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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
Amsterdam E. JACC. 2014
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.
In-Hospital Management
Acute Stabilization
UA/NSTEMI
Early Revascularization
Medical Management
STEMI
Revascularization
Amsterdam E. JACC. 2014
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Invasive 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
Prasugrel 60 mg
Maintenance dose, continued for at least 12 months
Clopidogrel 75 mg daily
Ticagrelor 90 mg/twice daily
Prasugrel 10 mg daily
Amsterdam E. JACC. 2014
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
0.15 mcg/kg/min infusion
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
Wiviott. NEJM. 2007.
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
Wiviott. NEJM. 2007.
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
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
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
In-Hospital Management
Acute Stabilization
UA/NSTEMI
Early Revascularization
Medical Management
STEMI
Revascularization
Amsterdam E. JACC. 2014
Invasive TherapyAspirin
Loading dose, non-enteric coated 325 mg
Maintenance dose, continued indefinitely 81 – 325 mg daily
P2Y12 inhibitors
Loading dose, as soon as possible or at the time of PCI
Clopidogrel 300 – 600 mg
Ticagrelor 180 mg
Prasugrel 60 mg
Maintenance dose, continued for at least 12 months
Clopidogrel 75 mg daily
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
0.125 mcg/kg/min infusion
Tirofiban 25 mcg/kg IV bolus
0.15 mcg/kg/min infusion
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
Pharmacist Assessment
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
Pharmacist Assessment
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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