Medications For Acute Coronary Syndromes

Drugs are used depending on the type of ACS, and include

Objectives of the treatment of acute coronary syndrome (ACS) are the elimination of pain, interruption of thrombosis, termination of the ischemia, limiting infarct size, reducing heart work, the prevention and treatment of complications. The ACS is a medical emergency and the result is significantly affected by an immediate diagnosis and treatment. The treatment is carried out parallel to the diagnostics. Treatment includes revascularization with percutaneous coronary intervention, coronary bypass surgery, or fibrinolysis) and drug therapy for the treatment of ACS and the underlying coronary artery disease. Drugs are used depending on the type of ACS and include aspirin, clopidogrel, or both (prasugrel or ticagrelor are alternatives to clopidogrel when no fibrinolysis was given) beta blockers glycoprotein IIb / IIIa inhibitors for certain patients undergoing PCI and for some other high-risk (z. B. with significantly elevated cardiac markers, thrombolysis in myocardial infarction (TIMI) risk score ?4, persistent symptoms) A heparin (unfractionated or low molecular weight heparin), or bivalirudin (especially with ST-segment elevation myocardial infarction (STEMI) patients with a high risk of bleeding) Iv Nitroglycerin (except for uncomplicated myocardial infarction with low risk) fibrinolytic for selected patients with STEMI when PCI administered not available in time ACE inhibitors (as early as possible) statin antiplatelet agents and anticoagulants, which prevent the formation of blood clots, routinely. Drugs with anti-ischemic effect (eg. As beta-blockers or i.v. nitroglycerin) are often added in addition, v. a. chest pain or hypertension (see table: drugs for coronary heart disease *). Fibrinolytic agents should be used, if they are not contraindicated in STEMI if primary PCI is not immediately available, but they worsen the result of unstable angina and non-ST elevation Myocardial Infarction (NSTEMI). Patients with chest pain can be treated with morphine or nitroglycerine. Morphine 2-4 mg iv, repeated every 15 minutes if necessary, is very effective, but can cause respiratory depression and impair myocardial contractile force. Furthermore, morphine is a potent venous vasodilator. A morphine-induced hypotension and bradycardia can be solved usually by immediate raising of the legs. Nitroglycerin is initially sublingual, then administered as needed in a continuous infusion. Most patients have a normal or slightly elevated blood pressure, which then gradually drops during the next hours on arrival at the emergency room. A sustained hypertension requires an antihypertensive treatment, preferably i.v. with nitroglycerin, to lower blood pressure and to reduce the heart’s work. A severe hypotension or other signs of shock are alarming and must aggressively with i.v. Infusions and sometimes treated with vasopressors. Medicines for coronary heart disease * drug dosing using ACE inhibitor benazepril, captopril, enalapril fosinopril lisinopril moexipril Perindopril Quinapril Ramipril Trandolapril Various All patients with coronary heart disease, especially those with large infarcts, renal failure, heart failure, hypertension or diabetes mellitus The contraindications include hypotension, hyperkalaemia , bilateral renal artery stenosis, pregnancy and a known allergy Angiotensin II receptor antagonist candesartan, eprosartan irbesartan, losartan, olmesartan, telmisartan valsartan Various An effective alternative for patients who do not ACE inhibitors (eg. can tolerate as for cough); not currently first-line treatment after MI The contraindications include hypotension, a Hyperkaämie, bilateral renal artery stenosis, Schwanerschaft and a known allergy anticoagulants argatroban 350 mcg / kg (iv bolus) followed by 25 mcg / kg / min (iv infusion ) patients with ACS and a known or suspected history of heparin-induced thrombocytopenia, as an alternative to heparin bivalirudin Various fondaparinux 2.5 mg sc every 24 h Low molecular weight heparins: dalteparin, enoxaparin ‡ tinzaparin Different patients with unstable angina or NSTEMI patients <75 yr, the tenecteplase receive Almost all patients with STEMI as an alternative to unfractionated heparin (if PCI is not indicated and can be performed in <90 min) ; Drug continued until PCI or CABG performed or patient is discharged Unfractionated heparin 60-70 I.U./kg i.v. (Maximum of 5000 I.U .; bolus) followed by 12-15 I.E./kg/h (maximum of 1000 I.E./h) for 3-4 days or until PCI is completely patients with unstable angina or NSTEMI as an alternative to enoxaparin 60 I.U./kg i.v. (Maximum of 4000 IE; bolus) given when alteplase, reteplase, or tenecteplase has been started, then followed by 12 IU / kg / h (maximum of 1000 IU / h) for 48 h or until PCI completely is patients who have STEMI and Akutkoronarangiographie and PCI are subjected, or patients> 75 yr, the tenecteplase receiving warfarin oral dose adjusted to keep INR of 2.5-3.5. (Editor’s note: INR goal is not in Europe from 2.5 to 3.5, but 2.0 to 3.0, also this is not a standard treatment for myocardial infarction.) Can be useful in the long term in patients at high risk of systemic emboli ( ie platelet-inflammatory drugs aspirin with a large anterior MI, known LV thrombus or atrial fibrillation) with stable angina pectoris †: po 75 or 81 mg 1 time / day daily ( “enteric-coated”). (Editor’s note: 75-100 mg in Europe) All patients with CHD or CHD to develop high-risk, unless, aspirin is not tolerated or is contraindicated; In the long term uses ACS: 160 to 325 mg po chewed (not “enteric-coated”) upon arrival in the emergency room and 1-times daily thereafter during hospitalization and 81 mg † p.o. 1 times a day long after release – Clopidogrel (preferred) 75 mg po used or 1 times daily with aspirin alone in patients who do not tolerate aspirin in patients undergoing PCI: 300-600 mg po 1 times, then 75 mg p.o. 1 times a day for 1-12 mo in patients undergoing PCI, clopidogrel loading dose is administered only in the cath lab after angiography has confirmed that coronary PCI is accessible (not to delay a CABG, unless it is indicated). Maintenance therapy for at least 1 Mo. with simple metal stents and for at least 12 Mo. in drug-eluting stents required. (Editor’s note: This statement is not consistent with the current guidelines recommendations of the European Society of Cardiology specialist!) Prasugrel 60 mg p.o. 1 time, followed by 10 mg p.o. 1 times daily Not in conjunction with fibrinolytic therapy used only in patients with ACS who undergo PCI are ticagrelor in patients undergoing PCI: 180 mg po 1 times before the intervention followed by 90 mg 2 times a day – 250 mg of ticlopidine p.o. 2 times daily used Seldom routinely as neutropenia is a risk and leukocyte counts are checked regularly must glycoprotein IIb / IIIa inhibitor abciximab Various Some patients with ACS, especially those that have a PCI with stent implantation and high-risk patients with unstable angina or NSTEMI treatment begins prior to PCI, and is continued for 18-24 hours thereafter. (Editor’s note: This is in Germany no more routine recommendation.) Various eptifibatide, tirofiban Various atenolol 50 mg po every 12 h acute; 50-100 mg p.o. long 2 times a day all patients with ACS, unless a beta blocker is not tolerated or is contraindicated, especially high-risk patients; long used the intravenous beta-blockers may occur in patients with persistent chest pain despite conventional measures or persistent tachycardia or hypertension are used in the setting of unstable angina and myocardial infarction. Caution is advised when a blood pressure drop or other signs of hemodynamic instability. Bisoprolol 2.5-5 mg p.o. 1 times a day, increasing to 10 to 15 mg of 1 times a day, depending on heart rate and blood pressure response Carvedilol 25 mg p.o. 2 times a day (in patients with heart failure or other hemodynamic instability, the starting dose should be as low as 1.625 to 3.125 mg 2 times its daily and slowly increased as tolerated) metoprolol 25-50 mg po every 6 h for 48 h; then 100 mg twice daily or 200 mg once / day long-term calcium antagonist amlodipine 5-10 mg p.o. 1 times daily patients with stable angina, if the symptoms persist despite the administration of nitrates or when nitrates are not tolerated diltiazem (extended-release) 180-360 p.o. 1 times daily felodipine 2.5 to 20 mg p.o. 1 times daily nifedipine (extended-release) 30-90 mg po 1 times daily verapamil (extended-release) 120-360 mg po 1 times a day statins atorvastatin fluvastatin lovastatin pravastatin simvastatin rosuvastatin Different patients with CAD for achieving a target LDL of 70 mg / dl (1.81 mmol / l) nitrate: short effective sublingual nitroglycerin (tablet or spray) from 0.3 to 0, 6 mg every 4-5 minutes up to 3 doses for immediate relief of chest pain in all patients; used as required nitroglycerin as a continuous i.v. Drip. (Editor’s note: nitroglycerin, if necessary, continuously iv via syringe pump.) Start with 5 mcg / min and increased to 2.5-5.0 mcg every few minutes until the desired reaction is carried out Selected patients with ACS: During the first 24 -48 h those with heart failure (unless hypotension is present), (reduces blood pressure by 10-20 mmHg, but not to <80-90 mmHg systolic) large anterior MI, persistent angina or hypertension to prolonged treatment in those with recurrent angina or persistent pulmonary congestion nitrate: long-acting isosorbide dinitrate 10-20 mg po 3 times a day; can be increased up to 40 mg 3 times daily patients who have unstable angina or persistent severe angina and continue to show anginal symptoms after the beta blocker dose was maximized A nitrate-free period of 8-10 hours (usually at night ) is recommended to avoid tolerance isosorbide dinitrate (sustained-release) 40-80 mg po 2 times a day (usually given at 8 and 2 Uhrmorgens Uhrmittags) isosorbide mononitrate 20 mg p.o. 2 times a day, 7 h with 1 to 2 dose isosorbide mononitrate (sustained-release) 30 or 60 mg of 1-times daily, often 240 mg nitroglycerin patch increased to 120 mg, or 0.2-0.8 mg / applied h 6:00 to 9:00 am and 12-14 h later removed to avoid tolerance nitroglycerin ointment, 2% preparation (15 mg / 2.5 cm) 1.25 cm evenly distributed over all upper body or arms 6-8 h and covered with plastic, increased to 7.5 cm, if tolerated, and for 8-12 hours every day removed to avoid tolerance Opioids morphine iv 2-4 mg, as required repeated all patients with chest pain by ACS to relieve pain (but ischemia may persist) Best used after drug treatment started or the decision was made to revascularization other drug ivabradine 5 mg p. o. 2 times a day to 7.5 mg p. increased o. 2 times a day if needed Inhibits sinus node. For the symptomatic treatment of chronic stable angina pectoris in patients with normal sinus rhythm who do not take beta blockers IIn combination with beta-blockers in patients inadequately controlled by beta-blockers alone and whose heart rate is> 60 beats / min. Ranolazine 500 mg p.o. twice daily, increased to 1000 mg po twice daily as needed patients whose symptoms persist despite treatment with other antianginal drugs * Doctors can use different combinations of drugs, depending on the type of existing coronary heart disease. † Higher doses of aspirin do not provide greater protection and increase the risk of side effects. ‡ Of the low molecular weight heparins (LMWH) is preferred enoxaparin. ACS = acute coronary syndrome; CABG = coronary artery bypass surgery; CHD = coronary artery disease; LV = left ventricular; MI = myocardial infarction; NSTEMI = non-ST-segment elevation MI; PCI = percutaneous Kornarintervention; STEMI = ST-segment elevation MI. Platelet-inflammatory medications These include aspirin, ticagrelor, ticlopidine and glycoprotein GP IIb / IIIa inhibitors. (Editor’s note: and prasugrel) Unless contraindicated, all patients received aspirin at admission 160-325 mg (not dünndarmlöslich) and then 81 mg / day indefinitely. The first dose is rapidly absorbed when the tablet is chewed. (Editor’s note:. Gift also possible iv) Aspirin reduces short and long term mortality risk. When a therapy with aspirin is not possible to clopidogrel can 75 mg p.o. 1 times daily or ticlopidine 250 mg po be administered two times a day. Routine therapy with ticlopidine has been largely replaced by clopidogrel, ticlopidine because at the risk of neutropenia is and the white blood cell count should be checked regularly. Patients undergoing any Revaskularsierung undergo in patients with unstable angina or NSTEMI, for whom therapy is not recommended possible or given aspirin in combination with clopidogrel for at least 1 month. The optimal duration of dual antiplatelet therapy for these patients is the subject of ongoing investigations, however, increasing evidence that a longer period (eg. As 9-12 months) may be beneficial. In general, it is the main focus of dosage and duration of the platelet aggregation inhibitors, the reduced risk of coronary thrombosis with an increased risk of bleeding to balance. If no PCI is performed, give some doctors a GP IIb / IIIa inhibitor for all high-risk patients (eg. As for those with markedly elevated cardiac markers, a TIMI risk score ? 4 or symptoms persist despite adequate medication Therapy). The administration is carried out for 24-36 h, and angiography is performed prior to settling of the glycoprotein IIb / IIIa inhibitor infusion. GP IIb / IIIa inhibitors are not recommended for patients receiving thrombolytic agents. Abciximab, tirofiban and eptifibatide seem to have an equivalent efficacy, and the choice of the drug should be from other factors (eg. As cost, availability, familiarity) .Patienten who undergo revascularization in patients PCI undergo improved a loading dose of clopidogrel (300-600 mg po 1 time), prasugrel (60 mg po 1 times) or ticagrelor (180 mg po 1 time), the results, especially when administered 24 h in advance. (Editor’s note: For prasugrel and ticagrelor, there is no changing doses, there is only each approved loading dose prasugrel 60 mg po, ticagrelor is 180 mg po There is no data, the advantage the prior administration over administration in HK lab. can appear, especially for prasugrel one knows when NSTEMI the opposite. in STEMI, the question settled, because you can not treat one day in advance.) for urgent PCI are prasugrel and ticagrelor faster achieve the effect and should be preferred over clopidogrel. However, it is not permissible to delay the PCI for many patients for ~ 24 h. Furthermore, such a loading dose increases the risk of perioperative bleeding in patients who require coronary artery bypass grafting (CABG) because their coronary anatomy proves to be unfavorable for PCI. Thus, many doctors administer the dose of these drugs only in the cath lab after the coronary anatomy and the lesions were determined and are considered to be amenable to PCI. For patients who received a stent for revascularization, aspirin continues to be prescribed indefinitely. Clopidogrel 75 mg p.o. once / day, 10 mg Prasugrel once p.o./Tag or 90 mg p.o. Ticagrelor 2 times / day should be used for at least 1 month in patients with bare-metal stent. (Editor’s note: – prasugrel and ticagrelor are only approved for ACS, here the duration of dual platelet inhibition is independent of the choice of the stent 12 Monate.- Even with clopidogrel applies to ACS at a bare-metal stent 12 months- 1 month clopidogrel in addition to aspirin applies only to the metal stent at elective intervention.) patients with a drug-eluting stent having an extended risk of thrombus formation and benefit of 12 months of treatment with clopidogrel (or prasugrel or ticagrelor). Anticoagulant drugs long as no contraindication exists (eg. As active bleeding or planned use of streptokinase or anistreplase), either a low molecular weight heparin (LMWH) or an unfractionated heparin (UFH) or Bivalirudin is routinely administered. The choice of the drug is somewhat complicated. Patients at high risk of systemic embolism also require long-term therapy with oral warfarin. (Editor’s note:. Long-term therapy with oral vitamin K antagonist warfarin in Germany rather unusual here warfarin is used.) The switch to warfarin should begin 48 hours after symptom resolution or PCI. (Editor’s note: Marcumar take warfarin) Unfractionated heparin Unfractionated heparin is more complex in its application because it frequent (every 6 h) dosage adjustments required to an activated PTT (aPTT) of 1.5 to 2 times the control value to to reach. In patients who undergo angiography, a further dosage match is autonomous in order to achieve an activated clotting time (ACT) of 200-250 seconds when the patient is treated with a GP IIb / IIIa inhibitors, and 250-300 seconds if no GP IIb / IIIa inhibitor is added. However, if developed bleeding after catheterization, the effects of unfractionated heparin are shorter and can be reversed (by the heparin infusion is stopped promptly and given protamine sulfate) .Niedermolekulares heparin The LMWHs have better bioavailability than a simple weight-based dose given without monitoring of aPTT and dose titration and have a lower risk of heparin-induced thrombocytopenia. They can be used in ACS patients similar to unfractionated heparin and seem even z. to have a better T. benefits. Among the LMWH enoxaparin, dalteparin or nadroparin appears to be superior. However, enoxaparin, a higher risk of bleeding in patients with STEMI who are> 75, representing and its effects are not fully reversibel.Wahl of heparin with protamine Will all this taken into consideration, recommend many published guidelines LMWH (z. B. enoxaparin) over unfractionated heparin in patients with unstable angina or NSTEMI and in patients <75 with STEMI not undergo PCI. In contrast, unfractionated heparin is recommended if an emergency PCI is performed (z. B. patients with acute STEMI, which are forwarded into the cath lab) if CABG is indicated within the next 24 h, and if the patient is a high risk of bleeding complications (eg. history of GI bleeding within the last 6 months B.) or creatinine clearance have <30 ml / min. Ongoing studies should help to clarify the choice between LMWH and unfractionated heparin. In patients undergoing PCI, heparin is no longer recommended after surgery unless the patients are at high risk of thromboembolic events (eg. As patient large anterior MI, known LV thrombus, atrial fibrillation), since ischemic events have been reduced after the procedure through the use of stents and platelet aggregation inhibitors. In patients who did not undergo PCI, heparin is continued for 48 hours (or longer, if symptoms persist). The difficulties with the heparins (including bleeding complications, the risk of heparin-induced thrombocytopenia and, with unfractionated heparin, the need for dose adjustments) have led to the search for better anticoagulants. The direct thrombin inhibitor, bivalirudin and argatroban could have a lower incidence of major bleeding and better outputs, especially in patients with renal insufficiency, have (hirudin, another direct thrombin inhibitor seems to cause more bleeding than other substances). The factor Xa inhibitor fondaparinux reduces mortality and reinfarction in patients with NSTEMI who undergo PCI, without increasing bleeding, but may result in patients with STEMI to poorer outputs than unfractionated heparin. Although a routine use of these alternative anticoagulants is therefore not currently recommended, they should with known or suspected history of heparin-induced thrombocytopenia used instead of unfractionated heparin or LMWH in patients werden.Heparin Alternatives bivalirudin is an acceptable anticoagulant for patients undergoing primary PCI undergo and have a high risk of bleeding, and is recommended for those with a known or suspected history of heparin-induced thrombocytopenia. the initial dose is a bolus of 0.1 mg / kg i.v., followed by a drop of 0.25 mg / kg / h for patients with unstable angina or NSTEMI. the initial dose is 0.75 mg / kg i.v., followed by 1.75 mg / kg / h for patients with STEMI. Beta blockers These drugs group is recommended if there are no contraindications (eg., Bradycardia, conduction block, hypotension or bronchial asthma) are present, v. a. in high risk patients. Beta-blockers decrease the heart rate, the arterial pressure and the contractility and thereby reduce the cardiac work and oxygen demand. The size of infarction determined to a great extent cardiac performance after recovery of the patient. Die orale Gabe von Betablockern innerhalb der ersten Stunden verbessert die Prognose, indem die Infarktgröße, die Rezidivrate, die Häufigkeit von Kammerflimmern und das Mortalitätsrisiko gesenkt werden (1). Während der Behandlung mit Betablockern müssen Herzfrequenz und Blutdruck sorgfältig überwacht werden. Bei der Entwicklung einer Bradykardie oder Hypotonie muss die Dosis reduziert werden. Massive unerwünschte Effekte können durch Infusion des beta-adrenergen Agonisten Isoproterenol 1–5 ?g/min aufgehoben werden. (Anmerkung der Redaktion: diesen gibt es in Deutschland nicht zur klinischen Anwendung!) Hinweis zu Betablockern Chen ZM, Pan HC, Chen YP, et al. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo controlled trial. Lancet 366:1622–1632, 2005. Nitrate Ein kurzwirksames Nitrat, Nitroglycerin, wird bei ausgewählten Patienten eingesetzt, um die Herzarbeit zu reduzieren. Nitroglycerin dilatiert Venen, Arterien und Arteriolen und vermindert so die linksventrikuläre Vor- und Nachlast. Dadurch wird der myokardiale Sauerstoffbedarf reduziert und die Ischämie verringert. Die Gabe von Nitroglycerin i.v. empfiehlt sich innerhalb der ersten 24–48 h bei Patienten mit einer Herzinsuffizienz, einem großen Vorderwandinfarkt, persistierendem Brustschmerz ode

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