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19 Cards in this Set
- Front
- Back
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Chronic stable angina drug therapies
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ASA (consistend survival benefit)
-Clopidogrel if ASA intolerant Beta blocker (consistent survival benefit; consider metoprolol, carvedilol) Consider adding long acting nitrate, CCB, ACEI (LV dysfunction survival benefit, decreases diabetic comorbidities, consider lisinopril), statins, or SL NTG for acute angina episodes |
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Current management strategies for ACS
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ST Elevation
-Fibrinolysis -Primary PCI No ST elevation -Early invasive -Early conservative |
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Fibrinolytic indications
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Primary use in AMI population
Chest pain < 12 hrs STE in 2 or more continuous leads New LBBB Ongoing Sx of AMI for 12-24 hrs w/persistent STE or LBBB if 1◦ PCI unavailable |
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Fibrinolytic absolute contraindications
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Any prior ICH
Known structural cerebral vascular lesion Ischemic stroke within 3 months, except AIS <3hrs Suspected aortic dissection Active bleeding or bleeding diathesis Intracranial neoplasm Significant closed-head/facial trauma Chest pain > 24 hrs |
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Fibrinolytic relative contraindications
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Traumatic/prolonged CPR
<2-4 week internal bleeding Noncompressible vascular puncture Active peptic ulcer Vit. K ant.: higher INR→higher risk of bleeding Pregnancy Chest pain > 12 hrs without AMI Sx Hx of chronic, severe, poorly controlled HTN SBP>180mm Hg or DBP>110mm Hg on presentation Hx of prior ischemic stroke > 3 months, dementia, intracranial pathology not covered in contraindications Major surgery (<3weeks) |
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Fibrinolytics: MOA
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Directly break down clot bound fibrin
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Fibrinolytic names
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SK
-Streptokinase r-PA -Reteplase t-PA -Alteplase -Used most for AMI TNK -Tenecteplase -Used most for AMI |
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Fibrinolytic characteristics: antigenicity, direct inhibitor, fibrin specific, conserve fibrinogen, PAI-1 resistant
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SK
-Antigenicity -Not direct inhibitor -Not fibrin specific -Doesn't conserve fibrinogen -Not PAI-1 resistant r-PA - No antigenicity -direct inhibitor -fibrin specific -conserve fibrinogen -PAI-1 resistant t-PA -No Antigenicity -direct inhibitor -fibrin specific -conserve fibrinogen -PAI-1 resistant TNK -No Antigenicity -direct inhibitor -fibrin specific -conserve fibrinogen -PAI-1 resistant |
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Fibrinolytic characteristics: onset, duration, half-life, excretion
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SK
-Immediate binding onset -Up to 24 hr duration -18-83 min half-life -reticuloendothelial system excretion r-PA -30-90 min onset -Up to 6 hr duration -12-16 min half life -Urine/feces excretion t-PA -30-60 min onset -up to 6 hr duration -24-46 min half life -hepatic excretion TNK -60 min onset -up to 6 hr duration -20-120 min half-life -hepatic excretion |
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Anticoagulant MOA
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Unfractionated heparin
-potentiates action of antithrombin LMWH -Factor Xa inhibition Fondaparinux, rivaroxaban -Antithrombin mediated factor Xa inhibition Direct thrombin inhibitors (Argatroban, bivalirudin, dabigatran) -Binds to thrombin directly Warfarin -Vitamin K antagonist |
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Heparin, LMWH, Direct thrombin inhibitor therapeutic uses
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AMI
Deep Venous Thrombosis Treatment/Prophylaxis Pulmonary Embolus Thrombotic Stroke |
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Warfarin therapeutic uses
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Deep Venous Thrombosis/Pulmonary Embolus prevention
Thrombosis associated with arrhythmias Stroke prevention |
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Fondaparinux, Dabigatran (DTI), Rivaroxaban therapeutic uses
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Fondaparinux
-Treatment of DVT/PE -Prophylaxis for DVT/PE Dabigatran -Thrombosis associated with Atrial Fibrillation/Flutter Rivaroxaban -Prophylaxis for DVT/PE |
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Heparin induced thrombocytopenia
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↓ in platelets by 50% from baseline or < 150,000
0.5% incidence; Day 5-10 of heparin exposure (earlier if prior exposure) IgG antibodies: Platelet Factor 4/ heparin complex Life or limb threatening thrombosis Confirm with PF4/heparin antibody assays DC heparin/LMWH (Avoid future use!) Treat with fondaparinux or DTI infusion No warfarin until thrombocytopenia resolved & on other anticoagulation! Overlap DTI infusion by 3-4 days Overlap fondaparinux until INR 2-3 |
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Anticoagulant monitoring parameters
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Unfractionated Heparin
-aPTT -heparin levels -ACT LMWH -FXa levels DTI -aPTT (for argatroban) Warfarin -PT/INR |
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Anticoagulant adverse effects
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Unfractionated heparin and LMWH
-HIT -Thrombocytopenia Fondaparinux, rivaroxaban -Thrombocytopenia (rare) DTIs (Argatroban, Bivalirudin, dabigatran) -Allergic reactions Warfarin -warfarin skin necrosis |
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Antiplatelet MOA
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Bind to GPIIb-IIIa receptor so fibrinogen can't bind and crosslink platelets
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Abciximab, Epifibatide, Tirofiban: Uses, chemical, structure, refersibility, return of platelet function, clearance
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Abciximab
-PCI -Ab fragment -Steric hindrance -Slow reversibility (days) -Slow return of platelet function -Clearance measurable for days Eptifibatide -ACS/PCI -Peptide -competitive binding -Fast reversibility -Fast return of platelet function -T1/2 clearance=90 min Tirofiban -ACS/PCI -nonpeptide -competitive binding -fast reversibility -fast return of platelet function -T1/2 clearance=120 min |
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Miscellaneous antithrombotic agents
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Pentoxifylline (Trental)
-Enhanced RBC deformability -Uses: Intermittent Claudication Cilostazol (Pletal) -PDE3 inhibitor (mild reversible antiplatelet) -Uses: Peripheral Vascular Disease, Intermittent Claudication -ADRs: peripheral edema, tachycardia --avoid use in HF |
