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Pharmacy & Acute Care University
Pharmacy & Acute Care University
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Acute Care Cardiology

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  1. Acute Coronary Syndrome
    8 Topics
  2. ADHF
  3. Lesson
  4. Hypertensive Crisis
  5. Atrial Arrythmias
  6. Ventricular Arrythmias
  7. Bradycardia
  8. Lesson
  9. Aortic Dissection

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Acute Care Cardiology Acute Coronary Syndrome Pharmacologic Intervention 1: Acute Coronary Syndrome
Lesson 1, Topic 3
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Pharmacologic Intervention 1: Acute Coronary Syndrome

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Pharmacotherapy

Pharmacotherapy for Acute Coronary Syndrome

Pharmacotherapy for Acute Coronary Syndrome (ACS) is intricate, with the approach varying depending on the type of ACS—ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), or unstable angina (UA). The initial management focuses on stabilizing the patient, relieving ischemia, and preventing further thrombus formation, with a particular emphasis on reperfusion therapy for STEMI.

Initial Emergency Management

Aspirin

Dosing:

  • Loading Dose: 162-325 mg orally, non-enteric coated, chewed. Administer immediately upon suspicion of ACS.
  • Maintenance Dose: 81-162 mg daily, continued indefinitely unless contraindicated.

Clinical Considerations:

  • Administer as soon as possible unless contraindicated (e.g., severe allergy, active bleeding).
  • Use non-enteric coated aspirin for rapid absorption and onset of action.
  • Consider rectal administration (300 mg) if oral route is not possible.

Clinical Pearls:

  • Rapid Action: Chewing ensures quicker absorption compared to swallowing enteric-coated forms.
  • DAPT: Often combined with P2Y12 inhibitors for dual antiplatelet therapy.
  • Bleeding Risk: Monitor for GI bleeding, especially in patients with peptic ulcer history. Consider PPI for gastroprotection in high-risk patients.
  • Long-term Use: Low-dose (81 mg) effective for secondary prevention with lower GI bleeding risk.

Guideline Recommendations:

ACC/AHA Guidelines: “Aspirin should be given as soon as possible after hospital presentation and continued indefinitely in patients who tolerate it (Class I, Level of Evidence A).” For STEMI: “Aspirin 162 mg to 325 mg should be given before primary PCI (Class I, Level of Evidence A).”

Evidence from Studies:

  • ISIS-2 Trial (1988): Demonstrated 23% reduction in vascular mortality with aspirin in suspected acute MI.
  • CURRENT-OASIS 7 Trial (2010): Higher loading doses beneficial for PCI; standard maintenance doses effective long-term.

P2Y12 Inhibitors

Clopidogrel

Dosing:

  • Loading Dose:
    • STEMI with fibrinolytics:
      • Age ≤75 years: 300 mg, then 75 mg daily for at least 14 days and up to 1 year
      • Age >75 years: No loading dose; 75 mg daily for at least 14 days and up to 1 year
    • NSTEMI/UA or PCI: 600 mg
  • Maintenance Dose: 75 mg daily

Clinical Considerations:

  • Preferred in higher bleeding risk or intolerance to prasugrel/ticagrelor.
  • Avoid in poor CYP2C19 metabolizers.
  • Consider early administration in NSTEMI/UA.

Clinical Pearls:

  • Combination Therapy: Often used with aspirin for DAPT.
  • Bleeding Risk: Lower risk compared to prasugrel and ticagrelor.
  • Genetic Variability: CYP2C19 testing can identify poor responders.

Guideline Recommendations:

ACC/AHA Guidelines: “Clopidogrel is an effective alternative to prasugrel or ticagrelor in DAPT after ACS (Class I, Level of Evidence B).”

Evidence from Studies:

  • CURE Trial (2001): Adding clopidogrel to aspirin significantly reduces cardiovascular events in ACS without ST-elevation.

Prasugrel

Dosing:

  • Loading Dose: 60 mg orally
  • Maintenance Dose: 10 mg daily

Clinical Considerations:

  • Avoid in patients with history of stroke or TIA due to increased bleeding risk.
  • More potent than clopidogrel, but higher risk of major bleeding.
  • For NSTEMI/UA: Recommended for PCI patients not at high bleeding risk.

Clinical Pearls:

  • Potency: Superior to clopidogrel in reducing ischemic events, especially in PCI patients.
  • Contraindications: Not for patients with stroke/TIA history or ≥75 years old, unless high risk.
  • Body Weight: Consider 5 mg daily for patients <60 kg to reduce bleeding risk.

Guideline Recommendations:

ACC/AHA Guidelines: “Prasugrel is recommended for ACS patients who undergo PCI and are not at high risk of bleeding (Class I, Level of Evidence B).”

Evidence from Studies:

  • TRITON-TIMI 38 Trial (2007): Prasugrel superior to clopidogrel in reducing cardiovascular events in ACS patients undergoing PCI, but with increased major bleeding risk.

Ticagrelor

Dosing:

  • Loading Dose: 180 mg orally
  • Maintenance Dose: 90 mg twice daily

Clinical Considerations:

  • Faster onset and greater platelet inhibition than clopidogrel.
  • Common side effects: dyspnea and bradyarrhythmias.
  • Avoid with strong CYP3A4 inhibitors/inducers.
  • Beneficial for NSTEMI/UA patients undergoing early invasive strategy.

Clinical Pearls:

  • Rapid Onset: Quicker platelet inhibition than clopidogrel, beneficial in acute settings.
  • Reversibility: Unlike clopidogrel/prasugrel, effects are reversible, advantageous for rapid reversal if needed.
  • Adherence: Twice-daily dosing may affect patient compliance compared to once-daily regimens.

Guideline Recommendations:

ACC/AHA Guidelines: “Ticagrelor is recommended for ACS patients treated with an early invasive strategy or those managed with coronary artery bypass graft surgery (CABG) (Class I, Level of Evidence B).”

Evidence from Studies:

  • PLATO Trial (2009): Ticagrelor superior to clopidogrel in reducing composite endpoint of cardiovascular death, MI, or stroke in ACS patients.