1. ANTIPLATELET
1.1. ASPIRIN
1.1.1. chew/crush 325mg
1.1.1.1. 4 baby asa, NOT EC
1.1.2. Check if EMS gave it to them or if they took it at home
1.1.3. early administration of aspirin in patients with MI reduces mortality by 23%
1.1.4. CI: GI bleed, coag disorder, G6PD, HTN, flu, dichlorphenamide, live nasal flu vax, live varicella vax,
1.1.5. AE: angioedema, bleeding, bronchospasm, GI perf, DIC, thrombocytopenia, Reye syndrome, dyspepsia, N/V, tinnitus,
1.2. CLOPIDOGREL (Plavix)
1.2.1. with aspirin
1.2.2. 300mg day 1, then 75mg/day
1.2.3. hold plavix 5-7 days prior to CABG
1.2.4. loading dose in ER
1.2.4.1. continuation at home
1.2.5. low efficacy in poor metabolizers
1.2.6. CI: bleeding, renal impairment, trauma, surgery within 5 days, GI disorder, grazoprevir
1.2.7. AE: bleed, TTP, aplastic anemia, SJS, erythema multiforme, itching,
1.3. *TICAGRELOR (Brilinta)
1.3.1. preferred if prior TIA, CVA, & STEMI
1.3.2. increased benefit in smokers
1.3.3. Start 180mg PO x 1 + aspirin 325mg PO x 1
1.3.3.1. then 75-100 mg PO qd
1.3.3.2. hold treatment > 5 days before surgery
1.3.4. CI: bleeding, CABG, hepatic impairment, elderly, every drug ever.
1.3.5. AE: bleeding, syncope, afib, dyspnea, HA, cough, dizziness, CP, N/D,
2. ANTICOAGULANTS
2.1. WARFARIN (Coumidin)
2.1.1. START: 2- 5mg daily
2.1.1.1. give a bottle of 100 tabs
2.1.1.2. one daily or as directed
2.1.1.2.1. change dose for K+ diet, new meds, easy bruising
2.1.1.3. continue 5mg until plateau
2.1.1.3.1. stay at the same reading for 2 weeks
2.1.1.3.2. adjust dose based on INR
2.1.2. INR goal is 2-3
2.1.2.1. monitor weekly until in therapeutic zone
2.1.2.1.1. then add a week for every check that they are in the therapeutic range ( <4 weeks between checks)
2.1.2.2. consider a correction dose if INR is unusually off, then resume normal dose
2.1.3. CI: bleeding risk, pregnancy, eclampsia, HTN
2.1.3.1. interacts with everything - defibrotide, mifepristone
2.1.4. AE: hemorrhage, necrosis, gangrene, anaphylaxis, cholestatic jaundice, hepatitis, anemia
2.2. NOAC
2.2.1. no monitoring, limited reversal abilities, expensive
2.2.2. APIXABAN (Eliquis)
2.2.2.1. factor Xa inhibitor
2.2.2.2. 2.5 - 5mg starting dose
2.2.2.3. CI: bleed risk, hepatic impairment, acute PE, >80, Cr > 1.5, defibrotide, mifepristone
2.2.2.4. AE: epidural/spinal hematoma, bleeding, thrombocytopenia, thrombosis, syncope, anemia, nausea
2.2.2.5. GET BASELINE Cr
2.2.2.6. BLACK BOX: thrombotic event risk, epidural hematoma
2.2.3. RIVAROXABAN (Xarelto)
2.2.3.1. factor Xa inhibitor
2.2.3.2. 20mg PO qd
2.2.3.2.1. decrease for renal
2.2.3.3. CI: bleed risk, hepatic impairment, CrCl < 30, PE, difibrotide, mifepristone
2.2.3.4. AE: bleed, epidural/spinal hematoma, thrombocytopenia, agranulocytosis, SJS, hepatitis, back pain, pruritus, elevated ALT, low platelets
2.2.3.5. monitor baseline Cr then periodically
3. VASODILATORS
3.1. FIRST LINE
3.1.1. NITROGLYCERINE SUBLINGUAL
3.1.1.1. .4mg SL
3.1.1.1.1. MAX: 3 doses with in 15 min
3.1.1.1.2. store tabs in original glass container
3.1.1.2. reduces preload
3.1.1.3. CI: right sided heart failure, hypotension, aortic stenosis, PDEi
3.1.1.4. AE: hypotension, syncope, bradycardia, HA, lightheadedness, dizziness, flushing, rash
3.2. SECOND LINE
3.2.1. NITROGLYCERIN IV (Nitro-Bid)
3.2.1.1. 5-200mcg/min IV
3.2.1.1.1. start 5mcg/min, increase by 5mcg/min q3-5 min until response or 20mcg/min
3.2.1.2. CI: tamponade, restrictive cardiomyopathy, anemiaa, pericarditis, shock, hypotension, hypovolemia, CHF, head injury, PDE5i, riociguat
3.2.1.3. AE: hypotension, bradycardia, syncope, HA, lightheadedness, dizziness, weakness, flushing, edema,
4. ANTITHROMBOTIC
4.1. restores circulation through previously occluded vessels
4.2. D/C on discharge
4.3. HEPARIN
4.3.1. ENOXAPARIN (Lovenox)
4.3.1.1. used once stable
4.3.1.2. 100U/kg (1mg/kg) SQ q12hrs
4.3.1.3. CI: bleed, elderly, neonates, renal/hepatic impairment, defibrotide, mifepristone
4.3.1.4. AE: bleed, epidural/spinal hematoma, anemia, thrombocytopenia, necrosis, hyperkalemia, hepatotoxicity, fever edeam, hematuria, ALT/AST elevation, diarreha
4.3.2. UNFRACTIONATED IV
4.3.2.1. first 2 days in ED
4.3.2.2. GOAL: PTT 50-70 sec
4.3.2.3. MAINTENANCE: 12 U/kg/hr IV
4.3.2.3.1. MAX 1000 U/hr >65kg, 800U/hr <65kg
4.3.2.4. LOADING: 60 U/kg IV bolus
4.3.2.4.1. MAX 5000 U if >65kg or 4000U if <65kg
4.3.2.5. CI: hypersensitivty to corn/pork/sulfites, IM admin, thrombocytopenia, HIT, bleed, defibrotide, mifepristone
4.3.2.6. AE: Bleed, thrombocytopenia, HIT, hivecs,fever, rigors
4.4. THROMBIN INHIBITORS
4.4.1. BILVALIRUDIN (Angiomax)
4.4.1.1. IV
4.4.1.2. .75mg/kg IV then 1.75mg/kg/h IV for procedure duration
4.4.1.2.1. continue for up to 4hrs post procedure
4.4.1.2.2. .2 mg/kg/h IV PRN up to 20h
4.4.1.3. for unstable angina undergoing PTCA/PCI
4.4.1.4. use with aspirin 300-325 mg/day +/- GP IIb/IIIa inhibitor
4.4.1.5. CI: bleed, renal impairment, bleed risk, brachytherapy, defibrotide, mifepristone
4.4.1.6. AE: bleed, thrombosis, bradycardia, back pain , nausea, hypotension, insomnia, HTN, fever
4.4.1.7. get CR baseline
4.4.2. DABIGATRAN (Pradaxa)
4.4.2.1. PO
4.4.2.2. 150mg PO bid
4.4.2.3. CI: PREGNANCY bleed, >75, spinal puncture, epidural, prosthetic heart valve, defibrotide, mifepristone
4.4.2.4. AE: epidural hematoma, bleeding, GI bleed, thrombocytopenia, thrombosis, anaphylasis, gastritis,
4.4.2.5. CR at baseline then periodically
5. GLYCOPROTEIN 2B/3A INHIBITORS
5.1. if they are going to get a PCI
5.2. D/C on discharge
5.3. ABCIXIMAB (Reopro)
5.3.1. .25mg/kg loading dose
5.3.1.1. max 10mcg/min
5.3.2. CI: active bleed, coag disorder, INR > 1.2, HTN, recent surgery or trauma, vasculitis, abciximab, eptifibatide, tirofiban
5.3.3. AE: Thrombocytopenia, bleeding AV block, anaphylaxis, hypotension, N/V, CP, HA, bradycardia, dizziness,
5.3.4. monitor aPTT, ACT, PT at baseline
5.3.4.1. PLT baseline, 2-4 hrs & 24hrs after bolus
5.4. EPTIFIBATIDE (Integrillin)
5.4.1. start 180mcg/kg up to 22.6 mg IV x 1
5.4.1.1. MAX: 15mg/h infusion
5.4.1.2. give until D/C or CABG
5.4.2. CI: bleeding, major surgery w/in 6wks, stroke w/in 30days, plt < 100,000, SBP > 200, DBP > 110, abciximab, eptifibatide, tirofiban
5.4.3. AE: bleeding, intracranial hemorrhage, thrombocytopenia, hypotension
5.4.4. monitor Cr, Hct, Hgb, Plt, pT baseline then periodically
5.5. TIROFIBAN (Aggrastat)
5.5.1. IV
5.5.2. 25mcg/kg IV x 1 then .15 mcg/kg/min IV up to 18 h
5.5.3. CI: thrombocytopenia, active bleed, coag disorder, tramua/surgery w/in 30 days, abciximab, eptifibatide, tirofiban
5.5.4. AE: anaphylaxis, bleeding, intracranial/ocular hemorrhage, retroperitoneal bleed, thrombocytopenia, dissection, edema, bradycardia, dizziness
5.5.5. monitor Cr, CBC at baseline than 6h after tx, then daily
6. BETA BLOCERS
6.1. initiated in the first 24 hours
6.2. CI: low output, >70 y/o, tachycardia >110, BP <120, CHF, asthma, PR > .24s, 2º/3º heart block
6.2.1. can ONLY use CCB if Beta blockers are CI
6.2.1.1. use amlodipine or diltiazem
6.2.1.2. especially NSTEMI with AFIB
6.3. AE: CHF, bradycardia, raynaud, gangrene, fatigue, dizziness, diarrhea, itching, rash, depression, dyspnea, bradycardia
6.4. FIRST LINE
6.4.1. METOPROLOL (Lopressor)
6.4.1.1. first line
6.4.1.2. goal HR 55-65 if indicated
6.4.1.3. 15mg IV x 1 then titrate to 200mg/day PO
6.4.1.4. acute: start 5mg IV q2min x 3 doses
6.4.1.4.1. after 15min give 50mg PO q6h x 48h
6.4.1.5. post: 100mg PO BID once stable
6.4.1.5.1. taper dose over 1-2 weeks to D/C
6.4.1.6. NOT for pregnancy 2nd & 3rd trimester
6.4.2. CARVEDILOL (Coreg)
6.4.2.1. 6.25mg BID titrated to 25mg BID
6.4.2.1.1. increase q3-10 days to 12.5mg PO BID
6.4.2.2. monitor BUN/Cr, glucose BP, HR
6.5. SECOND LINE
6.5.1. ESMOLOL (Brevibloc)
6.5.1.1. Start 50mcg/kg/min IV x 4 min incr by 50mcg/kg/min IV q4min PRN
6.5.1.1.1. MAX: 200mcg/kg/min
6.5.2. ATENOLOL (Tenormin)
6.5.2.1. 5-10mg IV x 1 then 100mg/day pO
6.5.2.2. BLACK BOX: abrupt cessation = angina, MI, arrhythmia
6.5.2.3. monitor baseline Cr, BP, HR
7. ACEi
7.1. when LVEF <40%
7.2. started in first 24 hours
7.2.1. organize squeeze back in heart
7.3. CI: hypotensive, renal failure, hyperkalemia, angioedema, PREGNANCY, renal impairment, aliskrien, sacubitril
7.4. AE: ANGIOEDEMA, SJS, hypotension, hyperkalemia, renal impairment, hepatotox, neutropenia, dizziness, BUN/Cr elevation, HA, diarrhea, COUGH, fatigue
7.5. FIRST LINE
7.5.1. LISINOPRIL (PRINIVIL)
7.5.1.1. start 5mg PO x 1 w/in 24hrs of MI
7.5.1.1.1. after 24h 5mg PO x 1
7.6. SECOND LINE
7.6.1. CAPTOPRIL (Capoten)
7.6.1.1. Start 6.25mg PO x 1 on day 3 post MI
7.6.1.1.1. titrate up as tolerated q3-7 days
7.6.1.1.2. give 1 hr before meals
7.6.1.1.3. decrease 25% for renal impairment
7.6.2. ENALAPRIL MALEATE (Vasotec
7.6.2.1. start 2.5mg PO qd w/in 48h post MI
7.6.2.1.1. titrate dose up quickly to 10mg PO BID
8. ARBs
8.1. organize squeeze back in heart
8.2. started in first 24 hours
8.2.1. organize squeeze back in heart
8.3. when LVEF <40%
8.4. CI: PREGNANCY, renal artery stenosis, renal impairment, hepatic impairment, volume depletion, hyponatremia, CHF, aliskiren, ACEi
8.5. AE: ANGIOEDEMA, hypotension, rhabdo, diarrhea, fatigue, CP, cough, hyperkalemia, dizziness,
8.6. FIRST LINE
8.6.1. LOSARTAN (Cozaar)
8.6.1.1. start 50mg pO qd
8.6.1.1.1. MAX: 100mg/day
8.7. SECOND LINE
8.7.1. VALSARTAN (Diovan)
8.7.1.1. start 20mg PO BID >12h post MI
8.7.1.1.1. increase to 40mg PO BID w/in 7 days
8.7.1.1.2. increase to 160mg PO BID as tolerated
8.7.1.1.3. MAX: 320mg/day
9. THROMBOLYTICS
9.1. ALTEPLASE (t-PA, Activase)
9.1.1. <67kg: 15mg IV x 1
9.1.1.1. then .75 mg/kg over 30min (MAX 50mg)
9.1.1.2. then .5 mg/kg over 60 min (MAX 35mg)
9.1.2. >67kg:15mg IV x 1
9.1.2.1. then 35mg over 60min MAX 100mg total
9.1.3. CI: active bleed, intracranial aneurysm/surgery/trauma, coag disorder, HTN, stroke, defibrotide, mifepristone
9.1.4. AE: intracranial hemorrhage, stroke, bleed, arrhythmias, PE,
9.1.5. monitor PT/INR, aPTT, BP
10. ANALGESICS
10.1. MORPHINE SULFATE (Duramorph)
10.1.1. IV
10.1.2. has been shown to increase death in MI
10.1.3. 2mg q 5-10 min for severe pain
10.1.3.1. can start 4-8mg
10.1.4. AE: respiratory distress, constipation, addiction/abuse, neonatal withdrawal
10.1.4.1. keep narcan nearby (.1-.2mg IV q15 min)
10.1.4.2. atrophine .5-1.5mg IV q 15 min to rev bradycardia
10.1.5. CI: benzos, CNS depressants, ETOH, morphine liposomal, tipranavir, asthma, shock, premature labor, post op
11. VITAMINS
11.1. MAGNESIUM
11.1.1. Genrally low in people with MI
11.1.2. improves angina and exercise tolerance
11.2. VITAMIN D
11.2.1. +/- Evidence
11.3. COQ10
11.4. FISH OIL
11.4.1. anti coagulant
11.5. THIAMINE/ B12
12. STATINS
12.1. CI: PREGNANCY, breastfeeding, hepatic disease, alcohol abuse, =avir, clarithromycin, cyclosporin, -azoles, mifepristone,
12.2. SIMVASTATIN (Zocor)
12.2.1. 20-40mg PO qPM
12.2.1.1. adjust dose after 4 weeks
12.2.2. AE: rhabdo, heaptotox, renal fialure, constipation, URI, asthenia, DM, myalgia,
12.3. ATORVASTATIN (Lipitor)
12.3.1. 80mg/day
12.3.2. CI: mifepristone, posaconazole
12.4. ROSUVASTATIN (Crestor)
12.4.1. 5-40mg PO qd