Pharmacist Objectives Technician Objectives · 2019-10-01 · death, nonfatal MI, or stroke • Secondary outcomes: severe ischemia, heart failure, and need for revascularization

9/27/2019

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Don’t Break My Heart: Acute Coronary Syndromes

Chancey Carothers, PharmD, BCCCPClinical Pharmacy Specialist, Critical Care Medicine

Orlando Regional Medical Center

www.fshp.org

Disclosure

I do not (nor does any immediate family member) have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias this presentation.

Pharmacist Objectives

• Recall diagnostic differences between unstable angina (UA), non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI)

• Define appropriate emergency room treatment principles for acute coronary syndromes (ACS)

• State clinical controversies in the early management of ACS

• Summarize pharmacotherapy used for in-hospital treatment of ACS

• Outline the major pharmacotherapeutic differences in the management of UA/NSTEMI and STEMI

Technician Objectives

• Distinguish differences in acuity in patients presenting with UA, NSTEMI, or STEMI

• Identify medications commonly used in the emergency room for acute coronary syndromes

• List adjunctive medications used in percutaneous coronary interventions

Scope of the Problem

• Healthcare burden:– $150 billion/year in direct and indirect costs

– Mortality 18-23% over the age of 40 within 1 year of initial event

– 20% of patients are re-hospitalized within 1 year

• Hospital burden:– 10-15% of all visits are chest pain related

– 2-5% receive a final diagnosis of ACS

– 1.5 million discharges

Kolansky D. Am J Managed Care. 2009Galli C. Ann Transl Med. 2016

Acute Coronary Syndrome

• Sudden imbalance of myocardial oxygen consumption and demand

• Constellation of symptoms reflecting ischemicchanges in coronary arteries – Anxiety

– Chest pain

– Diaphoresis

– Dyspnea

– Referred pain (arm, jaw, back)

– Nausea & Vomiting

Amsterdam E. Circulation. 2014

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Libby P. NEJM. 2013

Acute Coronary Syndromes

• Unstable angina– Ischemic symptoms without cardiac biomarkers

• NSTEMI– Ischemic symptoms with cardiac biomarkers

• STEMI– Ischemic symptoms with persistent ST-elevation and

cardiac biomarkers

EKG Goals

• STAT 12- lead EKG and interpretation within 10 minutes of presentation

• Serial EKGs every 15-30 minutes if symptoms continue

• Pre-hospital, electronic transmission has greatly improved response times

Troponins

• Structural components of myofilaments regulating muscle contraction

• Muscle damage (i.e. ischemia) results in the spillage of troponins C, I, and T into circulation

• 1980’s- 1st cardio selective radioimmunoassay– Detects cardiac isoforms of I and T

– Rapid results in <15 minutes

• Troponins > 0.05 ng/ml are suggestive of some process, >0.4 ng/ml reflects increased mortality

Galli C. Ann Transl Med. 2016. Antman EM. NEJM. 1996 Bolooki H.M. Cleveland Clinic. 2010

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Pharmacist Question

A 55 year old woman presents to the ED with upper abdominal pain radiating to the back. A STAT EKG is ordered and shows ST-depression and labs return with a troponin of 3 ng/ml. Which of the following is the most likely etiology of the abdominal pain?

a) Unstable angina

b) STEMI

c) NSTEMI

d) Gastroparesis

Pharmacist Question

A 55 year old woman presents to the ED with upper abdominal pain radiating to the back. A STAT EKG is ordered and shows ST-depression and labs return with a troponin of 3 ng/ml. Which of the following is the most likely etiology of the abdominal pain?

a) Unstable angina

b) STEMI

c) NSTEMI

d) Gastroparesis

Clinical Pathways: STEMI

Confirmed STEMI

Non-PCI capable hospital

DIDO≤30 minutes: transfer

DIDO>30 minutes:

Fibrinolytics

PCI capable hospital

Reperfusion Intervention

PCI: percutaneous interventionDIDO: Door-in, Door-out

Clinical Pathways: UA/NSTEMI

Chest Pain +/-EKG changes

Low risk symptoms/scoring

Chest Pain Center

Observation Unit

High risk symptoms/scoring

Ischemia guided treatment

Early intervention

Risk Factors & Scoring

• Risk factors– Age

– Male sex

– Prior/Family history

– Peripheral artery disease

– Diabetes mellitus

– Smoking

• Validated prognostic scores:– Thrombolysis in Myocardial Infarction (TIMI)

– Global Registry of Acute Coronary Events (GRACE)

– Heart (History, ECG, Age, Risk Factors, Troponin)

– Hess prediction rule

EMERGENCY DEPARTMENT MEDICAL MANAGEMENT

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Emergency management

• Oxygen supplementation in hypoxemia or respiratory distress (saturation <90%)

• Aspirin 162-325 mg chewable x 1

• Nitroglycerin 0.4 mg sublingual q 5 minutes x 3 doses

• STAT EKG transmitted to receiving hospital

• Morphine, Oxygen, Nitroglycerin, Aspirin

Amsterdam E. Circulation 2014

Beta-blockers in ACS

• Reduces infarct size and mortality when started early in STEMI patients

• COMMIT trial– 45,852 patients with suspected MI randomized to

metoprolol or placebo

– IV metoprolol/placebo given immediately on suspected diagnosis

– Primary outcome: Death/re-infarction/cardiac arrest, NS

– Secondary outcomes (metoprolol vs placebo):• Re-infarction 2.0% vs 2.5% (p=0.001)

• Ventricular fibrillation 2.5% vs 3.0% (p=0.001)

• Cardiogenic shock 5% vs 3.9% (p<0.00001)Xie J. Lancet 2005

Parenteral Anticoagulation-NSTEMI

Study Patients Intervention Results Misc.ESSENCE.1997.

• 3171 patients with UA/NSTEMI

• Randomized, double-blind

Enoxaparin 1mg/kg q 12 vs UFH bolus & drip titrated to aPTT

• Death, MI, or recurrent angina in 14 days: 19.8% vs 16.6%, p=0.02

• Minor hemorrhage 7.2% vs 11.9%, p<0.001

• UFH not weight based

• Treatment duration 2-8 days

• No DAPT use

SYNERGY. 2004.

• 9,978 high risk patients with NSTEMI

• Randomized, open-label

Enoxaparin 1 mg/kg q 12 h vs weight based UFH bolus & drip titrated to aPTT

• All cause death or nonfatal MI: 14% vs 14.5%, p=NS

• Major bleeding 9.1% vs 7.6%, p=0.008

• No difference in transfusions

• Patients were intended for early invasive therapy

Enoxaparin and UFH

• Benefits of anticoagulation have limited evidence in the setting of recent changes in practice

• The use of P2Y12 antagonists (clopidogrel, ticagrelor) may increase clinically significant bleeding risks

• Unfractionated heparin adverse events are easier to mitigate in the acute setting

• Fondaparinux may be an alternative in heparanoid allergic patients

Mayer M. Am J Em Med. 2017Yusuf S. NEJM. 2004

Amsterdam E. Circulation 2014

Pharmacist Question

Which of the following medical treatments should be initiated FIRST for an NSTEMI?

a) Oxygen supplementation in a non-hypoxic patient

b) Fentanyl for chest pain

c) Nitroglycerin sublingual for chest pain

d) Morphine for chest pain

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Pharmacist Question

Which of the following medical treatments should be initiated FIRST for an NSTEMI?

a) Oxygen supplementation in a non-hypoxic patient

b) Fentanyl for chest pain

c) Nitroglycerin sublingual for chest pain

d) Morphine for chest pain

Fibrinolytic management- STEMI

• MOA: Dissolution of thrombus causing ischemic damage by inducing fibrinolysis converting plasminogen to plasmin

• Consider in patients in non-PCI capable hospitals– When FMC to Needle > 120 minutes

– Give within 30 minutes of FMC

• Contraindications

Clinical Pearls of Early Management

• Beta blockers should be held until patients are stable

• The benefits of enoxaparin vs UFH are not as well established

• Ischemia guided, NSTEMI patients may require additional care (i.e. nitroglycerin drips)

• STEMI patients may be at high risk for sudden cardiac death and require close monitoring until in the Cath lab

Technician Question

Which of the following medications and dosage are NOT appropriate for a patient with a confirmed NSTEMI?

a) Heparin 5000 units

b) Enoxaparin 1 mg/kg

c) Heparin drip

d) Fondaparinux 2.5 mg

Technician Question

Which of the following medications and dosage are NOT appropriate for a patient with a confirmed NSTEMI?

a) Heparin 5000 units

b) Enoxaparin 1 mg/kg

c) Heparin drip

d) Fondaparinux 2.5 mg

Technician Question

Which of the following patients would most likely need STAT medications delivered to the Emergency room?

a) Hemodynamically stable patient with UA

b) STEMI patient with plans for STAT intervention

c) NSTEMI patient with severe chest pain

d) All of the above

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Technician Question

Which of the following patients would most likely need STAT medications delivered to the Emergency room?

a) Hemodynamically stable patient with UA

b) STEMI patient with plans for STAT intervention

c) NSTEMI patient with severe chest pain

d) All of the above IN-HOSPITAL ACUTE MANAGEMENT

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Acronyms

• PCI: percutaneous coronary intervention

• CABG: coronary artery bypass graft

• DAPT: dual antiplatelet therapy

• ACT: activated clotting time

In-Hospital Management

Acute Stabilization

UA/NSTEMI

Early Revascularization

Medical Management

STEMI

Revascularization

Amsterdam E. JACC. 2014

Platelet Activation

http://what-when-how.com/acp-medicine/hemostasis-and-its-regulation-part-1/

Platelet Inhibition Targets

Pignone. Nature Reviews Endocrinology. 2010.

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Medical Management TherapyAspirin

Loading dose, non-enteric coated 325 mg

Maintenance dose, continued indefinitely 81 – 325 mg daily

P2Y12 inhibitors

Loading dose Clopidogrel 300 – 600 mg

Ticagrelor 180 mg

Maintenance dose, continued for at least 12 months

Clopidogrel 75 mg daily

Ticagrelor 90 mg twice daily

Parenteral anticoagulants

Enoxaparin, subcutaneous- duration of stay/PCI

1 mg/kg twice daily

Fondaparinux, subcutaneous- duration of stay/PCI

2.5 mg daily

Unfractionated heparin- up to 48 hours/PCI Per cardiac protocol


Antiplatelet Management with No Planned Intervention

• 12,562 patients who presented within 24 hrs of ACS onset without ST-segment elevation

• All patients received aspirin (75-325 mg daily)– Study group: 6259 patients given 300 mg clopidogrel, followed

by 75 mg daily– Placebo group: 6303 patients

• Study treatment duration– Aspirin indefinitely, study drug for 3-12 months– Mean duration of 9 months

• Primary outcome: composite of cardiovascular related death, nonfatal MI, or stroke

• Secondary outcomes: severe ischemia, heart failure, and need for revascularization

Yusuf S. NEJM. 2001.

Results

• Primary outcome significantly reduced in clopidogrel group (9.3% vs 11.4%, p< 0.001)

• Reduced secondary outcomes in clopidogrel group– Severe ischemia (2.8% vs 3.8%, p= 0.01)

– In hospital revascularization (20.8% vs 22.7%, p= 0.03)

– Heart failure (3.7% vs 4.4%, p= 0.03)

• More major bleeding in clopidogrel group (3.7% vs 2.7%, p= 0.001)– No difference in life threatening bleeding

– Higher rates of minor and non-life threatening, severe bleeding

Yusuf S. NEJM. 2001. Yusuf S. NEJM. 2001.

What About Prasugrel?

• No recommendation for prasugrel in UA/NSTEMI guidelines for patients with ischemia-driven, conservative approach

• “Up-front” use of prasugrel found to increase bleeding rates with no improvement in outcomes

Amsterdam. JACC. 2014Montalescot. NEJM. 2013.


Acute Stabilization

UA/NSTEMI


Medical Management

STEMI

Revascularization


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Invasive TherapyAspirin



P2Y12 inhibitors

Loading dose Clopidogrel 300 – 600 mg

Ticagrelor 180 mg

Prasugrel 60 mg



Ticagrelor 90 mg/twice daily

Prasugrel 10 mg daily


Invasive Therapy, continuedParenteral anticoagulants

Enoxaparin, subcutaneous- duration of stay/PCI 1 mg/kg twice daily

Bivalirudin- until angiography/PCI 0.75 mg/kg IV bolus

1.75 mg/kg/h infusion

Fondaparinux, subcutaneous- duration of stay 2.5 mg daily

Unfractionated heparin- up to 48 hours/PCI Per cardiac protocol

GP IIb/IIIa inhibitors

Abciximab 0.25 mg/kg IV bolus

0.125 mcg/kg/min infusion

Tirofiban 25 mcg/kg IV bolus


Eptifibitide 180 mcg/kg IV bolus x2

2 mcg/kg/minAmsterdam E. JACC. 2014

Prasugrel in ACS (TRITON Study)

• 13,608 patients with ACS scheduled for PCI• Aspirin 75-162 mg, plus intervention

– Clopidogrel: 300 mg load, 75 mg daily– Prasugrel: 60 mg load, 10 mg daily

• Study treatment duration: 6-15 months• Primary endpoint: composite of cardiovascular

related death, nonfatal MI, or stroke• Safety endpoint: Major/life threatening bleeding

not related to CABG and major and minor bleeding

Wiviott. NEJM. 2007.

TRITON ResultsResult Clopidogrel (n= 6716) Prasugrel (n= 6741) p value

Primary endpoint 12.1% 9.9% <0.001

Cardiovascular death 2.4% 2.1% 0.31

Nonfatal MI 9.5% 7.3% <0.001

Nonfatal stroke 1.0% 1.0% 0.93

Death from any cause 3.2% 3.0% 0.64

Stent thrombosis 2.4% 1.1% <0.001

Non-CABG major bleeding

1.8% 2.4% 0.03

Major or minorbleeding

3.8% 5.0% 0.002

Bleeding requiring transfusion

3.0% 4.0% <0.001


TRITON Results

• Subgroup analysis performed revealed no benefit from/harm from prasugrel in certain populations– History of stroke or TIA: no clinical benefit, net harm

(mostly due to bleeding)

– Age ≥75 years: no benefit over clopidogrel

– Body weight <60 kg: no benefit over clopidogrel

• Among patients without these risk factors– Prasugrel more effective than clopidogrel

– No significant difference in bleeding


Ticagrelor in ACS (PLATO Study)

• 18,624 patients with ACS in the previous 24 hours

• Aspirin 75-100 mg, plus intervention– Clopidogrel

• 300 mg load (if not on previously), then 75 mg daily

• Additional 300 mg load with PCI

– Ticagrelor• 180 mg load, 90 mg twice daily

• Additional 90 mg dose with PCI >24 hours from admission

• Study treatment duration: 12 months

• Primary endpoint: composite of death from vascular cause, MI, or stroke

• Safety endpoint: first occurrence of any major bleeding

Wallentin. NEJM. 2009.

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PLATO Results

Result Clopidogrel (n= 9291) Ticagrelor (n= 9333) p value

Primary end point 11.7% 9.8% <0.001

MI 6.9% 5.8% 0.005

Death from vascular causes 5.1% 4.0% 0.001

Stroke 1.3% 1.5% 0.22

Mortality 5.9% 4.5% <0.001

Major bleeding 11.2% 11.6% 0.43

Fatal intracranial bleeding 0.01% 0.1% 0.02

Dyspnea 7.8% 13.8% <0.001

Discontinuation of medication

21.5% 23.4% 0.002

Wallentin. NEJM. 2009.

Ticagrelor and Aspirin

• Ticagrelor superior to clopidogrel everywhere except North America

• Median aspirin dose ≥300 mg/day in 54% of North America patients vs <2% elsewhere

• No benefit from ticagrelor seen in subgroup analysis of patients with aspirin doses >100 mg/day

• FDA black box warning: maintenance doses of aspirin above 100 mg reduce the effectiveness of ticagrelor and should be avoided

DAPT SelectionClopidogrel Prasugrel Ticagrelor

Advantages

Once daily administration Once daily administration More efficacious than clopidogrel

Cheapest option More efficacious thanclopidogrel

No activation required

Lack of drug interactions Lack of drug interactions

Disadvantages

Less effective Higher risk of bleeding Twice daily administration

Prodrug that requires activation

More expensive More expensive

Drug interactions*

Coronary Stents

Bare Metal Stent (BMS)

• No drug released by stent

• High risk of short term in stent thrombosis

• High risk of long term in stent restenosis

• DAPT recommended for 12 months

Drug Eluting Stent (DES)

• Slowly releases paclitaxel, sirolimus, or evirolimus

• Reduces the risk of long term in stent restenosis

• Increases the long term risk of in stent thrombosis

• DAPT therapy recommended for at least12 months

Yin. Theranostics. 2014.https://sites.ualberta.ca/~rmclean/stentweb2.jpg

Coronary Stents

Bare Metal Stent (BMS)

• No drug released by stent

• High risk of short term in stent thrombosis

• High risk of long term in stent restenosis

• DAPT recommended for 12 months

Drug Eluting Stent (DES)

• Slowly releases paclitaxel, sirolimus, or evirolimus

• Reduces the risk of long term in stent restenosis

• Increases the long term risk of in stent thrombosis

• DAPT therapy recommended for at least12 months

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Pharmacist Assessment

Which of the following dual antiplatelet regimens would be appropriate for a patient who just received a drug eluting stent?A. Aspirin 81 mg daily plus prasugrel 10 mg dailyB. Clopidogrel 75 mg daily plus ticagrelor 90 mg

twice dailyC. Aspirin 325 mg daily plus ticagrelor 90 mg twice

dailyD. Prasugrel 10 mg daily plus ticagrelor 90 mg

twice daily


Which of the following dual antiplatelet regimens would be appropriate for a patient who just received a drug eluting stent?A. Aspirin 81 mg daily plus prasugrel 10 mg dailyB. Clopidogrel 75 mg daily plus ticagrelor 90 mg

twice dailyC. Aspirin 325 mg daily plus ticagrelor 90 mg twice

dailyD. Prasugrel 10 mg daily plus ticagrelor 90 mg

twice daily

Technician Assessment

Which of the following antiplatelet agents is not appropriate in a patient who just received a stent for ACS?

A. Ticagrelor

B. Clopidogrel

C. Prasugrel

D. Ticlopidine

Technician Assessment

Which of the following antiplatelet agents is not appropriate in a patient who just received a stent for ACS?

A. Ticagrelor

B. Clopidogrel

C. Prasugrel

D. Ticlopidine


Acute Stabilization

UA/NSTEMI


Medical Management

STEMI

Revascularization


Invasive TherapyAspirin



P2Y12 inhibitors

Loading dose, as soon as possible or at the time of PCI

Clopidogrel 300 – 600 mg

Ticagrelor 180 mg

Prasugrel 60 mg



Ticagrelor 90 mg/twice daily

Prasugrel 10 mg daily

O’Gara P. JACC. 2013.

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Invasive Therapy, continuedParenteral anticoagulants

Bivalirudin 0.75 mg/kg IV bolus

1.75 mg/kg/h infusion

Unfractionated heparin 50-70 units/kg with GP IIb/IIIainhibitor use

70-100 units/kg without GP IIb/IIIa inhibitor use

GP IIb/IIIa inhibitors

Abciximab 0.25 mg/kg IV bolus


Tirofiban 25 mcg/kg IV bolus


Eptifibitide 180 mcg/kg IV bolus x2

2 mcg/kg/min

O’Gara P. JACC. 2013.

Adjunctive Anticoagulation

Unfractionated Heparin

• Potentiates antithrombin III, inactivating thrombin and the conversion of fibrinogen to fibrin

• Given as boluses in cath lab to maintain goal ACT (generally 200-350 s)

• Reversible

Bivalirudin• Direct thrombin inhibitor,

preventing conversion of fibrinogen to fibrin

• Given as bolus followed by infusion during PCI

• May be continued up to 4 hours post PCI

• No reversal agent (half life 30-60 min depending on renal function)

Heparin vs BivalirudinStudy Patients Intervention Results Misc.Horizons-AMI.2008.

• 3602 patients with STEMI within 12 hours of presentation

• Planned to undergo PCI treatment

Heparin + GP IIb/IIIa inhibitor vs bivalirudin,ending at completion of PCI

• 30 day adverseclinical events: 12.1% heparin group vs 9.2% bivalirudin group*

• Lower major bleeding in bivalirudin group*

• Lower mortality in bivalirudin group (2.1%vs 3.1%)*

• Clopidogrel utilized in ~99% of patients for DAPT

• Adverse clinical events: major bleeding, death, reinfarction, need for revascularization, and stroke

Heat-PPCI. 2014.

• 1829 patients presenting to the primary PCI (PPCI) service

Heparin vs bivalirudin, GP IIb/IIIa inhibitor used permitted for bailout therapy

• Major adversecardiac event (MACE): 8.7% bivalirudin group vs 5.7% heparin group*

• Higher stent thrombosis rate in bivalirudin group*

• No difference in major bleeding rate

• Ticagrelor or prasugrel utilized in ~90% of patients for DAPT

• MACE: mortality, stroke, reinfarction, unplanned revascularization

• GP IIb/IIIa inhibitor usage similar in both groups (~10%)

*Indicates statistical significanceStone. NEJM. 2008.Shahzad. Lancet. 2014.

Heparin vs BivalirudinStudy Patients Intervention Results Misc.Cavender.2014.

• Meta-analysis• 16 trials involving

33958 patients with planned PCI

Included studies that randomized patients to heparin or bivalirudin, with or without GP IIb/IIIa inhibitors

• Increased risk of MACE with bivalirudin based regimens vs heparin based regimens (8% vs 7%)*

• Lower risk of major bleeding in bivalirudin groups*

• Bleeding rates only different if heparin used with GP IIb/IIIa inhibitors

Matrix.2015.

• 7213 patients with ACS with planned PCI

Heparin vs bivalirudin(through end of PCI vs post-PCI infusion, up to 4-6 hours)

• No difference in rates of MACE or adverse cardiovascular events

• No benefit seen with post-PCI bivalirudin infusion

• Less bleeding and major bleeding in bivalirudin group *

• MACE: death, MI, or stroke

• Adverse cardiovascular events: major bleeding or MACE

• Ticagrelor or prasugrel utilized in majority of patients for DAPT

• GP IIb/IIIa inhibitor usage higher in heparin group*

*Indicates statistical significanceValgimigli. NEJM. 2015.Cavender. Lancet. 2014.

Heparin vs Bivalirudin

• Superiority of one agent over the other not established

• Usage of more potent P2Y12 inhibitors may negate benefit originally seen with bivalirudin

• Factors affecting choice of agent:– Cost

– Choice of DAPT

– Risk of bleeding/catheterization access approach• Femoral

• Radial

GP IIb/IIIa Inhibitor Use

• Majority of trials showing benefit performed before routine use of P2Y12 inhibitors as DAPT

• Introduction of more potent P2Y12 inhibitors (ticagrelor and prasugrel) calls into question the need for IIb/IIIa inhibitor use

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GP IIb/IIIa InhibitorsHorizons-AMI Heat-PPCI Cavender, et al Matrix

Use of IIb/IIIainhibitors

Used in all heparin patients, “bail-out” in bivalirudin

Only allowed as “bail-out” in both groups (~10% use)

N/A Usagesignificantly higher in heparin group

DAPT selection

~99%clopidogrel

~90% prasugrelor ticagrelor

N/A Prasugrel and ticagrelor in majority of patients

Results Bivalirudin more effective with less bleeding

Heparin more effective but no difference in bleeding

Heparinmarginally better, but with more bleeding in combination with GP IIb/IIIa inhibitors

No difference in outcomes but less bleeding with bivalirudin

Stone. NEJM. 2008. Shahzad. Lancet. 2014. Valgimigli. NEJM. 2015.Cavender. Lancet. 2014.

Use of GP IIb/IIIa Inhibitors

• Guideline recommendation- “reasonable”– Large thrombus burden

– Inadequate P2Y12 loading

• Adjunctive use with bivalirudin not recommended unless as “bail-out” therapy


For which patient would “up-front” use of a GP IIb/IIIainhibitor be inappropriate?

A. STEMI patient who only received aspirin in the emergency room

B. STEMI patient who received an aspirin and ticagrelorload in the emergency room

C. STEMI patient who is found to have a large clot burden during catheterization

D. STEMI patient who has in-stent thrombosis immediately after deployment while in the cath lab


For which patient would “up-front” use of a GP IIb/IIIainhibitor be inappropriate?

A. STEMI patient who only received aspirin in the emergency room

B. STEMI patient who received an aspirin and ticagrelorload in the emergency room

C. STEMI patient who is found to have a large clot burden during catheterization

D. STEMI patient who has in-stent thrombosis immediately after deployment while in the cath lab

ACS Chronic Therapy

• Beta blockers initiated within 24 hours and continued outpatient unless contraindicated

• Angiotensin converting enzyme inhibitors or angiotensin receptor antagonists initiated in patients with hypertension and/or low ejection fraction (<40%)

• High intensity statin initiated and continued

O’Gara P. JACC. 2013.Amsterdam E. JACC. 2014

In Hospital ACS Management

• Dual antiplatelet therapy essential for prevention of in-stent thrombosis– Efficacy and safety profiles unique to each medication

– Choice of agent dependent on patient specific factors

• Anticoagulation required to prevent thrombosis during procedure– Heparin and bivalirudin acceptable options

– Conflicting data precludes selecting best agent

• Use of GP IIb/IIIa inhibitors largely outdated due to new, more potent antiplatelet agents

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QUESTIONS?

Don’t Break My Heart: Acute Coronary Syndromes

Chancey Carothers, PharmD, BCCCPClinical Pharmacy Specialist, Critical Care Medicine

Orlando Regional Medical Center

www.fshp.org

Levine. Nature Reviews Cardiology. 2014.

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Documents

Pharmacist Objectives Technician Objectives · 2019-10-01 · death, nonfatal MI, or stroke • Secondary outcomes: severe ischemia, heart failure, and need for revascularization