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Acute Coronary Syndrome (ACS) Matt Hafermann, PharmD, BCPS Cardiology Clinical Pharmacist University of Washington Medical Center OBJECTIVES 1. 2. 3. 4. Introduction and background to ACS Outline treatment strategies for ACS Review medications used in acute coronary syndromes Discuss quality performance medications used upon discharge from the hospital after a myocardial infarction Cardiovascular Disease • • • Number one killer of Americans: • Estimated 785,000 cases of CVD annually in the US • Coronary heart disease responsible for 1 in 6 deaths in the US • 470,000 recurrent attacks • 195,000 silent MIs ~34% of Americans have metabolic syndrome $297.7 billion- Associated cost of CVD and related conditions Circulation 2012:125 Progression and Terminology of ACS Plaque Disruption/Fissure/Erosion Thrombus Formation UA STEMI STEMI Progression Source: American Heart Association Case study MR • • • • MR is a 76 YO male who comes to the ER complaining of 10\10 chest pain. He started to have chest pain 3 hours ago while watching TV He states that it feels like “an elephant is on my chest” PMH: Hypertension, diabetes, former smoker 1ppd x 20 years FH: Father died at age 80 of a stroke SH: retired, spends a lot of time watching TV • • • Medications upon admission • Aspirin 325mg QD • Atorvastatin 20mg QPM • Lisinopril 5mg daily • Glyburide 5mg daily • Sildenafil 25mg prn ED Allergies: PCN Physical exam: • Vitals: BP 140\100 HR 100 RR 24 O2 sat 98% RA, weight = 111 kg • Ashen, diaphoretic, anxious • Normal heart sounds Case study MR • • ECG: sinus tachycardia with ST segment depression in the anterior leads suggesting ischemia CXR: No apparent edema, normal heart size • • • Labs: CK-MB elevated at 10 ng\mL, first Troponin 0.7ng\mL (+) ROS: Patient’s current chest pain is now 7\10 and he is in distress Assessment: admit with rule out MI (ROMI) protocol : serial enzymes, ECG Risk factors of Heart Disease • • • • • • • • • Male Smoking Family history Hypertension Diabetes Elevated lipids Obesity Lack of exercise Chronic kidney disease Determining a Treatment Plan History and physical Biochemical markers ECG Determine treatment plan STEMI vs Non-STEMI? “tombstones” Interpretation • • • • ST segment elevation = acute injury • >1mm in 2 consecutive leads ST segment depression • >1mm = ischemia High risk unstable angina Non-ST segment elevation MI Locations: anterior, lateral, and inferior Initial Recognition and Management • • • Quality of chest pain: • 10/10 chest pain , crushing band-like • 20% of patients have “prodromal” Pain at rest, change in pattern Physical exam • • Ashen, diaphoretic Presence of risk factors Laboratory Findings • Troponin is the gold standard • Troponin q6h x 3 values • CK-MB helpful for reinfarction • Monitor until levels have plateaued or you get 2 negative values • Troponin-I value of >0.4ng\mL is suggestive of myocardial infarction • Can be laboratory dependent Cardiac Enzymes Relationship Between Degree of Troponin Elevation and Likelihood for Long-term Mortality % mortality at 42 days 8 6 4 2 0 <0.4 <1.0 <2.0 Troponin levels Antman EM, it al. N Engl J Med. 1996; 335: 1342-1349. <5.0 <9.0 9.0 Case of MR- Treatment Options • • The ER attending decides to admit this patient and wants to start to initiate therapy in the ER. What we know so far: • + ECG for ST segment depression in the anterior leads • + History and physical findings • + First troponin and CK • • • What are the treatment goals for MR? Devise a pharmacotherapeutic strategy to be initiated in ER? What other baseline data should be obtained before you can begin? Treatment Options Thrombolytic therapy Urgent PCI Medical therapy • Targeted H and P for thrombolytic therapy • If no available cath lab • STEMI only • Available cath lab • Diagnostic or PCI • If not a thrombolytic candidate • If no viable targets Early Management: Relieve pain, save myocardium Immediate 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) Obtain initial serum cardiac marker levels Request CXR (<30 min) * May consider clopidogrel if aspirin allergic 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 135 106 13 3.5 22 0.84 109 WBC 7 HCT 40 Plts 200 INR 1.2 ACC/AHA 2007 guidelines supports administration of nitrates only if 24 hours have elapsed after last dose of sildenafil and 48hrs for Tadalafil Case of MR After MONA the BEST early treatment for this patient is A. IV Heparin bolus 4000 units then IV heparin at 1000 units per hour to obtain aPTT 60-100 B. Oxycodone 20mg x 1 then 5mg q6h prn pain C. Call to cardiology fellow to mobilize the cath lab and consider clopidogrel loading D. A and C Goal is to prevent myocardial damage and treat chest pain and resolution of EKG changes to baseline. Diagnostic Algorithm for Acute Coronary Syndrome Management &/or ST-segment elevation MI Therapeutic goal: rapidly break apart fibrin mesh to quickly restore blood flow Non-ST Elevation ACS* + Tn &/or + CK-MB Non-ST Elevation MI Therapeutic goal: prevent progression to complete occlusion of coronary artery and resultant MI or death Consider fibrinolytic therapy, if indicated Consider GP IIb-IIIa inhibitor + aspirin + heparin Braunwald E, et al. 2002. http://www.acc.org/clinical/guidelines/unstable/unstable.pdf. The role of the thrombus — mechanism of action in ST-segment elevation ACS Generally caused by a completely occlusive thrombus in a coronary artery Results from stabilization of a platelet aggregate at site of plaque rupture by fibrin mesh platelet RBC fibrin mesh GP IIb-IIIa The Role of the Platelet: Mechanism of NSTE ACS Generally caused by a partially occlusive, platelet-rich thrombus in a coronary artery Results from cross-linking of platelets by fibrinogen at platelet receptors GP IIb-IIIa at site of plaque rupture Unobstructed lumen GP IIb-IIIa platelet thrombus fibrinogen Ruptured plaque Artery wall Acute Coronary Syndromes Algorithm. O'Connor R E et al. Circulation 2010;122:S787-S817 Copyright © American Heart Association Treatment of Non-ST segment elevation MI N-STEMI Current Management of Non-ST-segment Elevation ACS in the U.S. High-Risk 35% 70% Diagnostic catheterization Diagnosis PCI 15% CABG 30% 20% Low-Risk Medical management Case of MR • • Pharmacotherapeutic plan before the cath lab: • Antiplatelet therapy with: • Aspirin • Clopidogrel, prasugrel, or ticagrelor loading Anticoagulant therapy: • Unfractionated heparin or enoxaparin • IIb \ IIIa inhibitor if deemed high risk. Timing dependent on management strategy Aspirin in Acute Coronary Syndromes Primary Prevention 2.5 *P<.0001 MI 2.2 Stable Angina 15 *P=.0003 MI 12.9 UA/NSTEMI 15 *P=.012 Death or MI 15 12.9 *P=.008 Death or MI 11.9 Patients (%) 2 1.3* 1.5 10 10 10 6.2* 1 3.9* 5 5 5 3.3* 0.5 0 Placebo ASA N= 11034 11037 0 Placebo ASA 155 178 0 Placebo ASA 279 276 0 Placebo ASA 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. Pathways to Platelet Aggregation Antiplatelet therapy Drug Aspirin Indication STEMI ACS Dose Adverse effects 162-325mg hospital day 1 Post PCI w\stent 162-325mg daily otherwise 75-162mg daily Dypepsia, bleeding and gastritis 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 Bleeding, diarrhea, rash, TTP (rare) Avoid in pts >75 yrs UA, NSTEMI, or STEMI managed medically or with PCI 180mg loading dose followed by 90mg twice daily Ticagrelor (Brilinta) Caution in pts <60kg may use 5mg (less data) Bleeding, dyspnea, headache, fatigue, diarrhea Monitoring Clinical signs of bleeding, baseline CBC & every 6 months Tips for Antiplatelet Therapy EVERYONE gets aspirin 81mg daily Older guidelines recommended higher doses Clopidogrel Cheapest option Prasugrel More expensive Not approved for medical management (only PCI) Dose reduction or avoid in patients >75 years or <60 kg Contraindicated in patients with previous stroke or TIA Ticagrelor Newest agent Must use aspirin 81 mg daily (don’t use higher dose) Expensive 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 Anticoagulants Drug Unfractionated Heparin Enoxaparin Indication STEMI, NSTE ACS, PCI ** For UA/ NSTEMI give for at least 48 hours if conservative management chosen Adverse Side Effects Monitoring Bleeding, HIT aPTT until target or change in dose. CBC , HIT if indicated Bleeding, HIT Avoid 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: Abciximab Tirofiban Eptifibitide With PCI: Abciximab Bleeding, Acute profound thrombocytopenia Baseline Scr and daily (for eptifibitide and tirofiban) Daily CBC (with emphasis on Plt count) 4hrs after initiation ACS: Epitifibitide Tirofiban For all above: Monitoring for clinical signs of bleeding The Role of the Platelet: Mechanism of NSTE ACS Generally caused by a partially occlusive, platelet-rich thrombus in a coronary artery Results from cross-linking of platelets by fibrinogen at platelet receptors GP IIb-IIIa at site of plaque rupture Unobstructed lumen GP IIb-IIIa platelet thrombus fibrinogen Ruptured plaque Artery wall Platelet Adhesion, Activation, and Aggregation Vessel wall White HD. Am J Cardiol. 1997; 80 (4A): 2B-10B. Mechanism of Action: GP IIb-IIIa Inhibitors Vessel wall White HD. Am J Cardiol. 1997; 80(4A):2B-10B. Glycoprotein II b/ IIIa inhibitors Abciximab • PCI: 0.25mg\kg IV bolus, then 0.125mcg\kg\min x 12 hrs • Cheapest option • Only for PCI patients Eptifibitide • ACS: 180mcg\kg IV then 2mcg\kg\min • PCI: 180mcg\kg x 2 (10 min after first bolus) then a drip of 2mcg/kg/min • Adjust for renal dysfunction Tirofiban • ACS: 0.4mcg\kg\min x 30min, then 0.1mcg\kg\min infusion • Adjust for renal dysfunction Summary For UA/NSTEMI Treatment Antiplatelet Aspirin always P2Y12 inhibitor or Glycoprotein (GP) IIb/IIIa inhibitor Heparin always Unfractionated or LMWH Bivalirudin can be used in place of heparin and glycoprotein IIb/IIIa inhibitor PCI vs medical management Determined by risk factors TIMI score, past medical history Statin therapy Pharmacologic treatment of ST segment elevation MI (STEMI) Case:SS Mr. SS is a 47 year old male who presents to a small hospital with 2hrs of chest pain. The hospital is without a cath lab. His chest pain is 10\10 in the ED PMH: s\p kidney transplant 2 yrs. ago, HTN, hyperlipidemia ECG shows ST segment elevation in the anterior leads. Meds upon admission: tacrolimus 2mg bid, Cellcept 1000 mg bid, prednisone 5mg daily, amlodipine 5mg daily, pravastatin 5mg daily Vitals: BP 140/90, RR 16 HR 100, O2 sat 95% Normal Labs: Na 130, K 4, Plts 300K, HCT 40, INR 1.0 STEMI Class I Recommendations Get a 12-lead ECG at the site of first medical contact Reperfusion therapy should be administered to all eligible patients with STEMI with symptom onset within prior 12 hours PCI recommended method of reperfusion when performed in timely fashion FMC-to-device time system goal of 90 minutes or less Immediate transfer to PCI-capable hospital for PCI with a goal of 120 minutes or less In the absence of contraindications, fibrinolytic therapy should be given if anticipated FMC-to-device time >120 minutes When fibrinolytic therapy is indicated or chosen, it should be given within 30 minutes of hospital arrival Circulation. 2013;127:529-555 STEMI Class I Recommendations Primary PCI should be performed within 12 hours of ischemic symptoms Aspirin 162-325mg before primary PCI Continue aspirin 81mg indefinitely Load with P2Y12 inhibitor before PCI Give for 1 year UFH or bivalirudin for PCI GP IIB/IIIa inhibitor if using UFH (IIb) Fibrinolytic therapy should be given to patients who cannot get PCI within 120 minutes Aspirin and clopidogrel should be given with fibrinolytics UFH for for at least 48 hours after fibrinolytics Circulation. 2013;127:529-555 STEMI - PCI Load with aspirin 162-325mg Load with P2Y12 inhibitor IV GP IIb/IIIa receptor antagonist with UFH Bivalirudin in selected patients LMWH can be considered STEMI – Fibrinolytics Indications • • • • • Chest pain suggesting MI ST-segment elevation > 1mm in 2 or more contiguous ECG leads, or new LBB PCI within 120 minutes not possible Time to therapy < 12 hours (up to 24 hours considered) Age < 75 yrs. • Age > 75 yrs is NOT a contraindication to thrombolytic therapy but carries a higher risk of Intra-cranial hemorrhage. • Lower treatment rates with lytics (~60%) as compared with PCI (90%) • Associated with higher bleeding risk than with PCI Prehospital fibrinolytic checklist. O'Connor R E et al. Circulation 2010;122:S787-S817 Copyright © American Heart Association Fibrinolytics and IIb \ IIIa inhibitors Drug Indication Fibrinolytics: TPA Retaplase Tenecteplase STEMI II b \ III a inhibitors: Abciximab Eptifibitide Tirofiban With PCI: Abciximab High risk ACS: Epitifibitide Tirofiban Adverse side effects Bleeding, especially intracranial hemorrhage Monitoring Clinical signs of bleeding CBC with platelets, INR, Apt in Bleeding, Thromoboconjunction Cytopenia, with heparin ACS: STEMI • Thrombolytics • TPA (>67kg) • Loading dose 15mg IV over 1-2min followed by 0.75mg\kg (50mg)over 30 min then 0.5mg\kg over 60min (35mg) (NTE 100mg) • Reteplase 10mg IV q30 min x 2 doses • Tenecteplase bolus with 30-50mg • Heparin • With lytics: UFH 60units\kg load then 12units\kg\hr • Without lytics: • LD 50-70 units\kg then infusion till aPTT therapeutic • Enoxaparin: • NSTEMI with ACS: 1mg\kg SQ q12h • STEMI with PCI: Additional 0.3mg\kg IV at time of PCI *(Adjust for renal function) Comparison of Fibrinolytic Agents Agent Fibrin Specificity TIMI-3 Blood Flow Complete Perfusion at 90 Minutes Systemic Bleeding risk/ICH Risk Streptokinase (Streptase) + 35% +++/+ Infusion over 60 minutes 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 ++++ 50-60% +/++ Single bolus dose, weight-based dosing $2,918 Tenecteplase (TNK-tPA) (TNKase) Administration AWP Other Approved Uses $563 Pulmonary embolism, DVT, clearance of an occluded arteriovenous catheter, intraplueral administration for clearance of pulmonary effusion DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy: A Pathophysiologic Approach, 7th Edition: http://www.accesspharmacy.com Treatment of Patients Who Present Late RR = 26% 12 RR = 5% RR = 14% Placebo t-PA 12 35-Day Mortality (%) 10.3 10 8.9 9.2 8.9 8.7 8 6 4 2 0 Treated at 6-12 h P=0.02 RR, risk reduction. Treated at 12-24 h P=0.60 Treated at 6-24 h P=0.07 Symptom Onset to Treatment (hours) Wilcox R, et al. Presented at 14th Annual Congress of the European Society of Cardiology; September 1992; Barcelona, Spain. Other Early Medications • • • ACE or ARB (for patients with EF less than 40%) Anxiolytics and Analgesics • Morphine as the drug of choice Vasodilators • Nitroglycerin • IV beta blockers in select groups of patients Treatment options Early (first 24-48 hours) MONA (Aspirin at admission) Mid to late Beta blocker ACE or ARB PO ACE or ARB Continued if LVEF is less than 40% (in the absence of hypotension) Lytics and\or Percutaneous intervention (PCI) Discharge medications For secondary prevention Aspirin Beta blocker ACE\ ARB Statin ACE or ARB Clopidogrel (RX management Or PCI) Early Beta-blocker The COMMIT study • • • Earlier studies: beta blockers administered early during AMI hospitalizations significantly reduce post infarction angina and re-infarction. Whether early beta blocker use reduces mortality in AMI patients remains controversial. COMMIT study: While beta blockers significantly reduced the risk of arrhythmic death and reinfarction, they significantly increased the risk of cardiogenic shock within the first 24 hrs of hospitalization COMMIT TRIAL Early Intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: Randomized Placebo-controlled trial. COMMIT Collaborative group Lancet 2005;366:1622-32 • • • • • Randomized, placebo controlled STEMI and NSTEMI (in China) Initial IV metoprolol vs. Placebo Primary outcome: composite of death, reinfarction or cardiac arrest Secondary outcome: death from any cause Conclusion • No difference in combined endpoint • Early beta blockade reduces death from arrhythmias by 22% but is counterbalanced by an increase in cardiogenic shock by 29% (5% vs. 3.9%). The highest risk of shock was within the first 24h Case BF • • • • • • BF presented 2 days ago with 10\10 chest pain • + first troponin and ECG with ST wave elevation in the anterior leads Hospital course: rushed to cath lab and received 1 DES stent to LAD MOA: None Allergies: NKA Vital signs: BP 140\90 HR 70 RR 18 Labs: all WNL • • • • • Hospital course: It is 2 days after his MI What are some complications after an MI? What test should be done after an MI to predict prognosis? Develop a long term monitoring plan for BF Complications following an MI • • • • Arrhythmias – early first 48 hrs and late Left ventricular failure • Pulmonary edema, atrial fibrillation Right Ventricular failure • Edema Cardiogenic Shock • Inotropes • Intra-aortic balloon pump (IABP) • May need consult for artificial heart support Prognosis • • • • Left ventricular function (EF<40%) • Echo, Cardiac cath Recurrent ischemia • Exercise treadmill (ETT) • Stress ECHO • (dobutamine, persantine, adenosine) • Nuclear medicine study Late Arrhythmias Other Coexisting disease related to CAD Circulation Nov 2008:228; Case BF • • • • • • • BF presented 2 days ago with 10\10 chest pain • + first troponin and ECG with ST wave elevation in the anterior leads Hospital course: rushed to cath lab and received 1 DES stent to LAD MOA: None Allergies: NKA SH: smokes 1\2 ppd Vital signs: BP 140\90 HR 70 RR 18 Labs: all WNL • Hospital course: • It is now 4 days after his DES stent and he is ambulating the halls and ready for discharge • Devise a pharmacotherapy and risk factor modification treatment plan for this patient for discharge. • What are his long term goals? Treatment Options: Secondary Prevention Early (first 24-48 hours) Mid to late MONA (Aspirin at admission) Beta blocker ACE or ARB PO if LVEF is less than 40% ACE or ARB Continued (in the absence of hypotension) Lytics and\or Percutaneous intervention (PCI) Discharge medications Aspirin Beta blocker ACE\ ARB Statin Clopidogrel (RX management Or PCI) Quality indicators for MI • • • • • Explain the quality or “Core” measures of MI and explain the rational behind each indicator at discharge Smoking cessation ACE\ARB Beta blocker Statin Secondary prevention of: • Death • Stroke • Recurrent infarctions Mid-Late Medications • Beta blockers • Arrhythmias – around 25% of MI mortality within the first 24 – 48 hours 1 • Metoprolol is the drug of choice in the US • Beta-1 selective • Oral to IV conversion 2.5:1 • Metabolism: Hepatic • If Hemodynamically stable with no history or signs and symptoms of heart failure: • IV Metoprolol 5mg q5min x 3 doses, then start 50mg po bid and titrate up to 100mg po as tolerated • Prophylactic lidocaine – No! • Amiodarone for VT or VF 1) Lancet 1986:2:57-66 Lipid Lowering Agents • • • • Based on the ATP 3 guidelines Patients with CAD have LDL cholesterol goal < 100 mg/dL • LDL cholesterol < 70 mg/dL: optional goal All ACS patients should receive a statin Statins have anti-inflammatory & anti-thrombotic properties • lipid lowering therapy at discharge is a quality care indicator 68 Heart Disease Prevention • • • • Stop smoking Control blood pressure • Goal <140/90 mm Hg • Goal <130/80 with chronic kidney disease or diabetes Weight management Take prescribed medications at discharge Heart Disease Prevention • • Weight loss and exercise • 30 minutes at least 3 to 4 times a week • Ideal BMI 18.5 to 24.9 kg/m2 = (weight in lbs/2.2)/ (Height in inches x 2.54/100)2 • Waist circumference < 40 inches in men and < 35 inches in women Control Diabetes • HbA1c < 7% Discontinuation prior to surgery • • • LMWH (enoxaparin) 24 hours prior to cardiac surgery IIb \ IIIa (tirofiban and eptifibatide) 4-8 hours off prior to to cardiac surgery (No ACC\AHA guidelines) Clopidogrel: 5-7 days prior to cardiac surgery Case of BF • You discharge BF. What are the long term monitoring plan for BF? • Seen in clinic 1 week after discharge • Monitor: vital signs • HR, BP, RR • Monitor labs: chem 7, CBC with platelets, LFT’s, serum lipids, CK • Hb -A1c • Monitor for side effects of medications 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? Minute to win it…….case • • • A. B. C. D. BF comes back in 4 months with repeated chest pain showing NSTEMI He is taken to the cath lab where he has an occlusion of the stent. The best management for this patient is: Low dose fibrinolytic therapy since he already has a stent Increasing the daily dose of clopidogrel Take the patient back to the cath lab for a intervention Start the patient on Imdur 60mg daily as an outpatient Case MR is a 90 YO who presents to the ER with shortness of breath and dyspnea and chest pain PHM: STEMI with PCI 4 yrs ago, HTN, hyperlipidemia and depression, CHF , Hx of stroke 1 yr ago Vitals: HR 78, RR 12, BP 140/95 PE: + JVD, 2+ pitting edema in the LE Labs: Na 120, K 4, Scr 2.7 BNP elevated at 900 MOA: Clopidogrel 75mg daily., aspirin 325 daily, Toprol XL 50mg daily, atorvastatin 80mg QPM, Celexa 10mg daily, lisinopril 10mg Q12H, furosemide 80mg daily, spironolactone 25mg daily. CXR: bilateral infiltrates suggesting edema ECHO: Last EF 2 months ago = 30% Case This patient is still having chest pain and will be going to the cath lab. The team wants you to suggest a loading dose of an antiplatelet medication. Choose the BEST answer from below: A. Load with clopidogrel 300mg in preparation for the cath lab B. Load with Prasugrel 60mg po x 1 since current clopidogrel dose is not working C. Load with both clopidogrel 600mg and Prasugrel 60mg D. None of the above. Summary • • • Recognition of Myocardial infarction includes: patients history, ECG and Cardiac enzymes Medications used in the acute phase are focused on PCI, thrombolytics and antiplatelet medications. Medications upon discharge should include: Aspirin, Statin, ACE or ARB, Beta-blocker and PY12 inhibitor (clopidogrel, prasugrel, ticagrelor) \. Questions?