proteolytic
enzyme plasmin
- Thrombolysis only if primary PCI is unavailable

SK Alteplase (rTPA) Reteplase (rPA) Tenectaplase (TNK)

Allergic reaction Yes No No No
Fibrin selectivity No Yes Yes Yes
Complete reperfusion
32% 54% 60% 55%
(%)
Concomitant AC ??? Yes Yes Yes
1.5 mil units over 1 3-part process= 100mg
Dosing 2 X 10 unit IVP 0.5mg/kg IVP
hour over 90 minutes

Thrombolytic Contraindications
- Active internal bleeding
- History of CVA
- Recent surgery or trauma
- Intracranial neoplasm or aneurysm
- Known bleeding disorder
- Severe uncontrolled HTN (SPB >180 mmHg)
o Despite giving antihypertensives

Secondary Prevention
- Lifestyle Changes - Medical Therapy
o Smoking o Antiplatelet agents (DAPT)
o Physical activity/cardiac rehabilitation o Lipid management (high intensity statin)
o Weight management o Beta blockers (majority of patients & for 3
o Depression- diagnosis and treatment years)
o RAAS blockers
o Blood pressure control
o DM management
o Influenza vaccination

Class Indications Duration

All patients post-MI or UA
Aspirin
Anyone with CAD
1. Clopidogrel
P2Y12 Inhibitor 2. Prasugrel (only if PCI)
3. Ticagrelor
Statin All patients post-ACS
Beta-Blocker All patients without contraindications
ACEi/ARB Low EF, HTN, DMII, or renal dysfunction
Aldosterone antagonist Low ED and HF symptoms or DMII