Acs Drugs

Front 1

Fibrinolytics

Back 1

MOA: Initiates fibrinolysis by binding to fibrin in a thrombus à converts entrapped plasminogen to plasmin

All currently available fibrinolytic agents reduce mortality in acute STEMI


Important factors:
Time to therapy (D2N)
Degree of flow obtained (TIMI)
Indications:
Chest pain suggestive of AMI
ST segment elevation > 1 mm in 2 or more contiguous leads

New left bundle branch block
(Age < 75)
Greatest benefit if given < 12 hours after onset of symptoms

Front 2

Streptokinase

Back 2

First generation fibrinolytic

Decrease cost
Dose: 1.5 million units over 30-60 minutes
Inferior outcomes
Allergic reaction concern

Front 3

Alteplase (tPA, Activase)

Back 3

 Lower mortality than streptokinase
 More difficult to administer d/t short half-life
Increase cost
Dose: 15 mg bolus à 0.75 mg/kg over 30 minutes (NTE 50 mg) à 0.5 mg/kg over next 60 minutes (NTE 35 mg)

Front 4

Reteplase (Retavase)

Back 4

 Similar outcomes as alteplase
 Dose: 10 units over 10 minutes, then repeat In 30 minutes
 Easier to administer

Front 5

Tenecteplase (TNKase)

Back 5

 Similar efficacy as alteplase (less bleeding and transfusions)
 One-time bolus based on patient’s weight

Front 6

Glycoprotein IIb/IIIa receptor antagonists (anti-platelet)

Back 6

 MOA: inhibits receptor on platelet surface, blocking platelet aggregation
 Indications: NSTEMI and PCI
 Reduce risk of recurrent coronary artery thrombosis (or stent thrombosis)
 CIs: Active internal bleeding or bleeding in past 30 days, h/o CVA w/in 30 days, severe HTN, major surgery w/in 6 weeks, PLT < 150,000

Front 7

Abciximab (ReoPro)

Back 7

 MOA: inhibits receptor on platelet surface, blocking platelet aggregation
 Indications: NSTEMI and PCI
 Reduce risk of recurrent coronary artery thrombosis (or stent thrombosis)
 CIs: Active internal bleeding or bleeding in past 30 days, h/o CVA w/in 30 days, severe HTN, major surgery w/in 6 weeks, PLT < 150,000

Front 8

Abciximab (ReoPro)

Back 8

 PCI, stent placement
 Dosing: 0.25 mg/kg bolus followed by 0.125 mcg/kg/minute for 12 hours
 Not indicated for UA alone
 Long duration of action, PLT effects reverse slowly (24-48 hours)
 Monitor PLTs
 Risk of thrombocytopenia

Front 9

Eptifibatide (Integrilin)

Back 9

 PCI, stents, UA medical management
 Dosing (PCI): 180 mcg/kg bolus (x2) then 2 mcg/kg/min infusion for 18-24 hours (??)
 Dosing (UA): 180 mcg/kg bolus then 2 mcg/kg/min infusion up to 72 hours
 Rapid onset and rapidly reversible
 t1/2 = 10-15 minutes
 Concurrent ASA and heparin recommended

Front 10

Tirofiban (Aggrastat®)

Back 10

 ACS medical management, PTCA
 Dosing: 0.4 mcg/kg/min x 30 minutes, then infuse 0.1 mcg/kg/min (12-24 hours)
 Given with heparin

Front 11

Aspirin (anti-platelet)

Back 11

 Irreversible PLT binding
 STEMI, NSTEMI
 Dose: 160 – 325 mg chewed or crushed (acute dose)
 Should be continued indefinitely (low dose)

Front 12

Thienopyridines (anti-platelet)

Back 12

 Indications: UA/NSTEMI, PCI, medically managed STEMI patients, ASA allergic ACS patients
 MOA: Blockade of ADP platelet receptors
 Dual platelet therapy: ASA (75-325 mg + clopidogrel
 Loading dose + maintenance dose

Front 13

Clopidogrel (Plavix)

Back 13

 Dosing: 300-600 mg loading dose, followed by 75 mg once daily
 LD given at least 2 hours prior to PCI
 CIs: pathological bleeding (i.e. peptic ulcer disease (PUD) or intracranial hemorrhage), coagulation disorders
 Hold 5-7 days before CABG (to avoid major bleeding)
Active metabolite via CYP2C19

Front 14

Prasugrel (Effient)

Back 14

 Dosing: 60 mg LD (≥ 60 kg) followed by 10 mg daily; <60 kg may use 5 mg daily
 CIs: ≥ 75 y.o.; h/o TIA or stroke; pathological bleeding
 AEs: BBW for “significant or fatal bleeding”; Thrombotic thrombocytopenic purpura (TTP)
 More potent; no CYP2C19 interaction

Front 15

Unfractionated Heparin (UFH)

Back 15

 Indications: NSTEMI and STEMI
 Dosing: weight based; continuous infusion
 Adjusted to maintain aPTT between 1.5 – 2.5x control
 MOA: Inhibition of clotting factors Xa and IIa (thrombin) via IIIa (antithrombin)
 CIs: active bleed, h/o HIT, recent stroke