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ICU ICU

QUICK DR UG GUID E

Elsevier

1600 John F. Kennedy Blvd.

Ste 1800 Philadelphia, PA 19103-2899

ICU QUICK DRUG GUIDE, FIRST EDITION ISBN: 978-0-323-68047-9

Copyright © 2021 by Elsevier, Inc. All rights reserved.

Notice

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Control Number: 2020936545

Content Strategist: Sara Watkins

Content Development Specialist: Michael Houston

Publishing Services Manager: Deepthi Unni

Project Manager: Radjan Lourde Selvanadin

Design Direction: Amy Buxton

Printed in the United States

To my soul mate, Joseph, and endearing angels, Jonathan and Joshua.

Foreword

The use of multiple pharmacologic interventions in patients in critical care scenarios requires an in-depth background and often a quick reference source. Working in the intensive care unit (ICU) as a pharmacist for many years, Dr. Lee identified the need for the quick reference to make our significant pharmacologic interventions as accurate and easy as possible. With this goal in mind and as part of her need to help the patients and their care providers, she created the ICU Quick Drug Guide reference book.

The ICU Quick Drug Guide is remarkable in its scope and detail. It is clearly organized and arranged to cover nearly all possible scenarios of the critically ill patients who may cross the doors of the ICU. The book is divided into six sections covering 24 different specific critical scenarios. Each chapter is divided into a brief discussion of drugs used for the specific treatment of the condition and clinical scenario. It is presented in an outline format accompanied by numerous clear descriptive tables of drug dosing, alternative agents, their antidotes (if available), potential complications, and drug interactions that may be encountered.

For the ICU nurses, residents, and physicians alike, this book will become an invaluable reference. For ICU teams rounding together, it will answer questions rapidly and accurately. I can find no other similar reference in medicine and believe that the ICU Quick Drug Guide will become a standard in the industry.

On a personal note, it was my pleasure to assist Dr. Lee in her pursuit of her career goals beyond her initial research studies on drugs for critically ill patients, particularly those involving renal failure and spinal cord injury. Jennifer has devoted her time and training toward the betterment of patients

through education and understanding of how our drugs work, in whom they best work, and in what circumstances problems with our drugs may be anticipated or avoided. I believe all readers will find this book useful and a highly valuable resource.

About the Author

Jennifer Pai Lee received her Doctorate of Pharmacy from the University of Southern California School of Pharmacy in 2001. Following graduation, she completed a residency in Clinical Pharmacy Practice at the Long Beach Memorial Medical Center in 2002. She is a Board Certified Pharmacotherapy Specialist and serves as an clinical faculty at University of California San Francisco, University of the Pacific, and University of Southern California Schools of Pharmacy. She has been teaching medical and pharmacy students and residents for almost twenty years as a clinical pharmacist in critical care. Her practice interests include pharmacokinetics, critical care medicine, and cardiology.

Jennifer is currently the Program Manager for Critical Care/Emergency Services at Veterans Affairs Long Beach Healthcare System. She has developed numerous guidelines and protocols that are essential in taking care of critical care patients to the present day. Furthermore, she has received a research grant and has been actively involved in conducting research studies as a principal investigator. She has given several invited presentations at conferences, and has authored many publications in peer-reviewed journals including New England Journal of Medicine and Nephron as a primary and corresponding author.

Preface

As a clinical pharmacist working and teaching for almost 20 years in the intensive care unit (ICU), I have needed to look to different references for different challenging situations. For example, how does one convert opioid dosing when transitioning from home oral oxycodone to intravenous (IV) hydromorphone or IV morphine to transdermal fentanyl? How do we select an anticonvulsant according to a validated clinical practice guideline for a patient in refractory status epilepticus with multiple drug allergies and interactions? What do we choose for an optimal formulary agent within the class of many similar drugs tailored to an individual patient? What source do we use when we are seeking a novel antibiotic for a multidrugresistant pathogen for a specific type of infection?

Now more than ever, there is overwhelming medical information available as reference books, articles, and online resources. However, they may not be readily available or may be too extensive and complex to search for answers while tending to a critically ill patient at bedside. In my experience, there is no single reference that meets the needs of a clinician who seeks urgently precise and accurate, evidence-based medical information while treating patients in the acute care setting. This fact compelled me to write a pocket book that provides the most current ICU drug information based on practice guidelines, along with expert opinions readily available at hand.

Each chapter is uniquely designed to provide a brief discussion of the disease state, followed by treatment algorithms and drug tables that compare and contrast vital information including pharmacokinetics, pharmacodynamics, drug interactions, adverse effects, contraindication, and hepatic/renal dosing along with clinical pearls to help clinicians decide on optimal drug therapy at glance without a delay.

This book is divided into six sections containing the major clinical ICU areas of practice. Section I highlights pharmacotherapy in cardiovascular critical care, including acute coronary syndromes, acutely decompensated heart failure, adult advanced cardiac life support, anticoagulation for atrial fibrillation/flutter, and hypertensive crisis. Section II addresses management of endocrine emergencies such as diabetic ketoacidosis, hyperosmolar hyperglycemic state, and adrenal and thyroid dysfunction. In addition, treatment strategies for acute pancreatitis, hepatic failure, and gastrointestinal complications such as fistulas, postoperative ileus/nausea/vomiting, and bleeding are depicted.

Section III presents empiric and definitive antimicrobial therapy for infections involving the brain, lung, bloodstream, abdomen, urinary tract, and skin and soft tissue. Section IV reviews pharmacotherapeutic interventions in neurocritical care, including, but not limited to, acute ischemic stroke, status epilepticus, and intracranial hemorrhage. Section V discusses treatment pathways for pulmonary disorders such as asthma and chronic obstructive pulmonary disease exacerbations and pulmonary hypertension. Section VI examines pharmacologic therapies for acute poisoning, anaphylaxis, drug-induced hyperthermia, rapid sequence intubation, venous thromboembolism, fluids and electrolytes, and pain, agitation/sedation, and delirium.

I hope this book becomes a valuable resource for all entrylevel clinicians including physicians, pharmacists, nurses, and other healthcare professionals needing a fundamental drug sourcebook while working in ICU, emergency departments, or acute care settings. Furthermore, it can serve as a quick reference that provides a summary or refresher to experienced clinicians working in the hospital setting.

I thank Dr. Morton J Kern for being a magnificent mentor who inspired and advised me throughout the long journey to completion of this book. In addition, I’d like to acknowledge the following invaluable experts for reviewing the chapters:

Ali K. Ashtiani, MD: Chapters 1–5

Ellis R. Levin, MD: Chapters 6 and 7

Timothy R. Morgan, MD: Chapters 8 and 9

Karen Tan, PharmD: Chapters 10 and 11

An T. Tran, MD: Chapters 13–15

Marius C. Viseroi, MD: Chapters 12, 16–19, 21–22, and 24

Syeda A. Quadri, MD: Chapters 20 and 23

Morton J Kern, MD: All chapters

Jennifer P. Lee, Pharm.D., BCPS Department of Pharmacy VA Long Beach, Long Beach, California

SECTION 1: CARDIOVASCULAR CRITICAL CARE

1 Acute Coronary Syndromes 3

2 Acutely Decompensated Heart Failure (ADHF) 18

3 Adult Advanced Cardiovascular Life Support 29

4 Anticoagulation for Atrial Fibrillation or Atrial Flutter 41

5 Hypertensive Crisis 48

SECTION 2: ENDOCRINE, GASTROINTESTINAL, AND HEPATIC DISORDERS

6 Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS) 59

7 Other Endocrine Emergencies 65

8 Gastroenterology 73

9 Severe Acute Pancreatitis and Liver Failure 87

SECTION 3: INFECTIOUS DISEASES

10 Abdominal infections 97

11 Other infections 110

12 Sepsis and Septic Shock 164

SECTION 4: NEUROCRITICAL CARE

13 Acute ischemic Stroke (AiS) 181

14 Other Neurocritical Care 189

15 Status Epilepticus 195

SECTION 5: PULMONARY DISORDERS

16 Asthma and Chronic Obstructive Pulmonary Disease (COPD) Exacerbation 207

17 Pulmonary Arterial Hypertension (Group 1 Pulmonary Hypertension) 219

SECTION 6: MISCELLANEOUS

18 Acute Alcohol and Drug Poisoning 237

19 Anaphylaxis 259

20 Drug- induced Hyperthermia 263

21 Fluids and Electrolyte Disorders 268

22 Pain, Agitation, Delirium, and Neuromuscular Blockade in the intensive Care Unit (iCU) 282

23 Rapid Sequence induction 298

24 Venous Thromboembolism (VTE) 303

SECTIONONE Cardiovascular Critical Care

1

Acute Coronary Syndromes

This chapter will review the pharmacologic management of acute coronary syndromes (ACS) according to the 2013 American College of Cardiology Foundation/American Heart Association (AHA) ST-Elevation Myocardial Infarction (STEMI) and 2014 AHA/American College of Cardiology Non-ST-Elevation Acute Coronary Syndromes (NSTE-ACS) guidelines.

CLINICAL SIGNS AND SYMPTOMS OF ACS (FIG. 1.1)

Clinical signs and symptoms of ACS:

Chest pain/discomfort radiating to neck, jaws, or shoulders; shortness of breath, nausea/vomiting, indigestion, or new weakness/malaise

Figure 1.1 Presentation a nd D iagnosis of Acute M yocardial I nfarctions. Data from Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2354–2394. ACS, Acute coronary syndromes; ECG, Electrocardiogram; NSTEMI, Non-ST-elevation myocardial infarction; STEMI, ST-elevation myocardial infarction.

CAUSES OF TROPONIN ELEVATIONS (BOX 1.1)

Box 1.1 Causes of Troponin Elevations

Acute decompensated heart failure

Acute MI

Acute pulmonary embolism

Aortic stenosis

Cardiac amyloidosis

Cardiotoxic chemotherapy

Chest compressions

Chest wall trauma

Chronic heart failure

Direct current cardioversion/defibrillation

Early post–cardiac surgery

Heart transplantation

Myocarditis

Pericarditis

Post-PCI

Rhabdomyolysis

Sepsis

Severe strenuous exercise

Tachyarrhythmia

Type A dissection

MI, Myocardial infarction; PCI, Percutaneous coronary intervention

ACUTE MANAGEMENT OF ACS Goals of Care (Box 1.2)

Box 1.2 Goals of Care

STEMI: REPERFUSION THERAPY

Primary PCI recommended if possible within 90 min of presentation

If primary PCI impossible within 120 min of medical contact, thrombolytic recommended within 30 min of presentation unless contraindicated

Surgical revascularization may be indicated

NSTE-ACS: PREVENT TOTAL OCCLUSION OF THE VESSEL

Revascularization within 24–72 h vs. medical management depending on risk stratification, symptom resolution, and indicators of ongoing myocardial damage/ ischemia

NSTE-ACS, Non-ST-elevation acute coronary syndromes; PCI, Percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction

Data from O’Gara PT, Kushner FG, Ascheim DD, et al. ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362–e425; Amsterdam EA, Wenger NK, Brindis RG, et al. AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2354–2394.

Initial Interventions on Presentation of ACS (Box 1.3)

Box 1.3

Morphine

Initial Interventions on Presentation of ACS

2–4 mg IV q5min prn chest pain

Provides analgesia and decreases pain-induced sympathetic tone

Morphine may induce vasodilation and preload reduction

Oxygen 2–4 L/min by nasal cannula or face mask if hypoxemia (SaO2 ,90%), HF, or dyspnea

Use cautiously because it may promote coronary vasoconstriction and generate toxic O2 metabolites

Aspirin 162–325 mg (non-EC) chewed and swallowed immediately, then 81 mg (EC) daily

Nitroglycerin (NTG)

b-Blockers

Inhibit platelet activation

Facilitate coronary vasodilation

NTG 0.4 mg sublingually or spray q5min 33. If continuous ischemic pain, HF, or htn, IV NTG 10 mcg/ min increased by 5 mcg/min q5min to desired effect (NTE 200 mcg/min)

Avoid NTG if:

• SBP ,90 mm Hg or SBP #30 mm Hg below baseline

• Severe bradycardia with HR #50

• HR 100 in the absence of symptomatic HF, or RV infarction

• Oral phosphodiesterase inhibitor within the past 24–48 h

Metoprolol 5 mg IV q5min up to 33 then 25–50 mg

PO q6–12h, transitioned to metoprolol tartrate BID or metoprolol succinate daily

Decreases risk of ventricular arrhythmias and sudden cardiac death post-MI

Improves oxygen flow through the coronary arteries

Initiate within first 24 h of ACS except for:

• Signs of HF or low-output state

• Increased risk of cardiogenic shock (SBP ,120, HR .110 or ,60, age .70)

• Other CI to b-blockade (i.e., active asthma, reactive airway disease, heart block)

Box 1.3 Initial Interventions on Presentation of ACS—cont’d

Acronym

MONA 6

b-Blockers

Morphine

Oxygen

Nitroglycerin

Aspirin

b-Blocker

ACS, Acute coronary syndromes; BID, Twice daily; CI, Contraindication; EC, Enteric coated; HF, Heart failure; HR, Heart rate; htn, Hypertension; MI, Myocardial infarction; NTE, Not to exceed; PO, Orally; RV, Right ventricular; SBP, Systolic blood pressure

Data from Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2354–2394.

Additional Intervention in ACS Management of NSTE-ACS (Fig. 1.2)

NSTE-ACS: Definite or likely

Ischemia-guided strategy

Initiate DAPT and anticoagulant therapy

1. ASA (Class I; LOE: A)

2. P2Y12 inhibitor (in addition to ASA) (Class I; LOE: B):

• Clopidogrel or

• Ticagrelor

3. Anticoagulant:

• UFH (Class I; LOE: B) or

• Enoxaparin (Class I; LOE: A) or

• Fondaparinux† (Class I; LOE: B)

Therapy effective

Early invasive strategy

Initiate DAPT and anticoagulant therapy

1. ASA (Class I; LOE: A)

2. P2Y12 inhibitor (in addition to ASA) (Class I; LOE: B):

• Clopidogrel or

• Ticagrelor

3. Anticoagulant:

• UFH (Class I; LOE: B) or

• Enoxaparin (Class I; LOE: A) or

• Fondaparinux† (Class I; LOE: B)

• Bivslirudin (Class I; LOE: B)

Can consider GPI in addition to ASA and P2Y12 inhibitor in high-risk (e.g., troponin positive) pts (Class IIB; LOE: B)

• Eptifibatide

• Tirofiban

Medical therapy chosen based on cath findings

Therapy ineffective

PCI with stenting

Initiate/continue antiplatelet and anticoagulant therapy

1. ASA (Class I; LOE: B)

2. P2Y12 inhibitor (in addition to ASA):

• Clopidogrel (Class I; LOE: B) or

• Prasugrel (Class I; LOE: B) or

• Ticagrelor (Class I; LOE: B)

3. GPI (if not treated with bivalirudin at time of PCI)

• High-risk features, not adequately pretreated with clopidogrel (Class I; LOE: A)

• High-risk features adequately pretreated with clopidogrel (Class IIa; LOE: B)

4. Anticoagulant:

• Enoxaparin (Class I; LOE: A) or

• Bivalirundin (Class I; LOE: B) or

• Fondaparinux† as the sole anticoagulant (Class III: Harm; LOE: B) or

• UFH (Class I; LOE: B)

CABG

Initiate/continue ASA therapy and discontinue P2Y12 and/or GPI therapy

1. ASA (Class I; LOE: B)

2. Discontinue clopidogrel/ ticagrelor 5 days before, and prasugrel at least 7 days before elective CABG

3. Discontinue clopidogrel/ ticagrelor up to 24 h before urgent CABG (Class I; LOE: B). May perform urgent CABG <5 days after clopidogrel/ticagrelor and <7 days after prasugrel discontinued

4. Discontinue eptifibatide/tirofiban at least 2–4 h before, and abciximab ≥12 h before CABG (Class I; LOE: B).

Late hospital/posthospital care

1. ASA indefinitely (Class I; LOE: A)

2. P2Y12 inhibitor (clopidogrel or ticagrelor), in addition to ASA, up to 12 months if medically treated (Class I; LOE: B)

3. P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor), in addition to ASA, at least 12 months if treated with coronary stenting (Class I; LOE: B)

Figure 1.2 Management of Non-ST-Elevation Acute Coronary Syndrome. From Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2354–2394. †Additional UFH or bivalirudin should be given at the time of PCI because of the risk of catheter thrombosis. ASA, Aspirin; CABG, Coronary artery bypass graft; DAPT, Dual antiplatelet therapy; GPI, Glycoprotein IIb/IIIa inhibitor; NSTE-ACS, Non-ST-elevation acute coronary syndromes; PCI, Percutaneous coronary intervention; UFH, Unfractionated heparin. Class I, Strong recommendation; Class IIa, Reasonable recommendation; Class IIb, May be considered; Class III, No befit; LOE: A, Multiple populations evaluated; LOE: B, Limited populations evaluated.

Oral Antiplatelets (Table 1.1)

Table 1.1 Oral Antiplatelet Therapy

Mechanism of action Inhibits

Comments Non-EC formulation for loading then EC formulation for maintenance Pharmacogenomic variability (CYP2C19) in response

CI: history of stroke/TIA; bleeding risk

Caution: age 75 yr, weight ,60 kg Avoid concomitant ASA .100 mg daily (lack of efficacy)

Notes:

• Aspirin plus P2Y12 for up to 12 months for patients treated initially with an invasive or ischemia-guided strategy

• Aspirin plus P2Y12 for at least 12 months for patients treated with coronary stents

ADP, Adenosine diphosphate; ASA, Aspirin; BID, Twice daily; CABG, Coronary artery bypass grafting; CI, Contraindication; CYP, Cytochrome P450 enzymes; EC, Enteric coated; TIA, Transient ischemic attack

a300 mg loading for #75 yr and no loading for .75 yr receiving fibrinolytic bPatients with weight ,60 kg should receive 5 mg daily

Data from O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362–e425; Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2354–2394; Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44–e122; Wijeyeratne YD, Heptinstall S. Anti-platelet therapy: ADP receptor antagonists. Br J Clin Pharmacol. 2011;4:647–657.

Parenteral Antithrombotics for Percutaneous Coronary Intervention (Table 1.2)

Table 1.2 Parenteral Antithrombotics for PCI

Indirect Thrombin Inhibitor

UFH With GP IIb/IIIa inhibitor: 50–70 units/kg

Without GP IIb/IIIa inhibitor: 70–100 units/kg

Direct Thrombin Inhibitor

Bivalirudin (Angiomax)

0.75 mg/kg

Rebolus to maintain goal

ACT during procedure

With GP IIb/IIIa inhibitor: 200–250 s

Without GP IIb/IIIa inhibitor: 250–300 s — Hepatic and RES No

Additional 0.3 mg/kg if needed 1.75 mg/kg/h CrCl ,30: 1 mg/kg/h With or without

GP IIa/IIIa Inhibitors

Abciximab (ReoPro)

Not in U.S. 0.25 mg/kg 0.125 mcg/kg/min

Max: 10 mcg/min 24–72 h; Up to 7 days RES No

,50: 1 mcg/kg/min HD: avoid

,60: 0.075

Direct P2Y

Inhibitor

ACT, Activated clotting time; CrCl, Creatinine clearance; DC, Discontinuation; GP, Glycoprotein; HD, Hemodialysis; IV, Intravenously; LD, Loading dose; MD, Maintenance dose; N/A, Not applicable; PCI, Percutaneous coronary intervention; PLT, Platelet; RES, Reticuloendothelial system; UFH, Unfractionated heparin

Data from O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362–e425; Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2354–2394; Wijeyeratne YD, Heptinstall S. Anti-platelet therapy: ADP receptor antagonists. Br J Clin Pharmacol. 2011;4:647–657.

Thrombolytics (Table 1.3)

Table 1.3 Thrombolytic Therapy for STEMI

DRUG

Alteplase 15 mg bolus over 1–2 min, then 0.75 mg/kg (NTE 50 mg) over 30 min, then 0.5 mg/kg (NTE 35 mg) over 60 min

Maximum: 100 mg over 90 min

Tenecteplase ,60 kg: 30 mg

60–69 kg: 35 mg

70–79 kg: 40 mg

80–89 kg: 45 mg

90 kg: 50 mg

All doses given as bolus over 5–10 s

Hepatic metabolism

.50% cleared within 5 min after infusion completed, 80% cleared within 10 min

Hepatic metabolism

Half-life elimination: Initial: 20–24 min Terminal: 90–130 min

Original and slow-acting thrombolytic but clinical outcomes are no different

Fast-acting thrombolytic but clinical outcomes are no different

Notes:

• Thrombolytic should be administered within 30 min of hospital arrival

• Administer concurrent aspirin, clopidogrel, and anticoagulant (UFH, enoxaparin, or fondaparinux)

• UFH: 60 units/kg IV bolus, then 12 units/kg/h titrated to target aPTT 1.5–2 times control for 48 h or until revascularization

• Enoxaparin

• STEMI and ,75 yr: 30 mg IV 31 then in 15 min 1 mg/kg subq q12h (max 100 mg for first two doses)

• STEMI and 75 yr: 0.75 mg/kg subq q12h (max 75 mg for first two doses)

• Up to 8 days or until revascularization

• CrCl ,30: same bolus as above then maintenance dose q24h

• Fondaparinux: 2.5 mg IV 31 then 2.5 mg subq daily starting the following day; contraindicated in CrCl ,30

aPTT, Activated partial thromboplastin time; CrCl, Creatinine clearance; IV, Intravenously; NTE, Not to exceed; PD/PK, Pharmacodynamics/pharmacokinetics; STEMI, ST-elevation myocardial infarction; subq, subcutaneously; UFH, Unfractionated heparin

Contraindications (Table 1.4)

Table 1.4 Contraindications to Thrombolytic Therapy

ABSOLUTE CONTRAINDICATIONS RELATIVE CONTRAINDICATIONS

Active bleeding excluding menses

Intracranial neoplasm

Arteriovenous malformation or aneurysm

Suspected aortic dissection

Ischemic stroke within 3 months

Prior intracranial hemorrhage

Significant closed head or facial trauma within 3 months

Intracranial/intraspinal surgery/trauma within 2 months

Bleeding diathesis

Systolic BP .180 mm Hg or diastolic BP .110 mm Hg

Active bleeding in past 4 weeks

Non-compressible vascular punctures

Major surgery in past 3 weeks

Traumatic or prolonged (.10 min) cardiopulmonary resuscitation

Ischemic stroke .3 months ago

Dementia

Active peptic ulcer disease

Pregnancy

Ongoing therapy with warfarin

Data from O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362–e425.

Medical Therapies for Stabilized ACS (Table 1.5)

Table 1.5 Routine Medical Therapies for Stabilized ACS

CLASS INDICATIONS

ORAL DRUG REGIMEN (TARGET DOSE)

b-Blockers All patients without CI Metoprolol tartrate 25–50 mg q6–12h, transitioned to BID of metoprolol tartrate or daily of metoprolol succinatea (200 mg/day)

Carvedilol 6.25 mg BID (25 mg BID)

Bisoprolol 1.25 mg daily (10 mg daily)

ACEI All patients with anterior infarction, post-MI LV systolic dysfunction (EF #40%), or HF

All patients without CI

ARB For patients intolerant of ACEI

Lisinopril 2.5–5 mg daily (10 mg daily)

Captopril 6.25–12.5 mg TID (25–50 mg TID)

Ramipril 2.5 mg BID (5 mg BID)

Trandolapril 0.5 mg daily (4 mg daily)

Valsartan 20 mg BID (160 mg BID)

AVOID/CAUTION

Signs of HF, low output state

Increased risk of cardiogenic shock

Prolonged first-degree or high-grade

AV block

Reactive airway disease

Hypotension

Renal failure

Hyperkalemia

Statins All patients without CI

Atorvastatin 80 mg daily

Hypotension

Renal failure

Hyperkalemia

DDI: CYP3A4, fibrates

Monitor for myopathy, hepatic toxicity

ACS, Acute coronary syndrome; ACEI, Angiotensin converting enzyme inhibitor; ARB, Angiotensin receptor blocker; AV, Atrioventricular; BID, Twice daily: CI, contraindication; CYP, cytochrome P450 enzymes; DDI, Drug-drug interaction; EF, Ejection fraction; HF, Heart failure; LV, Left ventricle; MI, Myocardial infarction; TID, Three times daily.

aSuccinate form rather than tartrate recommended if concomitant non-ST-elevation myocardial infarction, stable HF, or reduced systolic function

Data from O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362–e425.

CHAPTER 1 Acute Coronary Syndromes

References

1 O’Gara PT, Kushner FG, Ascheim DD, et al. ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362–e425.

2. A msterdam EA, Wenger NK, Brindis RG, et al. AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2354–2394.

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