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RxPrep
ACS + Stroke (CH 30 + 33)
| Question | Answer |
|---|---|
| 3 main types of ACS? | UA, NSTEMI, and STEMI |
| Fibrinolytics for ACS (mainly STEMI) should be given within _____ of admission. | 30 minutes |
| Fibrinolytics normal use? | Used when PCI is not available in time (within 120 minutes of admission) |
| PCI is generally recommended when? | For STEMI (almost always) and can be used for NSTEMI |
| What is MONA? | Morphine, Oxygen, Nitrates, Aspirin |
| When is oxygen indicated for ACS? | O2 sat < 90% |
| Benefits of nitrates in ACS? | ↓ preload/afterload, relieve chest pain |
| Avoid nitrates when? | Right ventricular infarction |
| Aspirin loading dose for ACS? | 162-325mg chewable |
| Beta blocker timing for ACS? | Within 24 hours |
| Avoid beta blockers in? | Decompensated HF, shock, HR <45 |
| ACE inhibitor timing for ACS? | Within 24 hours |
| ACE inhibitor indication(s)? | LVEF <40%, HTN, DM, CKD |
| Plavix loading dose for ACS? | 300–600 mg |
| Boxed warning for Plavix? | CYP2C19 poor metabolizers, less effective |
| Interactions for Plavix? | omeprazole, esomeprazole |
| MOA of plavix? | Irreversible P2Y12 inhibition |
| Prasugrel loading dose? | 60mg |
| Prasugrel maintenance dose? | 10mg daily |
| Prasugrel box warning? | Fatal bleeding |
| Prasugrel should be avoided in what age(s)? | >75 years old |
| CI for prasugrel | history of TIA or stroke |
| Prasugrel use? | ACS managed with PCI (dont use in patient who didnt have PCI) |
| Plavix should be stopped ______ before surgery | 5 days |
| Prasugrel should be stopped _______ before surgery | 7 days |
| Ticagrelor loading dose? | 180mg |
| Ticagrelor maintenance? | 90 mg BID × 1 year then 60 mg BID |
| Prasugrel Brand name | Effient |
| Ticagrelor brand name | Brilinta |
| Cangrelor brand name | Kengreal |
| Boxed warning Brilinta? | Bleeding |
| Aspirin dose with ticagrelor? | ≤ 100 mg daily |
| Ticagrelor contraindication? | History intracranial hemorrhage |
| Ticagrelor side effect? | Dyspnea |
| Ticagrelor MOA | Reversible P2Y12 inhibitor |
| Ticagrelor interaction? | Strong CYP3A4 inhibitors and inducers (just like ranolizine) |
| Cangrelor use? | PCI patients unable to take oral P2Y12 inhibitors, transition to oral P2Y12 after PCI if possible. |
| Cangrelor dose? | 30 mcg/kg bolus then 4 mcg/kg/min |
| CI for ALL P2Y12 inhibitors? | Active bleeds |
| Cangrelor duration? | 2 hours or duration of PCI |
| Cangrelor transition? | Switch to oral P2Y12 after (usually after PCI) |
| Which P2Y12 inhibitor is ONLY indicated for patients with ACS managed with PCI? | Prasugrel (Effient) |
| Which drugs are GP IIb/IIIa inhibitors? | Eptifibatide (Integrilin) and Tirofiban (Aggrastat) |
| When are GP IIb/IIIa inhibitors indicated in ACS? | Usually just given for patient with PCI, MUST be used with heparin |
| CI of Eptifibatide (Integrilin)? | Thrombocytopenia |
| Both of the GP IIb/IIIa inhibitors should be avoided when? | During active bleed |
| Eptifibatide loading dose and maintenance dose? | LD: 180 mcg/kg bolus ×2 MD: 2 mcg/kg/min infusion |
| Tirofiban loading and maintenance dose? | LD: 25 mcg/kg IV bolus MD: 0.15 mcg/kg/min |
| Which drugs are fibrinolytics? | Alteplase (Activase), Tenecteplase (TNKase), Vorapaxar (Zontivity) |
| Alteplase use? | STEMI when PCI unavailable |
| Major risks with alteplase? | Bleeding, ICH (CI in patients with history of brain hemorrhage) |
| Brand name alteplase? | Activase |
| Brand name of tenectaplase | TNKase |
| Which fibrinolytics have boxed warnings for ICH? | Alteplase and vorapaxar (tenecteplase does NOT have this box warning) |
| Duration of P2Y12 therapy after ACS event? | At least 12 months |
| Beta blocker duration after ACS? | 3 years (or indefinite if HF) |
| ACE inhibitor after ACS? | Indefinite if LVEF ≤40% |
| What are the two major categories of stroke? | Ischemic stroke and hemorrhagic stroke (most, 87% are ischemic) |
| What is a TIA sometimes called? | Mini-stroke |
| Does a TIA cause permanent brain damage? | No, symptoms resolve without permanent damage |
| Why must hemorrhagic stroke be ruled out before ischemic stroke drug therapy? | Drugs used for ischemic stroke can increase bleeding and may be harmful/fatal in hemorrhagic stroke |
| Common cardioembolic cause of ischemic stroke? | Afib |
| Which drug is our first-line agent with FDA approval for Ischemic stroke? | Alteplase (aka Activase) |
| Alteplase MOA? | Fibrinolytic, binds fibrin in thrombus and converts plasminogen → plasmin, causing fibrinolysis |
| What must we rule out before giving alteplase or tennectaplase for ischemic strokes? | Must rule out ICH and SAH |
| Guideline time window for alteplase in most patients? | Stroke symptom onset ≤4.5 hours, FDA says within 3 hours of symptoms |
| Alteplase door-to-needle goal? | Give within 60 minutes of hospital arrival |
| Alteplase dose for acute ischemic stroke? | 0.9 mg/kg IV, max 90 mg |
| How is alteplase administered? | Give 10% of calculated dose as IV bolus over 1 minute, then infuse remainder over 60 minutes |
| Alteplase max dose? | 90mg |
| Alteplase major ADR? | Major bleeding, including ICH |
| CIs to alteplase? | Active bleed, bleeding diathesis (they have a medication or condition that increases their baseline bleed risk), BP > 185/110, prior ICH, or a stroke in the last 3 months. |
| What labs would contraindicate alteplase? | INR >1.7, aPTT >40 sec, platelets <100,000/mm³, or BG <50 |
| What medication history would automatically contraindicate the use of alteplase? | If a patient took a DOAC or LMWH in the last 24-48 hours. For UFH and warfarin, it depends on their labs |
| So what is our next drug option if alteplase is CI'd? | Aspirin or (UFH/LMWH) + IPC |
| When can aspirin, UFH, or LMWH be used for ischemic strokes? | They can be used for ischemic strokes, but cannot be given within 24 hours of fibrinolytic therapy. |
| What is the BP goal AFTER alteplase is given? | Maintain <180/105 mmHg for at least 24 hours after infusion |
| When should we halt/stop an alteplase infusion? | if severe headache, acute hypertension, N/V, or worsening neuro function occurs during alteplase infusion |
| If BP is ≥220/120 and no alteplase is given, what BP reduction is considered safe in first 24 hours? | About 15% reduction |
| Blood glucose target range after stroke? | 140-180 |
| Why avoid hypoglycemia after stroke? | Hypoglycemia can mimic stroke symptoms |
| If UFH/LMWH is used after alteplase, what must be done first? | Wait at least 24 hours after alteplase is used before administering. |
| If aspirin is used for ischemic stroke, when should it be administered? | Within 48 hours of stroke, unless the patient recieved alteplase, in which case you would need to wait 24 hours |
| First-line antiplatelet options for non-cardioembolic ischemic stroke/TIA? | Aspirin, aspirin/ER dipyridamole, or clopidogrel |
| Which antiplatelet is contraindicated in patients with history of TIA/stroke? | Prasugrel |
| Why is prasugrel contraindicated with prior TIA/stroke? | Increased risk of ICH |
| When can aspirin + clopidogrel together? | Within 24 hr of minor ischemic stroke, NIHSS ≤3, if patient did not receive alteplase Max time of 21-90 days of combo use |
| Can aspirin + plavix be used for >90 days? | No, incresed risk of ICH/SAH |
| When can ticagrelor + aspirin be considered? | Minor to moderate stroke, NIHSS ≤5 |
| Maximum duration for ticagrelor + aspirin after minor/moderate stroke? | 30 days |
| Dipyridamole MOA? | Inhibits adenosine uptake into platelets and increases cAMP, reducing platelet aggregation |
| Clopidogrel MOA? | Prodrug that IRREVERSIBLY inhibits P2Y12 ADP-mediated platelet activation |
| Yosprala contains what? | Aspirin + omeprazole |
| Aspirin contraindications? | NSAID/salicylate allergy, children/teens with viral infection, nasal polyps/asthma with urticaria/angioedema/bronchospasm risk |
| Key warning sign of aspirin overdose? | Tinnitus |
| What is Aggrenox? | Aspirin + extended-release dipyridamole |
| Key warning of Aggrenox? | Hypotension, headache, and chest pain due to vasodilation from dipyridamole |
| Is Aggrenox interchangable with individual components? | NO |
| Is the aspirin dose in Aggrenox adequte for MI prevention? | NO, each dose contains 200mg/25mg of dipyridamole/aspirin, which only provides 50mg daily of aspirin with BID dosing. |
| Box warning for plavix? | Reduced effectiveness in CYP2C19 poor metabolizers |
| When should clopidogrel be stopped before elective surgery? | 5 days prior |
| Clopidogrel unique warning? | Thrombotic thrombocytopenic purpura / TTP |
| Major DDI concern with Plavix? | Omeprazole and esomeprazole (2C19 inhibition) |
| What are the main types of hemorrhagic stroke? | Intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) |
| Should anticoagulants be used while a patient is actively bleeding from hemorrhagic stroke? | NO |
| If we cant use anti-platelets in ICH/SAH patients, what can we do to prevent DVT? | Use IPC devices |
| What do we do with a ICH/SAH patient who is currently taking anticoagulants? | Stop anticoags and reverse when appropriate |
| What ICH should patients with severe coagulation factor deficiency or thrombocytopenia receive? | Factor replacement or platelet transfusion, as appropriate |
| Should prophylactic antiseizure meds always be used in ICH? | No, only if seizures occur |
| Drug options to lower an elavated ICP during an ICH? | Hypertonic saline (3% or 23.4%) or mannitol |
| How do mannitol/hypertonic saline lower ICP during an ICH? | Increase plasma osmolality → draw water out of brain tissue |
| Mannitol brand? | Osmitrol |
| Mannitol indication in stroke? | For ICH/brain edema |
| Mannitol dosing for ICH? | 0.25-1 g/kg IV q6-8 hours AS NEEDED |
| Preferred dosing/timing for mannitol? | Intermittent boluses are preferred over continuous infusions |
| Mannitol contraindications? | Severe renal disease/anuria (needs urine for drug to work), severe hypovolemia (can cause hypovolemia), pulmonary edema/congestion, active intracranial bleeding except during craniotomy |
| How does mannitol work? | It increases osmolarity in the bloodstream, pulls water from interstitial spaces (initial hypervolemia in the plasma), then it gets flushed out by the kidneys (similar to a diuretic) |
| Major warnings with mannitol? | Can cause rebound increased ICP (CNS toxicity) Is a vexicant (can cause extravasation) |
| Important electrolyte/renal issues with mannitol? | Nephrotoxicity, dehydration, hyperkalemia, acidosis |
| Mannitol monitoring? | Renal function, daily I/O, electrolytes, serum/urine osmolality, ICP, CPP |
| What is a key thing you must do before dispensing/administering mannitol? | Check for crystals, if present, warm the solution to redissolve them. Use a filtered needle if using 20% mannitol |
| What is SAH? | Bleeding into the subarachnoid space |
| Cerebral artery vasospasm after SAH can occur when? | 3-21 days after the bleed |
| What drug improves outcomes related to vasospasm-induced ischemia after SAH? | Oral nimodipine, a D-CCB |
| Brand name of nimodipine? | Nymalize |
| Why is nimodipine preferred for SAH? | It is selective for cerebral arteries |
| Nimodipine dosing? | Normal dosing: 60mg PO q4h x 21 days cirrhosis dosing: 30mg PO q4h x 21 days |
| Nimodipine administration timing? | Empty stomach, at least 1 hour before or 2 hours after meals |
| Nimodipine boxed warning? | Do NOT give IV or other parenteral route, can cause severe hypotension, CV collapse, death, etc |
| Major ADR with nimodipine? | Hypotension |
| DDI concerns for nimodipine? | Contraindicated with strong 3A4 inhibitors Avoid with strong 3A4 inducers as well |
| Nimodipine monitoring? | CPP, ICP, BP, HR, neurologic checks |
| What do we do if a patient cant swallow nimodipine capsules? | Capsule contents can be withdrawel with a syringe transfered to an oral syringe and given orally or in a NG tube |
Created by:
cdaughtry