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Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Matt Hafermann, PharmD, BCPS Cardiology Clinical Cardiology Clinical Pharmacist University of Pharmacist University of Washington Medical Center Washington Medical Center

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Page 1: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Acute Coronary Syndrome (ACS)

Matt Hafermann, PharmD, BCPSMatt Hafermann, PharmD, BCPSCardiology Clinical Pharmacist University of Cardiology Clinical Pharmacist University of

Washington Medical CenterWashington Medical Center

Page 2: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

OBJECTIVES

1.1. Introduction and background to ACSIntroduction and background to ACS2.2. Outline treatment strategies for ACSOutline treatment strategies for ACS3.3. Review medications used in acute coronary Review medications used in acute coronary

syndromessyndromes4.4. Discuss quality performance medications used Discuss quality performance medications used

upon discharge from the hospital after a upon discharge from the hospital after a myocardial infarction myocardial infarction

Page 3: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Cardiovascular Disease• Number one killer of Americans: Number one killer of Americans:

• Estimated 785,000 cases of CVD annually in the US Estimated 785,000 cases of CVD annually in the US • Coronary heart disease responsible for 1 in 6 Coronary heart disease responsible for 1 in 6

deaths in the USdeaths in the US• 470,000 recurrent attacks 470,000 recurrent attacks • 195,000 silent MIs195,000 silent MIs

• ~34% of Americans have metabolic syndrome~34% of Americans have metabolic syndrome• $297.7 billion- Associated cost of CVD and related $297.7 billion- Associated cost of CVD and related

conditionsconditions

Circulation 2012:125

Page 4: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Progression and Terminology of ACS

UA STEMI STEMI

Plaque Disruption/Fissure/Erosion

Thrombus Formation

Source: American Heart Association

Progression

Page 5: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Case study MR• MR is a 76 YO male who comes to MR is a 76 YO male who comes to

the ER complaining of 10\10 the ER complaining of 10\10 chest pain. He started to have chest pain. He started to have chest pain 3 hours ago while chest pain 3 hours ago while watching TV watching TV

• He states that it feels like “an He states that it feels like “an elephant is on my chest”elephant is on my chest”

• PMH: Hypertension, diabetes, PMH: Hypertension, diabetes, former smoker 1ppd x 20 years former smoker 1ppd x 20 years FH: Father died at age 80 of a FH: Father died at age 80 of a stroke stroke

• SH: retired, spends a lot of time SH: retired, spends a lot of time watching TVwatching TV

• Medications upon admissionMedications upon admission• Aspirin 325mg QDAspirin 325mg QD• Atorvastatin 20mg QPMAtorvastatin 20mg QPM• Lisinopril 5mg dailyLisinopril 5mg daily• Glyburide 5mg daily Glyburide 5mg daily • Sildenafil 25mg prn EDSildenafil 25mg prn ED

• Allergies: PCNAllergies: PCN• Physical exam:Physical exam:

• Vitals: BP 140\100 HR 100Vitals: BP 140\100 HR 100 RR 24 ORR 24 O22 sat 98% RA, weight sat 98% RA, weight = 111 kg= 111 kg• Ashen, diaphoretic, anxiousAshen, diaphoretic, anxious• Normal heart soundsNormal heart sounds

Page 6: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Case study MR• ECG: sinus tachycardia ECG: sinus tachycardia

with ST segment with ST segment depression in the depression in the anterior leads anterior leads suggesting ischemiasuggesting ischemia

• CXR: No apparent CXR: No apparent edema, normal heart edema, normal heart sizesize

• Labs: CK-MB elevated at Labs: CK-MB elevated at 10 ng\mL, first Troponin 10 ng\mL, first Troponin 0.7ng\mL (+)0.7ng\mL (+)

• ROS: Patient’s current ROS: Patient’s current chest pain is now 7\10 chest pain is now 7\10 and he is in distressand he is in distress

• Assessment: admit with Assessment: admit with rule out MI (ROMI) rule out MI (ROMI) protocol : serial enzymes, protocol : serial enzymes, ECGECG

Page 7: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Risk factors of Heart Disease

• MaleMale• SmokingSmoking• Family historyFamily history• HypertensionHypertension• DiabetesDiabetes• Elevated lipidsElevated lipids• ObesityObesity• Lack of exerciseLack of exercise• Chronic kidney Chronic kidney

diseasedisease

Page 8: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Determining a Treatment Plan

Page 9: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

STEMI vs Non-STEMI?

“tombstones”

Page 10: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Interpretation

• ST segment elevation = acute injuryST segment elevation = acute injury• >1mm in 2 consecutive leads>1mm in 2 consecutive leads

• ST segment depression ST segment depression • >1mm = ischemia>1mm = ischemia

• High risk unstable anginaHigh risk unstable angina• Non-ST segment elevation Non-ST segment elevation MI MI

Page 11: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center
Page 12: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Locations: anterior, lateral, and inferior

Page 13: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Initial Recognition and Management

• Quality of chest pain:Quality of chest pain:• 10/10 chest pain , crushing band-like10/10 chest pain , crushing band-like• 20% of patients have 20% of patients have ““prodromalprodromal””

• Pain at rest, change in patternPain at rest, change in pattern• Physical examPhysical exam

• Ashen, diaphoreticAshen, diaphoretic• PresencePresence of risk factors of risk factors

Page 14: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Laboratory Findings

• Troponin is the gold standardTroponin is the gold standard• Troponin q6h x 3 valuesTroponin q6h x 3 values• CK-MB helpful for reinfarctionCK-MB helpful for reinfarction• Monitor until levels have plateaued or you Monitor until levels have plateaued or you

get 2 negative valuesget 2 negative values• Troponin-I value of >0.4ng\mL is Troponin-I value of >0.4ng\mL is

suggestive of myocardial infarctionsuggestive of myocardial infarction•Can be laboratory dependentCan be laboratory dependent

Page 16: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Relationship Between Degree of Troponin Elevation and Likelihood for Long-term Mortality

Relationship Between Degree of Troponin Elevation and Likelihood for Long-term Mortality

Antman EM, it al. N Engl J Med. 1996; 335: 1342-1349.

% mortality at 42 days

<0.4 <1.0 <2.0 <5.0 <9.0 9.0

2

4

6

8

0

Troponin levels

Page 17: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Case of MR- Treatment Options• The ER attending decides The ER attending decides

to admit this patient and to admit this patient and wants to start to initiate wants to start to initiate therapy in the ER.therapy in the ER.

• What we know so far:What we know so far:• + ECG for ST segment + ECG for ST segment

depression in the depression in the anterior leadsanterior leads

• + History and physical + History and physical findingsfindings

• + First troponin and CK+ First troponin and CK

• What are the treatment What are the treatment goals for MR?goals for MR?

• Devise a Devise a pharmacotherapeutic pharmacotherapeutic strategy to be initiated in strategy to be initiated in ER?ER?

• What other baseline data What other baseline data should be obtained before should be obtained before you can beginyou can begin??

Page 18: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Treatment Options

Page 19: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Early Management: Relieve pain, save myocardiumImmediate assessment < 10min Immediate treatment

Measure vital signs Oxygen at 4 liters\min

Measure oxygen saturation Aspirin 160-325mg (chew) *

Obtain IV access Nitroglycerin SL or spray 0.4mg Q5min x 3 doses->IV

Obtain 12-lead ECG (MD review) Morphine IV 2-4 mg q5-15 min

Perform brief targeted history and PE (focus on thrombolytic therapy)

*memory aid “MONA” (Morphine,O2,nitroglycerin, aspirin)

* May consider clopidogrel if aspirin allergic

Obtain initial serum cardiac marker levels

Request CXR (<30 min) 

Page 20: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Case of MR• The ER attending decides to admit this patient. In order to initiate medical

therapy, what labs baseline labs should be drawn?• Basic chem 7, CBC, Serial cardiac enzymes, INR

• Your labs results return• First troponin + at 0.7ng/mL and CK-MB 10ng\mL

ACC/AHA 2007 guidelines supports administration of nitrates only if 24 hours have elapsed after last dose of sildenafil and 48hrs for Tadalafil

Page 21: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Case of MR After After MONAMONA the the BESTBEST early treatment for this patient is early treatment for this patient is

A.A. IV Heparin bolus 4000 units then IV heparin at 1000 IV Heparin bolus 4000 units then IV heparin at 1000 units per hour to obtain aPTT 60-100units per hour to obtain aPTT 60-100

B.B. Oxycodone 20mg x 1 then 5mg q6h prn pain Oxycodone 20mg x 1 then 5mg q6h prn pain C.C. Call to cardiology fellow to mobilize the cath lab Call to cardiology fellow to mobilize the cath lab

and consider clopidogrel loadingand consider clopidogrel loadingD.D. A and CA and C

Goal is to prevent myocardial damage and treat chest pain and Goal is to prevent myocardial damage and treat chest pain and resolution of EKG changes to baseline.resolution of EKG changes to baseline.

Page 22: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Diagnostic Algorithm for Acute Coronary Syndrome Management

Therapeutic goal: rapidly break apart fibrin mesh to quickly restore blood flow

ST-segment elevation MI Non-ST Elevation ACS* Non-ST Elevation MI

+ Tn &/or+ CK-MB

Consider fibrinolytic therapy, if indicated

Therapeutic goal: prevent progression to complete occlusion of coronary artery

and resultant MI or death

Consider GP IIb-IIIa inhibitor + aspirin + heparin

&/or

Braunwald E, et al. 2002. http://www.acc.org/clinical/guidelines/unstable/unstable.pdf.

Page 23: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

The role of the thrombus — mechanism of action in ST-segment elevation ACS

Results from stabilization of a platelet aggregate at site of

plaque rupture by fibrin mesh

platelet

RBC

fibrin mesh

GP IIb-IIIa

Generally caused by a completely occlusive

thrombus in a coronary artery

Page 24: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

The Role of the Platelet: Mechanism of NSTE ACS

The Role of the Platelet: Mechanism of NSTE ACS

Results from cross-linking of platelets by fibrinogen at

platelet receptors GP IIb-IIIaat site of plaque rupture

platelet

fibrinogen

Rupturedplaque

GP IIb-IIIa

Generally caused by a partially occlusive, platelet-rich thrombus in a coronary artery

Unobstructedlumen

thrombus

Artery wall

Page 25: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Acute Coronary Syndromes Algorithm.

O'Connor R E et al. Circulation 2010;122:S787-S817Copyright © American Heart Association

Page 26: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center
Page 27: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Treatment of Non-ST segment elevation MIN-STEMI

Page 28: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Current Management of Non-ST-segment Elevation ACS in the U.S.

Current Management of Non-ST-segment Elevation ACS in the U.S.

Diagnosis

Diagnosticcatheterization

35%

15%

30% 20%

70%PCI

CABG

Medicalmanagement

High-Risk

Low-Risk

Page 29: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center
Page 30: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Case of MR• Pharmacotherapeutic plan before the cath lab:Pharmacotherapeutic plan before the cath lab:

• Antiplatelet therapy with:Antiplatelet therapy with:• AspirinAspirin• Clopidogrel, prasugrel, or ticagrelor loadingClopidogrel, prasugrel, or ticagrelor loading

• Anticoagulant therapy:Anticoagulant therapy:• Unfractionated heparin or enoxaparinUnfractionated heparin or enoxaparin• IIb \ IIIa inhibitor if deemed high risk. Timing IIb \ IIIa inhibitor if deemed high risk. Timing

dependent on management strategy dependent on management strategy

Page 31: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Aspirin in Acute Coronary Syndromes

12.9

3.9*

ASA0

5

10

1511.9

3.3*

ASA0

5

10

1512.9

6.2*

ASA0

5

10

152.2

1.3*

ASA0

0.5

1

1.5

2

2.5

UA/NSTEMIPrimary

PreventionStable Angina

*P<.0001MI

*P=.0003MI

*P=.008Death or MI

*P=.012Death or MI

N= 11034 11037 155 178 279 276 118 121

MI, myocardial infarction; ASA, acetylsalicylic acid; RISC, Research on InStability in Coronary artery disease; ISIS-2, Second International Study of Infarct Survival.

PHS. N Engl J Med. 1989;321:129-35.Ridker PM, et al. AJC. 1991;114:835-839.

Cairns JA, et al. N Engl J Med. 1985;313:1369-1375.Theroux P, et al. N Engl J Med. 1988;319:1105-1111.

Placebo Placebo Placebo Placebo

Pat

ien

ts (

%)

Page 32: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Pathways to Platelet Aggregation

Page 33: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Drug Indication Dose Adverse effects Monitoring

Aspirin STEMI

ACS

162-325mg hospital day 1 Post PCI w\stent 162-325mg daily otherwise 75-162mg daily

Dypepsia, bleeding and gastritis

Clinical signs of bleeding, baseline CBC & every 6 months

Clopidogrel(Plavix)

STEMI and NSTEMI, PCI with stent added to aspirin Alternative to aspirin in pts with allergy

300-600mg loading dose, then 75mg daily

Bleeding, diarrhea, rash, TTP (rare)

Prasugrel(Effient)

Patient undergoing PCI for ACS

60mg LD then 10mg Qday

Caution in pts <60kg may use 5mg (less data)

Bleeding, diarrhea, rash, TTP (rare)Avoid in pts >75 yrs

Ticagrelor(Brilinta)

UA, NSTEMI, or STEMI managed medically or with PCI

180mg loading dose followed by 90mg twice daily

Bleeding, dyspnea, headache, fatigue, diarrhea

Antiplatelet therapy

Page 34: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Tips for Antiplatelet Therapy EVERYONE gets aspirin 81mg dailyEVERYONE gets aspirin 81mg daily

Older guidelines recommended higher dosesOlder guidelines recommended higher doses ClopidogrelClopidogrel

Cheapest optionCheapest option PrasugrelPrasugrel

More expensiveMore expensive Not approved for medical management (only PCI)Not approved for medical management (only PCI) Dose reduction or avoid in patients >75 years or <60 kgDose reduction or avoid in patients >75 years or <60 kg Contraindicated in patients with previous stroke or TIAContraindicated in patients with previous stroke or TIA

TicagrelorTicagrelor Newest agentNewest agent Must use aspirin 81 mg daily (don’t use higher dose)Must use aspirin 81 mg daily (don’t use higher dose) ExpensiveExpensive

Page 35: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Antiplatelet agents

• Bare metal stents• Minimum of 1 month of clopidogrel. Ideal

treament is up to one year if patients are not at a high risk of bleeding

• Drug eluting stents• Ideally up to at least 12 months of clopidogrel

in patients who are not at high risk of bleeding

Page 36: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

AnticoagulantsDrug Indication Adverse Side Effects Monitoring

Unfractionated Heparin

STEMI, NSTE ACS, PCI

** For UA/ NSTEMI give for at least 48 hours if conservative management chosen

Bleeding, HIT aPTT until target or change in dose. CBC , HIT if indicated

Enoxaparin Bleeding, HITAvoid if severe bleeding risk

CBC and Scr, HIT if indicated. Avoid if CrCl<15

Fondaparinux STEMI, NSTEMI(Not well studied in pts with PCI)

Bleeding CBC and Scr

Bivalirudin NSTE ACS, PCI Bleeding Direct thrombin inhibition (DTI), CBC and Scr

GP IIb \ IIIa inhibitors:AbciximabTirofibanEptifibitide

With PCI:Abciximab

ACS: EpitifibitideTirofiban

Bleeding, Acute profound thrombocytopenia

Baseline Scr and daily (for eptifibitide and tirofiban)Daily CBC (with emphasis on Plt count) 4hrs after initiation

For all above: Monitoring for clinical signs of bleeding

Page 37: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

The Role of the Platelet: Mechanism of NSTE ACS

The Role of the Platelet: Mechanism of NSTE ACS

Results from cross-linking of platelets by fibrinogen at

platelet receptors GP IIb-IIIaat site of plaque rupture

platelet

fibrinogen

Rupturedplaque

GP IIb-IIIa

Generally caused by a partially occlusive, platelet-rich thrombus in a coronary artery

Unobstructedlumen

thrombus

Artery wall

Page 38: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Platelet Adhesion, Activation, and Aggregation

Platelet Adhesion, Activation, and Aggregation

White HD. Am J Cardiol. 1997; 80 (4A): 2B-10B.

Vessel wall

Page 39: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Mechanism of Action: GP IIb-IIIa InhibitorsMechanism of Action: GP IIb-IIIa Inhibitors

White HD. Am J Cardiol. 1997; 80(4A):2B-10B.

Vessel wall

Page 40: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Glycoprotein II b/ IIIa inhibitors

Page 41: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Summary For UA/NSTEMI Treatment AntiplateletAntiplatelet

Aspirin alwaysAspirin always P2Y12 inhibitor or Glycoprotein (GP) IIb/IIIa inhibitorP2Y12 inhibitor or Glycoprotein (GP) IIb/IIIa inhibitor

Heparin alwaysHeparin always Unfractionated or LMWHUnfractionated or LMWH

Bivalirudin can be used in place of heparin and glycoprotein Bivalirudin can be used in place of heparin and glycoprotein IIb/IIIa inhibitorIIb/IIIa inhibitor

PCI vs medical management PCI vs medical management Determined by risk factorsDetermined by risk factors

TIMI score, past medical historyTIMI score, past medical history Statin therapyStatin therapy

Page 42: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center
Page 43: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Pharmacologic treatment of ST segment elevation MI

(STEMI)

Page 44: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Case:SS Mr. SS is a 47 year old male Mr. SS is a 47 year old male

who presents to a small who presents to a small hospital with 2hrs of chest hospital with 2hrs of chest pain. The hospital is without pain. The hospital is without a cath lab. His chest pain is a cath lab. His chest pain is 10\10 in the ED10\10 in the ED

PMH: s\p kidney transplant 2 PMH: s\p kidney transplant 2 yrs. ago, HTN, hyperlipidemia yrs. ago, HTN, hyperlipidemia

ECG shows ST segment ECG shows ST segment elevation in the anterior elevation in the anterior leads. leads.

Meds upon admission: Meds upon admission: tacrolimus 2mg bid, tacrolimus 2mg bid, Cellcept 1000 mg bid, Cellcept 1000 mg bid, prednisone 5mg daily, prednisone 5mg daily, amlodipine 5mg daily, amlodipine 5mg daily, pravastatin 5mg dailypravastatin 5mg daily

Vitals: BP 140/90, RR 16 Vitals: BP 140/90, RR 16 HR 100, O2 sat 95%HR 100, O2 sat 95%

Normal Labs: Na 130, K 4, Normal Labs: Na 130, K 4, Plts 300K, HCT 40, INR 1.0Plts 300K, HCT 40, INR 1.0

Page 45: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center
Page 46: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

STEMI Class I Recommendations Get a 12-lead ECG at the site of first medical contactGet a 12-lead ECG at the site of first medical contact Reperfusion therapy should be administered to all eligible patients Reperfusion therapy should be administered to all eligible patients

with STEMI with symptom onset within prior 12 hourswith STEMI with symptom onset within prior 12 hours PCI recommended method of reperfusion when performed in timely PCI recommended method of reperfusion when performed in timely

fashionfashion FMC-to-device time system goal of 90 minutes or lessFMC-to-device time system goal of 90 minutes or less Immediate transfer to PCI-capable hospital for PCI with a goal of 120 Immediate transfer to PCI-capable hospital for PCI with a goal of 120

minutes or lessminutes or less In the absence of contraindications, fibrinolytic therapy should be In the absence of contraindications, fibrinolytic therapy should be

given if anticipated FMC-to-device time >120 minutesgiven if anticipated FMC-to-device time >120 minutes When fibrinolytic therapy is indicated or chosen, it should be given When fibrinolytic therapy is indicated or chosen, it should be given

within 30 minutes of hospital arrivalwithin 30 minutes of hospital arrival

Circulation. 2013;127:529-555

Page 47: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

STEMI Class I Recommendations Primary PCI should be performed within 12 hours of ischemic Primary PCI should be performed within 12 hours of ischemic

symptomssymptoms Aspirin 162-325mg before primary PCIAspirin 162-325mg before primary PCI Continue aspirin 81mg indefinitelyContinue aspirin 81mg indefinitely Load with P2Y12 inhibitor before PCILoad with P2Y12 inhibitor before PCI

Give for 1 yearGive for 1 year UFH or bivalirudin for PCIUFH or bivalirudin for PCI

GP IIB/IIIa inhibitor if using UFH (IIb)GP IIB/IIIa inhibitor if using UFH (IIb) Fibrinolytic therapy should be given to patients who cannot get PCI Fibrinolytic therapy should be given to patients who cannot get PCI

within 120 minuteswithin 120 minutes Aspirin and clopidogrel should be given with fibrinolytics Aspirin and clopidogrel should be given with fibrinolytics UFH for for at least 48 hours after fibrinolyticsUFH for for at least 48 hours after fibrinolytics

Circulation. 2013;127:529-555

Page 48: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

STEMI - PCI

Load with aspirin 162-325mgLoad with aspirin 162-325mg Load with P2Y12 inhibitorLoad with P2Y12 inhibitor IV GP IIb/IIIa receptor antagonist with UFHIV GP IIb/IIIa receptor antagonist with UFH

Bivalirudin in selected patientsBivalirudin in selected patients LMWH can be consideredLMWH can be considered

Page 49: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

STEMI – Fibrinolytics Indications• Chest pain suggesting MIChest pain suggesting MI• ST-segment elevation > 1mm in 2 or more contiguous ECG ST-segment elevation > 1mm in 2 or more contiguous ECG

leads, or new LBBleads, or new LBB• PCI within 120 minutes not possiblePCI within 120 minutes not possible• Time to therapy < 12 hours (up to 24 hours considered)Time to therapy < 12 hours (up to 24 hours considered)• Age < 75 yrs. Age < 75 yrs.

• Age > 75 yrs is Age > 75 yrs is NOTNOT a contraindication to thrombolytic a contraindication to thrombolytic therapy but carries a higher risk of Intra-cranial therapy but carries a higher risk of Intra-cranial hemorrhage.hemorrhage.

• Lower treatment rates with lytics (~60%) as compared Lower treatment rates with lytics (~60%) as compared with PCI (90%)with PCI (90%)

• Associated with higher bleeding risk than with PCIAssociated with higher bleeding risk than with PCI

Page 50: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Prehospital fibrinolytic checklist.

O'Connor R E et al. Circulation 2010;122:S787-S817Copyright © American Heart Association

Page 51: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Fibrinolytics and IIb \ IIIa inhibitors

Drug Indication Adverse side effects Monitoring

Fibrinolytics:TPARetaplaseTenecteplase

STEMI Bleeding, especially intracranial hemorrhage

Clinical signs of bleedingCBC with platelets, INR, Apt in conjunction with heparin

II b \ III a inhibitors:AbciximabEptifibitideTirofiban

With PCI:Abciximab

High risk ACS: EpitifibitideTirofiban

Bleeding, Thromobo-Cytopenia,

Page 52: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

ACS: STEMI• Heparin

• With lytics: UFH 60units\kg With lytics: UFH 60units\kg load then 12units\kg\hrload then 12units\kg\hr

• Without lytics: Without lytics: • LD 50-70 units\kg then LD 50-70 units\kg then

infusion till aPTT therapeuticinfusion till aPTT therapeutic• Enoxaparin: Enoxaparin:

• NSTEMI with ACS: 1mg\kg NSTEMI with ACS: 1mg\kg SQ q12h SQ q12h

• STEMI with PCI: STEMI with PCI: Additional Additional

0.3mg\kg IV at time of PCI0.3mg\kg IV at time of PCI*(Adjust for renal function)*(Adjust for renal function)

• Thrombolytics• TPA (>67kg)TPA (>67kg)• Loading dose 15mg IV Loading dose 15mg IV

over 1-2min followed by over 1-2min followed by 0.75mg\kg (50mg)over 30 0.75mg\kg (50mg)over 30 min then 0.5mg\kg over min then 0.5mg\kg over 60min (35mg) (NTE 60min (35mg) (NTE 100mg)100mg)

• Reteplase 10mg IV q30 Reteplase 10mg IV q30 min x 2 dosesmin x 2 doses

• Tenecteplase bolus with Tenecteplase bolus with 30-50mg30-50mg

Page 53: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Comparison of Fibrinolytic Agents

Agent Fibrin Specificity

TIMI-3 Blood Flow Complete Perfusion at 90

Minutes

Systemic Bleeding

risk/ICH Risk

Administration AWP Other Approved Uses

Streptokinase (Streptase)

+ 35% +++/+ Infusion over 60 minutes

$563 Pulmonary embolism, DVT, clearance of an occluded arteriovenous catheter, intraplueral administration for clearance of pulmonary effusion

Alteplase (rt-PA) (Activase)

+++ 50-60% ++/++ Bolus followed by infusions over 90 minutes, weight based dosing

$3,826 Pulmonary embolism, acute ischemic stroke, clearance of an occluded arteriovenous catheter

Reteplase (rPA) (Retavase)

++ 50-60% ++/++ Two bolus doses, 30 minutes apart

$2,896

Tenecteplase (TNK-tPA) (TNKase)

++++ 50-60% +/++ Single bolus dose, weight-based dosing

$2,918

DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy: A Pathophysiologic Approach, 7th Edition: http://www.accesspharmacy.com

Page 54: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Treatment of Patients Who Present Late

12

8.9 9.28.7

10.3

8.9

0

2

4

6

8

10

12

Placebo

t-PA

RR, risk reduction.

Wilcox R, et al. Presented at 14th Annual Congress of the European Society of Cardiology; September 1992; Barcelona, Spain.

Treated at 6-12 hTreated at 6-12 hPP=0.02=0.02

Treated at Treated at 12-24 h 12-24 h PP=0.60=0.60

Treated at 6-24 hTreated at 6-24 hPP=0.07=0.07

RR = 14%RR = 26% RR = 5%

Symptom Onset to Treatment (hours)

35-D

ay M

ort

alit

y (%

)

Page 55: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Other Early Medications• ACE or ARB (for patients with EF less than 40%)ACE or ARB (for patients with EF less than 40%)• Anxiolytics and AnalgesicsAnxiolytics and Analgesics

• Morphine as the drug of choiceMorphine as the drug of choice• VasodilatorsVasodilators

• Nitroglycerin Nitroglycerin • IV beta blockers in select groups of patientsIV beta blockers in select groups of patients

Page 56: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Treatment optionsEarlyEarly

(first 24-48 hours)(first 24-48 hours)Mid to lateMid to late Discharge medicationsDischarge medications

For secondary For secondary preventionprevention

MONAMONA(Aspirin at admission) (Aspirin at admission)

Beta blockerBeta blocker

AspirinAspirinBeta blocker Beta blocker ACE\ ARBACE\ ARBStatin Statin ACE or ARBACE or ARBClopidogrel (RX Clopidogrel (RX management Or PCI) management Or PCI)

ACE or ARB POACE or ARB POif LVEF is less than 40% if LVEF is less than 40% (in the absence of (in the absence of hypotension)hypotension)

ACE or ARB ContinuedACE or ARB Continued

Lytics and\orLytics and\orPercutaneous Percutaneous intervention (PCI)intervention (PCI)

Page 57: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Early Beta-blockerThe COMMIT study

• Earlier studies: beta blockers administered early Earlier studies: beta blockers administered early during AMI hospitalizations significantly reduce post during AMI hospitalizations significantly reduce post infarction angina and re-infarction.infarction angina and re-infarction.

• Whether early beta blocker use reduces mortality in Whether early beta blocker use reduces mortality in AMI patients remains controversial.AMI patients remains controversial.

• COMMIT study: While beta blockers significantly COMMIT study: While beta blockers significantly reducedreduced the risk of arrhythmic death and re-infarction, the risk of arrhythmic death and re-infarction, they significantly they significantly increasedincreased the risk of cardiogenic the risk of cardiogenic shock within the first 24 hrs of hospitalizationshock within the first 24 hrs of hospitalization

Page 58: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

COMMIT TRIALEarly Intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: Randomized Placebo-controlled trial. COMMIT Collaborative groupLancet 2005;366:1622-32

• Randomized, placebo controlled STEMI Randomized, placebo controlled STEMI and NSTEMI (in China) and NSTEMI (in China)

• Initial IV metoprolol vs. PlaceboInitial IV metoprolol vs. Placebo• Primary outcome: composite of death, Primary outcome: composite of death,

reinfarction or cardiac arrestreinfarction or cardiac arrest• Secondary outcome: death from any Secondary outcome: death from any

cause cause • Conclusion Conclusion

• No difference in combined endpointNo difference in combined endpoint• Early beta blockade reduces death Early beta blockade reduces death

from arrhythmias by 22% but is from arrhythmias by 22% but is counterbalanced by an increase in counterbalanced by an increase in cardiogenic shock by 29% (5% vs. cardiogenic shock by 29% (5% vs. 3.9%). The highest risk of shock was 3.9%). The highest risk of shock was within the first 24h within the first 24h

Page 59: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Case BF• BF presented 2 days ago with BF presented 2 days ago with

10\10 chest pain 10\10 chest pain • + first troponin and ECG with + first troponin and ECG with

ST wave elevation in the ST wave elevation in the anterior leadsanterior leads

• Hospital course: rushed to cath Hospital course: rushed to cath lab and received 1 DES stent to lab and received 1 DES stent to LADLAD

• MOA: NoneMOA: None• Allergies: NKAAllergies: NKA• Vital signs: BP 140\90 HR 70 RR Vital signs: BP 140\90 HR 70 RR

1818• Labs: all WNLLabs: all WNL

• Hospital course: Hospital course: • It is 2 days after his MIIt is 2 days after his MI• What are some What are some

complications after an MI?complications after an MI?• What test should be done What test should be done

after an MI to predict after an MI to predict prognosis?prognosis?

• Develop a long term Develop a long term monitoring plan for BFmonitoring plan for BF

Page 60: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Complications following an MI• Arrhythmias – early first 48 hrs and lateArrhythmias – early first 48 hrs and late• Left ventricular failureLeft ventricular failure

• Pulmonary edema, atrial fibrillationPulmonary edema, atrial fibrillation• Right Ventricular failureRight Ventricular failure

• EdemaEdema• Cardiogenic ShockCardiogenic Shock

• InotropesInotropes• Intra-aortic balloon pump (IABP)Intra-aortic balloon pump (IABP)• May need consult for artificial heart supportMay need consult for artificial heart support

Page 61: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Prognosis• Left ventricular function (EF<40%)Left ventricular function (EF<40%)

• Echo, Cardiac cathEcho, Cardiac cath• Recurrent ischemiaRecurrent ischemia

• Exercise treadmill (ETT)Exercise treadmill (ETT)• Stress ECHO Stress ECHO

• (dobutamine, persantine, adenosine)(dobutamine, persantine, adenosine)• Nuclear medicine studyNuclear medicine study

• Late ArrhythmiasLate Arrhythmias• Other Coexisting disease related to CADOther Coexisting disease related to CAD

Page 62: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Circulation Nov 2008:228;

Page 63: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Case BF• BF presented 2 days ago with 10\10 BF presented 2 days ago with 10\10

chest pain chest pain • + first troponin and ECG with ST + first troponin and ECG with ST

wave elevation in the anterior wave elevation in the anterior leadsleads

• Hospital course: rushed to cath lab Hospital course: rushed to cath lab and received 1 DES stent to LADand received 1 DES stent to LAD

• MOA: NoneMOA: None• Allergies: NKAAllergies: NKA• SH: smokes 1\2 ppdSH: smokes 1\2 ppd• Vital signs: BP 140\90 HR 70 RR 18Vital signs: BP 140\90 HR 70 RR 18• Labs: all WNLLabs: all WNL

• Hospital course: Hospital course: • It is now 4 days after his DES It is now 4 days after his DES

stent and he is ambulating stent and he is ambulating the halls and ready for the halls and ready for discharge discharge

• Devise a pharmacotherapy Devise a pharmacotherapy and risk factor modification and risk factor modification treatment plan for this treatment plan for this patient for discharge.patient for discharge.

• What are his long term What are his long term goals?goals?

Page 64: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Treatment Options: Secondary Prevention

EarlyEarly

(first 24-48 hours)(first 24-48 hours)

Mid to lateMid to late Discharge Discharge medicationsmedications

MONAMONA

(Aspirin at (Aspirin at admission) admission)

Beta blockerBeta blocker

AspirinAspirin

Beta blocker Beta blocker

ACE\ ARBACE\ ARB

Statin Statin

Clopidogrel (RX Clopidogrel (RX management Or PCI) management Or PCI)

ACE or ARB POACE or ARB PO

if LVEF is less than if LVEF is less than 40%40%(in the absence of (in the absence of hypotension)hypotension)

ACE or ARB ACE or ARB ContinuedContinued

Lytics and\orLytics and\or

Percutaneous Percutaneous intervention (PCI)intervention (PCI)

Page 65: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Quality indicators for MI• Explain the quality or Explain the quality or

“Core” measures of “Core” measures of MI and explain the MI and explain the rational behind each rational behind each indicator at dischargeindicator at discharge

• Smoking cessation Smoking cessation • ACE\ARBACE\ARB• Beta blockerBeta blocker• StatinStatin

Secondary prevention Secondary prevention of:of:

• DeathDeath• StrokeStroke• Recurrent Recurrent

infarctionsinfarctions

Page 66: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center
Page 67: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Mid-Late Medications• Beta blockersBeta blockers

• Arrhythmias – around 25% of MI mortality within the first Arrhythmias – around 25% of MI mortality within the first 24 – 48 hours 24 – 48 hours 11

• Metoprolol is the drug of choice in the USMetoprolol is the drug of choice in the US• Beta-1 selectiveBeta-1 selective• Oral to IV conversion 2.5:1Oral to IV conversion 2.5:1• Metabolism: Hepatic Metabolism: Hepatic • If Hemodynamically stable with no history or signs and If Hemodynamically stable with no history or signs and

symptoms of heart failure:symptoms of heart failure:• IV Metoprolol 5mg q5min x 3 doses, then start 50mg IV Metoprolol 5mg q5min x 3 doses, then start 50mg

po bid and titrate up to 100mg po as toleratedpo bid and titrate up to 100mg po as tolerated• Prophylactic lidocaine – No!Prophylactic lidocaine – No!• Amiodarone for VT or VFAmiodarone for VT or VF

1) Lancet 1986:2:57-66

Page 68: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Lipid Lowering Agents• Based on the ATP 3 guidelinesBased on the ATP 3 guidelines• Patients with CAD have LDL cholesterol goal < 100 mg/dLPatients with CAD have LDL cholesterol goal < 100 mg/dL

• LDL cholesterol < 70 mg/dL: optional goalLDL cholesterol < 70 mg/dL: optional goal• All ACS patients should receive a statinAll ACS patients should receive a statin• Statins have anti-inflammatory & anti-thrombotic propertiesStatins have anti-inflammatory & anti-thrombotic properties

• lipid lowering therapy at discharge is a quality care lipid lowering therapy at discharge is a quality care indicatorindicator

68

Page 69: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Heart Disease Prevention

• Stop smokingStop smoking• Control blood pressureControl blood pressure

• Goal <140/90 mm Hg Goal <140/90 mm Hg • Goal <130/80 with chronic kidney Goal <130/80 with chronic kidney

disease or diabetesdisease or diabetes• Weight managementWeight management• Take prescribed medications at dischargeTake prescribed medications at discharge

Page 70: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Heart Disease Prevention• Weight loss and exerciseWeight loss and exercise

• 30 minutes at least 3 to 4 times a week30 minutes at least 3 to 4 times a week• Ideal BMI 18.5 to 24.9 kg/mIdeal BMI 18.5 to 24.9 kg/m2 2 = (weight in = (weight in

lbs/2.2)/ (Height in inches x 2.54/100)lbs/2.2)/ (Height in inches x 2.54/100)22

• Waist circumference Waist circumference << 40 inches in men and 40 inches in men and << 35 inches in women 35 inches in women

• Control DiabetesControl Diabetes• HbA1HbA1c c < 7%< 7%

Page 71: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Discontinuation prior to surgery

• LMWH (enoxaparin) 24 hours prior to cardiac LMWH (enoxaparin) 24 hours prior to cardiac surgery surgery

• IIb \ IIIa (tirofiban and eptifibatide) 4-8 hours off IIb \ IIIa (tirofiban and eptifibatide) 4-8 hours off prior to to cardiac surgery (No ACC\AHA prior to to cardiac surgery (No ACC\AHA guidelines)guidelines)

• Clopidogrel: 5-7 days prior to cardiac surgery Clopidogrel: 5-7 days prior to cardiac surgery

Page 72: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Case of BF• You discharge BF. What are the long term monitoring You discharge BF. What are the long term monitoring

plan for BF?plan for BF?• Seen in clinic 1 week after dischargeSeen in clinic 1 week after discharge• Monitor: vital signsMonitor: vital signs

• HR, BP, RRHR, BP, RR• Monitor labs: chem 7, CBC with platelets, LFT’s, Monitor labs: chem 7, CBC with platelets, LFT’s,

serum lipids, CKserum lipids, CK• Hb -A1Hb -A1cc

• Monitor for side effects of medications Monitor for side effects of medications

Page 73: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Minute to win it…how long to treat?Case of SO

• SO is a 85 YO M who had a NSTEMI 1 day ago and received a drug eluting stent 2 days ago.

• PHM: HTN, Renal insufficiency Scr 2.7, TIA’s 1 year ago.• Which agent is best to load with clopidogrel, prasugrel, or

ticagrelor? Why? • How long should you treat with an either of these agents?• He has repeat chest pain and now needs coronary bypass

surgery as the stents are now occluded. How long should he be off clopidogrel?

Page 74: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Minute to win it…….case• BF comes back in 4 months with repeated chest pain showing BF comes back in 4 months with repeated chest pain showing

NSTEMINSTEMI• He is taken to the cath lab where he has an occlusion of the He is taken to the cath lab where he has an occlusion of the

stent.stent.• The best management for this patient is:The best management for this patient is:

A.A. Low dose fibrinolytic therapy since he already has a stentLow dose fibrinolytic therapy since he already has a stentB.B. Increasing the daily dose of clopidogrelIncreasing the daily dose of clopidogrelC.C. Take the patient back to the cath lab for a interventionTake the patient back to the cath lab for a interventionD.D. Start the patient on Imdur 60mg daily as an outpatientStart the patient on Imdur 60mg daily as an outpatient

Page 75: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Case MR is a 90 YO who MR is a 90 YO who

presents to the ER with presents to the ER with shortness of breath and shortness of breath and dyspnea and chest pain dyspnea and chest pain

PHM: STEMI with PCI 4 yrs PHM: STEMI with PCI 4 yrs ago, HTN, hyperlipidemia ago, HTN, hyperlipidemia and depression, CHF , Hx and depression, CHF , Hx of stroke 1 yr ago of stroke 1 yr ago

Vitals: HR 78, RR 12, BP Vitals: HR 78, RR 12, BP 140/95140/95

PE: + JVD, 2+ pitting PE: + JVD, 2+ pitting edema in the LEedema in the LE

Labs: Na 120, K 4, Scr 2.7 BNP Labs: Na 120, K 4, Scr 2.7 BNP elevated at 900elevated at 900

MOA: MOA: Clopidogrel 75mg daily., aspirin 325 Clopidogrel 75mg daily., aspirin 325

daily, Toprol XL 50mg daily, daily, Toprol XL 50mg daily, atorvastatin 80mg QPM, Celexa atorvastatin 80mg QPM, Celexa 10mg daily, lisinopril 10mg Q12H, 10mg daily, lisinopril 10mg Q12H, furosemide 80mg daily, furosemide 80mg daily, spironolactone 25mg daily.spironolactone 25mg daily.

CXR: bilateral infiltrates suggesting CXR: bilateral infiltrates suggesting edemaedema

ECHO: Last EF 2 months ago = 30%ECHO: Last EF 2 months ago = 30%

Page 76: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Case This patient is still having chest pain and will be going to the This patient is still having chest pain and will be going to the

cath lab. cath lab. The team wants you to suggest a loading dose of an The team wants you to suggest a loading dose of an

antiplatelet medication. Choose the BEST answer from below:antiplatelet medication. Choose the BEST answer from below:A.A. Load with clopidogrel 300mg in preparation for the cath labLoad with clopidogrel 300mg in preparation for the cath labB.B. Load with Prasugrel 60mg po x 1 since current clopidogrel Load with Prasugrel 60mg po x 1 since current clopidogrel

dose is not workingdose is not workingC.C. Load with both clopidogrel 600mg and Prasugrel 60mg Load with both clopidogrel 600mg and Prasugrel 60mg D.D. None of the above.None of the above.

Page 77: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Summary

• Recognition of Myocardial infarction includes: Recognition of Myocardial infarction includes: patients history, ECG and Cardiac enzymespatients history, ECG and Cardiac enzymes

• Medications used in the acute phase are focused Medications used in the acute phase are focused on PCI, thrombolytics and antiplatelet medications.on PCI, thrombolytics and antiplatelet medications.

• Medications upon discharge should include: Aspirin, Medications upon discharge should include: Aspirin, Statin, ACE or ARB, Beta-blocker and PY12 Statin, ACE or ARB, Beta-blocker and PY12 inhibitor (clopidogrel, prasugrel, ticagrelor) \. inhibitor (clopidogrel, prasugrel, ticagrelor) \.

Page 78: Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center

Questions?