Cardiovascular ACS Medications PDF

Cardiovascular ACS Medications ACP 212 Module 4 Lesson 1 Objectives • Understand the generic name, trade name, classification, supply, pharmacological actions, indications, dosage, routes, contraindications, precautions and special considerations of the medications listed in this module • acetylsa...

Cardiovascular ACS Medications ACP 212 Module 4 Lesson 1 Objectives • Understand the generic name, trade name, classification, supply, pharmacological actions, indications, dosage, routes, contraindications, precautions and special considerations of the medications listed in this module • acetylsalicylic acid • clopidogrel • enoxaparin • nitroglycerine • Tenecteplase (TNK) • ticagrelor • tranexamic acid • Tissue plasminogen activator (tPA), Alteplase https://www.researchgate.net/figure/Piggyback-system-for-intravenous-therapy-used-in-the-hospital-of-the-present-study-The_fig1_5609912 https://www.youtube.com/watch?v=yC_DyYv1DCA https://www.ismp.org/resources/hidden-medication-loss-when-using-primary-administration-set-small-volume-intermittent Nitroglycerin https://www.stepwards.com/?page_id=4503 • Nitroglycerin is a nitrate • Dilates all blood vessels from relaxation of smooth muscle cells on the structure of the veins and arteries. • Potent dilating effect on coronary arteries • Predominately venous vascular beds (low doses) • Dose dependent for arterial vasodilation effects (high doses) • Dilation of vessels cause: • Dilates the coronary arteries to allow perfusion to the heart • Reduce venous return • Reduce the left ventricular end-diastolic volume (preload) • Reduced afterload (from relaxation of arteries) • Reduces the workload on the heart Variant angina – nito relaxes, reduces the spasm of the coronary arteries. Nitroglycerin with Pulmonary Edema https://en.wikipedia.org/wiki/Vasodilation https://nursingnerds.tumblr.com/page/5 Nitroglycerin Indications: • Initial antianginal for suspected ischemic chest pain • For initial 24 – 48 hours in patient with AMI and CHF, large interior wall infarction, persistent or recurrent ischemia • Continued use (beyond 48 hours) for patients with recurrent angina or persistent pulmonary congestion • Pulmonary Edema • An IV must be initiated prior to the administration of nitroglycerin. • Remove other nitro sources (e.g. Nitro patch before administering SL or IV nitro). • Monitor vital signs closely Contraindications: • Hypersensitivity to nitrates • Right ventricular infarction (Sublingual Spray Administration- 0.3mg to 0.4 mg are too large a dose and will drop preload and significantly decreasing cardiac output. These increases mortality rates in these patients) • Avoid use in extreme bradycardia (<50 bpm) or extreme tachycardia (>160 bpm) • Hypotension (<90 mmHg) or a drop of >30 mmHg below baseline (systolic BP) • Uncorrected hypovolemia • sildenafil (Viagra), vardenafil (Levitra), avanafil (Stendra),) use within 24 hours or tadalafil (Cialis) within 48 hours • Severe anemia • Pericardial Tamponade and pericarditis Precautions: • Head trauma • Closed-angle glaucoma • Orthostatic hypotension may occur – consider administering while patient recumbent or after placing on stretcher. IV Nitroglycerin Use glass bottles and special tubing provided by the manufacturer for infusion. (PVC plastic may absorb up to 80% of the nitroglycerin Nitro infusion must be diluted with either D5W or NS Indications for initiating a nitro infusion in a STEMI are: (Discuss with medical direction/cardiologist) • Recurrent or continuing chest discomfort unresponsive to sublingual nitro • Pulmonary edema complicating STEMI • Hypertension complicating STEMI Treatment Goals for IV nitroglycerin - ACLS page 43 For relief of ischemic chest discomfort: • Titrate to effect • Keep SBP greater than 90 mm Hg • Limit drop in SBP to 30 mm HG below baseline in a hypertensive patient For improvement in pulmonary edema and hypertension: • Titrate to effect • Limit drop in SBP to 10 % of baseline in normotensive patient • Limit drop in SBP to 30 mm Hg below baseline in hypertensive patient Nitroglycerin Dosage Adult SL - 0.3 mg tab or 0.4 mg spray q 5-minute intervals (prn); max of 3 doses IV - begin infusion at 5 mcg/min; titrate to effect; increase prn by 5 – 10 mcg/min q 5 min. Max dose of 200 mcg/min; Mix: 25 mg of nitroglycerin to a 250 ml NS or D5W (100 mcg/ml) Transdermal Patch – 0.2 – 0.8 mg/hr. Topical nitrates are acceptable alternatives for antianginal therapy with hemodynamic stability in the absence of ongoing refractory ischemic symptoms. Pediatric 0.25 - 0.5 mcg/kg/min IV/IO increase by 0.5- 1 mcg/kg/min prn as tolerated q 15-20 mins to a max of 5 mcg/kg/min. Coagulation Modifier Drugs • Anticoagulants (prevents clots): Inhibit the action or formation of clotting factors • Antiplatelet drugs (prevents platelet plugs): Inhibit platelet aggregation • Hemorheological drugs: Alter platelet function without preventing the platelets from working • Thrombolytic drugs (breaks clots): Lyse (break down) existing clots • Antifibrinolytic or hemostatic (helps clots): Promote blood coagulation Extrinsic vs Intrinsic Pathway in the Coagulation Cascade • Activated clotting factors serve as a catalyst that amplifies the next reaction, ultimately resulting in a clot • Extrinsic Pathway: activated by penetration from the outside ex. Knife wound • Intrinsic Pathway: activated when factor XII comes in contact with exposed collagen on the inside of damaged blood vessels • These pathways meet after Factor X in the Common Pathway EXTRINSIC PATHWAY Formation of a thrombosis https://www.med.unc.edu/wolberglab/scientific-images-2/ INTRINSIC PATHWAY COMMON PATHWAY Anticoagulants • Anticoagulants AKA Blood thinners • Heparin • Warfarin • Low-Molecular-Weight Heparin (ex: Lovenox) • Have no direct effect on a blood clot that is already formed • ↓ blood coagulability • Prolong bleeding time to prevent clot formation • Prevent clots from enlarging enoxaparin sodium – Lovenox • Indications: • Acute STEMI /NSTEMI/ACS – As Directed from VHR physican • Contraindications: • Hypersensitivity to Sulfite or heparin • Active major bleeding or bleeding disorders • Type II Heparin or LMWH induced thrombocytopenia • Severe thrombocytopenia (low platelets) • Peptic ulceration • Aortic aneurysm • Precautions: • Pregnancy or lactation • Patients using anticoagulants • Uncontrolled HTN • Recent surgery • Renal insufficiency enoxaparin sodium – Lovenox AHS MCP – As directed by VHR physician / protocol Dosage: <75 yr: Initial dose: 30mg IVP followed by a Second dose of 1mg/kg SQ Note: maximum dose of 100mg SQ (Maximum SQ dose does NOT include IV dose) >75 yr: Eliminate initial IV dose; Give 0.75 mg/kg SQ Note: maximum dose 75mg SQ Platelet Adhesion Antiplatelet drugs • Prevent/reduce platelets from sticking together to form a clot • ↑ bleeding time by preventing clot formation in arteries and inhibiting platelet aggregation • ASA • Clopidogrel (Plavix) • ticagrelor Knowledge Check Which sites does ASA inhibit? A. Cox-1 B. Cox-2 C. Both Cox-1 and Cox-2 D. Neither Cox-1 or Cox-2 E. What is Cox-1 and Cox-2??? acetylsalicylic acid Novasen (canada), Aspirin, ASA, Bufferin • ASA is an Anticoagulant • Non-selective Irreversible inhibitor of COX-1 and Cox-2 • The effects of ASA last 7 – 10 days • Prevents the formation of TXA2 (a substance that causes platelet adhesion and vasoconstriction) • Cox-1 gives ASA the benefit of prevention of platelet aggregation • Other benefits of ASA: • Inhibits Cox-2 – Pain perception • Inhibits Cox-2 Fever Non-benefit of ASA it inhibits: • Cox-1 maintenance of intestinal mucosa • Cox-1 vasodilation to the kidneys • Salicylic acid binds to plasma and albumin acetylsalicylic acid Novasen (canada), Aspirin, ASA, Bufferin Indications: • Acute coronary syndromes suggestive of an acute myocardial infarction Contraindications: • Hypersensitivity to ASA and NSAIDS or other salicylates • Hypersensitivity to tartrazine (FDC yellow dye #5) • Active GI Bleed • Known bleeding disorders or thrombocytopenia (excessive low platelet levels) • Children or adolescents with viral infections, chicken pox or flu-like symptoms (can increase risk or Reye’s syndrome) • Pregnancy after 30 weeks gestation • Hemorrhagic stroke Precautions: • Active ulcer disease • Chronic alcohol abuse • Asthma (may induce bronchospasm- Ask these patients if they have taken Aspirin before) • Impaired renal and hepatic function acetylsalicylic acid Novasen (canada), Aspirin, ASA, Bufferin Dosage: 160-325 mg PO – Chewed and swallowed *Note: May be given even if patient has taken ASA prior to incident Ask the patient the dose of ASA they have taken – was it only 81 mg? Non-enteric chewable or soluble aspirin should be used P2Y12 ADP Receptor Antagonists Clopidogrel: cardiologists’ panacea or neurologists’ headache? | Future Cardiology (futuremedicine.com) • Blocks P2Y12 Adenosine Diphosphate (ADP) Receptor on the platelet surface. • Inhibits platelet aggregation by altering the platelet membrane so it can no longer receive the signal to aggregate and form a clot. Clopidogrel (Plavix) • Irreversible receptor blockage • Last 7-10 days • Metabolized through the liver to form a metabolite Ticagrelor (Brilinta) • reversible receptor blockage • Lasts 5 days • Not metabolized through the liver clopidogrel bisulfate Plavix Indications: • Acute STEMI/NSTEMI ACS – As Directed by VHR Physician Contraindications: • Hypersensitivity • Active bleeding • Significant liver impairment or cholestatic jaundice • Suspected liver impairment with history of hepatitis; long term ETOH abuse; or a presentation of jaundice • Thrombotic thrombocytopenic purpura • Suspected aortic dissection • Do not give if coronary bypass graft (CABG) surgery is planned, withhold for 5 days before CABG unless need for revascularization Precautions: • In patients with increased risk of bleeding from trauma; surgery or other pathologic conditions Dosage: ADULTS: Loading dose of 300-600 mg PO/OG followed by a maintenance daily dose of 75 mg PO Ticagrelor Brilinta Indications As directed by VHR Physician: • Reduction of thrombolytic cardiovascular events in conjunction with aspirin in patients with acute coronary syndrome. • Treatment of STEMI patients Contraindications: • Hypersensitivity • Diabetic Foot Infections • History of intracranial hemorrhage • active bleeding • D/C 5 days prior to CABG surgery Precautions: • severe hepatic impairment (decreased maintenance dose required) • Pregnancy – use only when potential maternal benefit outweighs fetal risk • Lactating women (pumping should be discussed) • Risk factors for bleeding Dosage: Adult – PO – 180 mg once Fibrinolytic System • Fibrinolysis = fibrin + lysis (disintegration) • Initiates the breakdown of clots and serves to balance the clotting process • Fibrin in the clot binds to a circulating protein known as plasminogen. This binding converts plasminogen to plasmin. • Plasmin is the enzymatic protein that eventually breaks down the fibrin thrombus into fibrin degradation products. This keeps the thrombus localized to prevent it from becoming an embolus. Thrombolytic Agents • Agents that break down, or lyse, pre-formed clots thereby restoring blood supply to damaged tissue • Activate the fibrinolytic system to break down the clot in the blood vessel quickly • Activates plasminogen and convert it to plasmin which breaks down or lyses the thrombus • Mimics the body’s own process of clot destruction • Non-specific, will dissolve all clots • Medications included: • Tissue plasminogen activator (tPA) (alteplase) • tenecteplase (TNKase) tenecteplase TNKase Indication As directed by VHR Physician: • ST elevation (threshold values: J-point elevation of 2 mm (men) or 1.5 mm (women) in leads V2 and V3 and 1 mm in all other leads) or new presumably new LBBB; in context of signs and symptoms of AMI and time of onset of signs and symptoms <12 hrs Contraindications: • Any prior intracranial hemorrhage or intraspinal injury • Known structural cerebral vascular lesion or aneurysm (e.g., AVM) • Known malignant intracranial neoplasm (primary or metastatic) • Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours • Suspected aortic dissection • Active internal/external bleeding or bleeding diathesis (excluding menses) • Significant closed head trauma or facial trauma within 3 months • Suspected aortic dissection or pericarditis Relative Contraindications: • Greater than 75 years of age (increased risk of ICP) • History of chronic, severe, poorly controlled hypertension or Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg or DBP >110 mm Hg) • History of prior ischemic stroke > 3 months, dementia, or known intracranial pathology not covered in contraindications • CPR (greater than 10 mins) • major surgery, trauma, GI or GU bleeding (within 10 days) • Recent (within 2 to 4 weeks) internal bleeding • Non-compressible vascular punctures • Transient ischemic attack (TIA) within 6 months • Pregnancy • Active peptic ulcer • Current use of anticoagulants (ex: Warfarin, Apixaban, Rivaroxaban, Dabigatran) (: the higher the INR, the higher the risk of bleeding • Advanced liver disease • Patients that have received streptokinase should not receive a second time. • Prior allergic reaction to these agents tenecteplase TNKase tissue plasminogen activator (tPA), alteplase Indications: • Lysis of thrombi obstructing coronary arteries in management of acute MI. • Lysis of thrombi obstructing cerebral arteries in the management of acute ischemic stroke. Contraindications: • Ensure BGL is above 3.3 mmol/l (Stroke) • Any prior intracranial hemorrhage • Known structural cerebral vascular lesion (e.g., arteriovenous malformation) • Known malignant intracranial neoplasm (primary or metastatic) • Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 4.5 hours • Suspected aortic dissection • Active bleeding or bleeding diathesis (excluding menses) • Significant closed head trauma or facial trauma within 3 months • Intracranial or intraspinal surgery within 2 months • Severe uncontrolled hypertension (unresponsive to emergency therapy) Relative Contraindications: • History of chronic, severe, poorly controlled hypertension or Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg or DBP >110 mm Hg) STEMI • History of chronic, severe, poorly controlled hypertension or Severe uncontrolled hypertension on presentation (SBP > 185 mm Hg or DBP >110 mm Hg) (Stroke) • History of prior ischemic stroke > 3 months, dementia, or known intracranial pathology not covered in contraindications • CPR (greater than 10 mins) • major surgery, trauma, GI or GU bleeding (within 10 days) • Recent (within 2 to 4 weeks) internal bleeding • Non-compressible vascular punctures • Transient ischemic attack (TIA) within 6 months • Pregnancy • Active peptic ulcer • Current use of anticoagulants (ex: Warfarin, Apixaban, Rivaroxaban, Dabigatran) (: the higher the INR, the higher the risk of bleeding • Advanced liver disease • Prior allergic reaction to these agents tissue plasminogen activator (tPA), alteplase Dosage: STEMI 6- 12 hours of symptoms: >67 kg: 15 mg initial IV bolus; followed by 50 mg infused over the next 30 mins; then 35 mg infused over the next 60 mins < 67 kg: 15 mg initial IV bolus; followed by 0.75 mg/kg (not to exceed 50 mg) over the next 30 min; then 0.5 mg/kg (not to exceed 35 mg) over 60 min Tranexamic Acid - TXA Anticoagulation Medications - Basic Science - Orthobullets tranexamic acid (TXA) Indications: • Bleeding within 3 hours of injury and presenting at any point with HR greater than 110 bpm or systolic BP less than 90 mmHg. Ex. TBI, Post-Partum hemorrhage, significant traumatic injury with internal bleeding. Contraindications: • Hypersensitivity to Tranexamic Acid • Active thromboembolic disease (pulmonary embolus, DVT or stroke) • Unable to initiate bolus within 3 hrs of injury onset • GI Bleeds • Subarachnoid hemorrhage • No Precaution Dosage (>16 years old): 1 g IV/IO dilute in 250 mL D5W or 100ml Normal Saline bag and infuse over 10 minutes; followed by as soon as practical an infusion of 1 g over 8 hours (<16 years old): 15mg/kg IV/IO to a max of 1g over 10 minutes. Follow bolus dose with 2mg/kg/hr IV/IO to a max of 1g over 8 hours. Let’s Practice You have a 55-year-old patient sitting on the couch rolling from side to side clutching his chest. He is ashen grey, pale and diaphoretic. C/o chest pain pressure, into jaw / teeth and left arm, he rates it at a 12/10 for pain. He feels SOB. LOC – A&O x 4 A – open and patent B – 24 bpm regular, shallow C – 78, regular, strong, pale, cool, diaphoretic (ashen gray) D-? D- ? V/S BP 98/60 P 78 Resps 24 SPO2 94% BGL 7.9 mmol/l Temp – 36.9 C S – as stated A – none M – none P- none L – hamburger E – Started having chet pain called EMS Treatment Summary • Discussed the generic name, trade name, classification, supply, pharmacological actions, indications, dosage, routes, contraindications, precautions and special considerations of the medications listed in this module • acetylsalicylic acid • clopidogrel • enoxaparin • nitroglycerine • tenecteplase • ticagrelor • tranexamic acid