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Acute Coronary Syndrome-In Hospital Antiplatelet Management PowerPoint Presentation

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Description : Check out this medical titled "Acute Coronary Syndrome: In Hospital Antiplatelet Management".

This medical talks about Acute Coronary Syndrome (ACS), a medical emergency caused by a blockage in the coronary arteries, which can lead to a heart attack. The goals of antiplatelet therapy in ACS management are to reduce the risk of thrombotic events, such as heart attack and stroke, and to prevent the formation of new clots in the coronary arteries.

In hospital antiplatelet management for ACS typically involves the use of aspirin and a P2Y12 receptor inhibitor, such as clopidogrel, ticagrelor, or prasugrel. The choice of P2Y12 inhibitor may depend on factors such as the patients age, risk of bleeding, and other comorbidities.

Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that irreversibly inhibits cyclooxygenase-1 (COX-1), an enzyme involved in platelet activation. Aspirin is typically given as a loading dose of 300 to 325 mg, followed by a maintenance dose of 81 to 325 mg per day.

P2Y12 receptor inhibitors block the activation of platelets by adenosine diphosphate (ADP) and prevent the formation of new clots. Ticagrelor and prasugrel are more potent than clopidogrel, but they also increase the risk of bleeding. The choice of P2Y12 inhibitor should be made based on the patients individual risk-benefit profile.

In addition to antiplatelet therapy, other treatments for ACS may include anticoagulants, such as heparin or low molecular weight heparin (LMWH), and invasive procedures, such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).

Overall, in hospital antiplatelet management for ACS is a critical component of ACS care and should be individualized based on the patients clinical characteristics and risk-benefit profile. Close monitoring of the patients clinical status and laboratory values, including platelet function testing, is also essential to ensure optimal management and minimize the risk of adverse events.

Tags : Acute Coronary Syndrome, coronary arteries, heart attack, In hospital antiplatelet management for ACS, Emergency Medicine, Emergency Medicine

Published on : Apr 14, 2023 | Views : 1149 | Downloads : 3

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Slide 1-

Acute Coronary Syndrome: In Hospital Antiplatelet Management
Slide 2-

Disclosures
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Learning Objectives At the completion of this program participants will be better able to: Apply the Canadian Cardiovascular Society antiplatelet guideline recommendations to hospitalized patients with acute coronary syndrome Recognize how patient characteristics impact the choice of antiplatelet therapy Recognize how the approach to revascularization impacts the choice of antiplatelet therapy
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Case: Mr. TC 67 yr old sedentary male with history of DM, HTN, dyslipidemia Medication: ramipril 10 mg OD, ASA 81 mg OD, simvastatin 40 mg OD, metformin 500 mg BID Presentation: new onset crescendo angina x 3 days culminating in rest pain for the past 1h No bleeding diathesis No history of TIA or stroke Weight: 80kg Exam: BP 150/85, HR 80 (sinus). No CHF; +S4 otherwise normal
Slide 5-

Mr. TC Labs: Normal CBC, electrolytes Creatinine: 112 umol/L Troponin: positive ECG:1-2 mm horizontal ST depression infero-lateral leads CXR: normal (no signs of volume overload)
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Mr. TC’s EKG
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Mr. TC Diagnosis: NSTEACS What is the CCS guideline recommended initial antiplatelet treatment?
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Metabolism of P2Y12 Receptor Antagonists Adapted from: Schomig A. NEJM. 2009;361(11):1108-1111. Effient (Prasugrel) Product Monograph March 11, 2011 version. Brilinta (Ticagrelor) Product Monograph May 26, 2011 version. Plavix (Clopidogrel) Product Monograph May 9, 2011 version.
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Properties of P2Y12 Receptor Antagonists ARR – Absolute Risk Reduction. Note: No head to head data between prasugrel and ticagrelor.
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CURE: Clopidogrel + ASA vs ASA (2001) Study design: Patients with NSTEACS with ECG changes or positive cardiac biomarkers All patients received standard therapy, including ASA Randomized to clopidogrel 300 mg load followed by 75 mg daily or placebo n=12,562 Yusuf S, et al. N Engl J Med. 2001;345(7):494-502.
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CURE (2001) Yusuf S, et al. N Engl J Med. 2001;345(7):494-502. Established DAPT, with clopidogrel + ASA as the standard of care Nonfatal MI, stroke or CV death ARR 2.1% NNT 48 Major bleeding: 3.7 vs 2.7% NNH 100 No difference in fatal bleeding
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TRITON: Prasugrel vs. Clopidogrel (2007) Study design: Patients with ACS with planned PCI Coronary anatomy defined prior to P2Y12 antagonist administration All patients received standard therapy, including ASA Randomized to prasugrel 60 mg load followed by 10 mg daily or clopidogrel 300 mg load followed by 75 mg daily n=13,608 Wiviott SD, et al. N Engl J Med. 2007;357(20):2001-2015.
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TRITON (2007) Wiviott SD, et al. N Engl J Med. 2007;357(20):2001-2015. ARR 2.2% NNT 45 Major bleeding: ARI 0.6 NNH: 166 Increase in fatal bleeding Nonfatal MI, stroke or CV death
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PLATO: Ticagrelor vs. Clopidogrel (2009) Study design: Patients with high risk ACS All patients received standard therapy, including ASA Excluded patients receiving lytics Randomized to ticagrelor 180 mg load followed by 90 mg bid or clopidogrel 300 mg load followed by 75 mg daily 46% in ticagrelor arm had already received clopidogrel load n=18,624 Wallentin L, et al. N Engl J Med. 2009;361(11):1045-1057.
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PLATO (2009) Wallentin L, et al. N Engl J Med. 2009;361(11):1045-1057. ARR 1.9% NNT 53 Nonfatal MI, stroke or CV death Non CABG major bleeding: 4.5 vs 3.8% NNH 143 No difference in fatal bleeding Months cumulative incidence of primary endpoint %
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CCS NSTEACS Antiplatelet Guideline Recommendations Tanguay J-F, et al. Can J Cardiol. 2013;29(11):1334-1345. * Prasugrel should be avoided in patients with previous TIA or stroke. A 5-mg maintenance dose of prasugrel should be considered in patients aged 75 years or older or weight < 60 kg. **Patients eligible for ticagrelor include those with at least 2 high risk criteria including: (1) ischemic ST changes on electrocardiogram; (2) positive cardiac biomarkers and (3) 1 of the following: 60 years of age or greater, previous MI or CABG, CAD > 50% stenosis in 2 vessels, previous ischemic stroke, diabetes, peripheral arterial disease, or chronic renal dysfunction. ***A 600 mg loading dose and a 150 mg daily maintenance dose of clopidogrel may be considered for the first 6 days.
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CCS Antiplatelet NSTEACS Guideline Text We recommend ASA 81 mg daily indefinitely in all patients with NSTEACS. (Strong Recommendation, High-Quality Evidence) We recommend ticagrelor 90 mg twice daily over clopidogrel 75 mg daily for 12 months in addition to ASA 81 mg daily in patients with moderate to high risk NSTEACS managed with either PCI, CABG surgery or medical therapy alone (Strong Recommendation, High-Quality Evidence) We recommend prasugrel 10 mg daily over clopidogrel 75 mg daily for 12 months in addition to ASA 81 mg daily in P2Y12 inhibitor-naïve patients with NSTEACS after their coronary anatomy has been defined and PCI planned(Strong Recommendation, High-Quality Evidence) Tanguay J-F, et al. Can J Cardiol. 2013;29(11):1334-1345.
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Mr. TC Diagnosis: NSTEACS Treatment: Receives ASA 160 mg chew, clopidogrel 300 mg, enoxaparin 1 mg/kg, metoprolol 25 mg, atorvastatin 80 mg Admitted to CCU for cardiac catheterization in morning
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Mr. TC More clopidogrel? Different P2Y12? More ASA? Tanguay J-F, et al. Can J Cardiol. 2013;29(11):1334-1345. If clopidogrel is to be continued and the patient undergoes PCI, a 150 mg daily maintenance dose of clopidogrel may be considered for the first 6 days. Ticagrelor and prasugrel are preferred ADP receptor antagonists by CCS guidelines. A switch from clopidogrel prior to discharge should be considered After an initial 160 mg load the optimal dose of ASA is 81 mg daily. No dose increase should be considered Would you make any changes to his antiplatelet therapy?
Slide 20-

CURRENT: Clopidogrel & ASA high vs standard dose (2010) Study design: Patients with ACS and ECG changes or positive cardiac biomarkers 2x2 design for dose investigation of clopidogrel & ASA Clopidogrel 600 mg load, 150 mg daily x 7 days then 75 mg daily vs 300 mg load, then 75 mg daily ASA 300-325 mg daily vs 75-100 mg daily n=25,087 Mehta SR, et al. Lancet. 2010;376(9748):1233-1243.
Slide 21-

CURRENT (2010) Conclusions Dose Comparison Double-dose clopidogrel significantly reduced stent thrombosis, CV death, MI and stroke in PCI patients. In patients not undergoing PCI, double dose clopidogrel was not significantly different. There was a modest excess in CURRENT-defined major bleeds but no difference in TIMI major bleeds, ICH, fatal bleeds or CABG-related bleeds. No significant efficacy or bleeding difference with increased ASA dose. Mehta SR, et al. Lancet. 2010;376(9748):1233-1243. How has this influenced clopidogrel dosing at your institution?
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P2Y12 Switching Regimens The only evidence to support switching P2Y12 receptor antagonists is from the PLATO trial In the PLATO trial 46% of ticagrelor subjects received clopidogrel, mainly at loading dose. They were subsequently randomized and received a loading dose of ticagrelor 180 mg within 24 hours of onset of chest pain regardless of the timing and dose of clopidogel Based on that evidence, if a switch from clopidogrel to ticagrelor is planned we suggest: Acute Phase (within 24 hours of onset of chest pain): administer loading dose of 180 mg (unless active bleeding) regardless of clopidogrel timing/dose
Slide 23-

No evidence exists to guide loading dose when switching between P2Y12 inhibitors beyond 24 hours after onset of chest pain If a switch is necessary the following are reasonable strategies, but are not evidence based Within 24 hours of onset of chest pain administer loading dose Beyond 24 hours of onset of chest pain the use of a loading dose should be determined by the ischemic and bleeding risk P2Y12 Switching Regimens
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Mr. TC What if he had a STEMI? …and primary PCI? …and thrombolysis? What if he has coronary anatomy requiring CABG?
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CLARITY: Clopidogrel vs placebo in STEMI (2005) Study design: Patients with STEMI All thrombolysed, 57% received secondary PCI All patients received standard therapy, including ASA Randomized to clopidogrel 300 mg load followed by 75 mg daily or placebo n=3491 Sabatine MS, et al. N Engl J Med. 2005;352(12):1179-89.
Slide 26-

CLARITY (2005) Sabatine MS, et al. N Engl J Med. 2005;352(12):1179-89. ARR 6.7% NNT 15 No difference in major bleeding
Slide 27-

CCS STEMI Antiplatelet Guideline Recommendations Tanguay J-F, et al. Can J Cardiol. 2013;29(11):1334-1345. * Prasugrel should be avoided in patients with previous TIA or stroke. A 5 mg maintenance dose of prasugrel should be considered in patients aged 75 years or older or weight < 60 kg. **In patients who are managed with PPCI, a 600 mg loading dose and a 150 mg daily maintenance dose of clopidogrel may be considered for the first 6 days.
Slide 28-

CCS Antiplatelet STEMI Guidelines We recommend clopidogrel 75 mg daily for at least 1 month in addition to ASA 81 mg daily in patients with STEMI who were managed with either fibrinolytic therapy or no reperfusion therapy (Strong Recommendation, High-Quality Evidence). We suggest that clopidogrel can be continued for 12 months (Conditional Recommendation, Low-Quality Evidence). We recommend either prasugrel 10 mg daily or ticagrelor 90 mg twice daily over clopidogrel 75 mg daily for 12 months in addition to ASA 81 mg daily after primary PCI (Strong Recommendation, Moderate-Quality Evidence). We recommend clopidogrel 75 mg daily for 12 months in addition to ASA 81 mg daily after primary PCI in patients who are not eligible for prasugrel or ticagrelor (Strong Recommendation, Moderate-Quality Evidence). Tanguay J-F, et al. Can J Cardiol. 2013;29(11):1334-1345.
Slide 29-

CCS Antiplatelet CABG Guidelines Typically dual antiplatelet therapy is started prior to coronary anatomy being defined If the anatomy is not amenable to PCI (eg. three vessel disease), CABG may be indicated ASA should be continued through surgery, however P2Y12 inhibition causes excess CABG bleeding and must be stopped prior to surgery If possible, hold clopidogrel and ticagrelor 5 days, prasugrel 7 days prior to surgery DAPT should be restarted within 48-72 hours after surgery when deemed safe by the cardiac surgical team
Slide 30-

CCS Antiplatelet CABG Guidelines
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Summary Dual antiplatelet therapy improves outcomes for patients with ACS Replacing clopidogrel with either ticagrelor or prasugrel improves outcomes to similar magnitude at a cost of increased bleeding Patient characteristics and revascularization method affect drug choice
Slide 32-

Supplementary material
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CCS Recommended Duration of DAPT STEMI: ST elevation myocardial infarction, DES: drug eluting stent, BMS: bare metal stent, MM: medical management 1 month 3 months 12 months
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CCS PPI Recommendation If the patient is deemed to require a PPI in combination with clopidogrel, use one least likely to inhibit CYP2C19 – pantoprozole or lansoprazole
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PPI CYP2C19 Inhibition Ogilvie BW, Yerino P, et al. Drug Metab Dispos. 2011 Nov;39(11):2020-33 Relative inhibition of CYP2C19
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PLATO Bleeding Definition Major life-threatening bleeding: fatal bleeding, intracranial bleeding, intrapericardial bleeding with cardiac tamponade, hypovolemic shock or severe hypotension due to bleeding and requiring pressors or surgery, a decline in the hemoglobin level of 5.0 g per deciliter or more, or the need for transfusion of at least 4 units of red cells. Other major bleeding: bleeding that led to clinically significant disability (e.g., intraocular bleeding with permanent vision loss) or bleeding either associated with a drop in the hemoglobin level of at least 3.0 g per deciliter but less than 5.0 g per deciliter or requiring transfusion of 2 to 3 units of red cells. Minor bleeding: bleeding requiring medical intervention but not meeting the criteria for major bleeding
Slide 37-

TRITON Bleeding Definition TIMI major bleeding not related to coronary-artery bypass grafting (CABG), non–CABG-related TIMI life-threatening bleeding, and TIMI major or minor bleeding See speakers notes for further definitions