So, unstable angina, we've got that anti-ischemic therapy because our goal is prevent infraction.
So, when we say anti-ischemia, we're trying to resolve that chest pain or ischemia.
Use nitroglycerin, beta blockers, oxygen and we consider ACE inhibitors, right?
These are ARBs. If they can't handle the ACE, we try an ARB.
Now, if you're not familiar with those medications, we have some great videos on both of those.
ACE inhibitors and angiotensin II receptor blockers.
So you wanna check those out in the RAAS but we're talking about -
remember we already -- this is different than MONA.
This is just some other things that we can lay on nitroglycerin, beta blockers, oxygen.
Those are kinda familiar to you but the ACE inhibitors and ARBs are other medications that are treated
if someone is experience unstable angina. It's not gonna deal with the acute event
but it'll help us over a longer period of time.
We're also worried about clots getting bigger or developing.
So we put patients on antiplatelet therapy.
Remember, that's what makes clots, platelets grouping together.
So, we're gonna look at aspirin and maybe think of some other antiplatelets
that we might put the patient on but you remember that from MONA.
Anticoagulation therapy is little bit different.
Here, we're gonna use a low molecular weight heparin. That's what LMW means.
We also might look at a direct thrombin inhibitor.
Now, if you've been with us for some of our videos,
you know that the medications are inhibitors are things that stop that actions.
So, thrombin is what helps make a clot stick together.
So, if we have a thrombin inhibitor, the patient is less likely to have a clot stick together.
We can also use unfractionated heparin but predominantly we use low molecular weight heparin
because it's a little bit better. It's just as effective and we don't have to do as much lab work to monitor it.
Which is why for most anticoagulant therapy we look at low molecular weight heparin.
So, thinking about thrombolytics is something that the health care team will do if we cannot resolve the chest pain.
If that clot is just too big or too tightly lodged, we're gonna consider thrombolytics.
But keep in mind, while these are highly effective medications, they're also high risk medications.
So, we're gonna want to rule out any contraindications for thrombolytic.
If the patient has had a recent trauma or surgery or they've had uncontrolled hypertension,
these drugs are just too risky.
They also need to have a thrombolytic medication within four hours usually of the onset of the symptoms.
Why is that? Because if it's longer than four hours, it's likely the tissue is just dead.
And restoring blood flow to dead tissue is really not gonna help us.
So we wouldn't risk a thrombolytic medication that breaks up all the clots in your bodies
including some that maybe keeping things together in your head or other areas of your body.
We wouldn't give a medication like this if we didn't think we could revive that tissue.
Beta blockers, how did these help?
Or remember, these will help prevent infarction
because they directly decrease the heart rate and the contractility of the heart -- how hard it's pumping.
So, the workload of the heart is less, since so they'll need less oxygen.
We can also use beta blockers after MI.
So even if the patient is had an infarction,
after MI it's very common for them to be placed on a beta blocker when they go home.
It reduces mortality and there are several studies that have shown that a patient who suffered in MI,
if we put them on a beta blocker long term, that would help them have much better results.
So this is one of the most common drugs to control ischemia and patients who have stable coronary artery disease.
Oxygen, we talked about that as -- we used that -- we used to give that to everybody
but now the patient needs it only if they have a sat that's less than 90% or they're showing us some sign of respiratory distress.
Okay, here's why you find yourself on the slide for antiplatelet and anticoagulant therapy.
Anti means against.
So antiplatelet and anticoagulant means we're gonna reduce the opportunity for platelets
to clump up or for things to coagulate.
Remember that's probably what got us into this problem with the unstable angina that progress to an MI.
So we're gonna give people medications that will minimize the risk for those platelets grouping together
and making a big clot and for things to coagulate and make up clot.
So, antiplatelet therapy, there's your old friend, aspirin.
Now, patient is likely gonna be on that from the rest of their life. So that's why it says indefinitely
after that, most people will be on that likely for the rest of their life.
Now the next medication is also kind of a tongue twister but wait, I've got some even better ones coming for you.
They'll only be on that medication for about 2 months.
So it's a little more potent medication than a regular aspirin
but the patient will be on that for likely just two months immediately following the event.
Yep, there it is. Do you see that? Abciximab.
Honestly, I had to listen to that on Google multiple times and that's a great tip.
If you ever find a drug and you say, "Huh? I don't even know how to pronounce that."
Just Google it and practice because I couldn't begin to remember how to pronounce this medication.
But we only use this medication if an angioplasty is planned.
That means if they're going to have a procedure.
Now this next one is another tongue twister. I'll let you look that one up and Google it.
But we only use this one for high risk patients if the angioplasty is not planned.
So the most important one I want you to keep in mind is the aspirin
but we've listed other antiplatelet therapy drug options for you there.
Now let's look at anticoagulant therapy. We're against coagulating.
Most often we use Subcutaneous Low Molecular Weight Heparin.
You'll see that as LMW Heparin.
When I say subcutaneous, that means the patient has to actually inject themselves.
When we first start using this, it was so amazing
because you didn't have to do the same lab work that you have to do with unfractionated heparin.
You don't draw on aPTT but you do have to stick yourselves.
So we used to send patients home with home health care nurses,
if they're going home on this medication. We made a really big deal about it.
Now, we simply educate the patient about how to give themselves a subq shot and it's always given in the abdomen.
We educate them on how to do it. We walk them through the process.
And then, we send them home to self-inject.
So we've come a long way than when we first started with this medication.
That's also very common. You'll notice that we take something very seriously in the beginning
and we still take it seriously but you'll see it progress in the outpatient setting over a course of time.
Now, we can also use IV unfractionated heparin but that one needs very close lab monitoring.
We do a test called an aPTT.
We would wanna watch that very closely to make sure patient doesn't get into risk of severe bleeding.
So, anticoagulants put your patient in increased risk for bleeding as do antiplatelets.
So write yourself a little note at the bottom of the slide -- increased risk for bleeding.
Now, an example of a direct thrombin inhibitors is bivalirudin.
That's a cool drive because thrombin is what helps keep those clots together.
So by taking this direct thrombin inhibitor, we're gonna have less chance of having those clots sticking around.
Now, fondaparinux, sounds very French doesn't it?
I don't think it is but it just sounded cool that way. That's a factor Xa inhibitor.
That's another opportunity for us to use anticoagulation therapy with our patients.
Who've already proven to us they're pretty good at making clots.
Okay, that was a lot of information on this slide. What are our take away points for this?
Well, first of all, let's think about, why would I put somebody who's had an unstable angina event
or an MI on drugs that are against platelets or against coagulating?
Ah, because I don't want them to make future bigger clots or some plaque breaks off.
I don't want extra thing sticking to it. Okay, cool.
What are the increased risks for my patient if they are on antiplatelet or anticoagulant?
Yeah, bleeding. That's gonna be a big risk.
Now, the drug names that I wanna make sure that you really highlight on this one -- aspirin is important.
And I want you to remember subq low molecular weight heparin.
The other ones are also useful but that's the minimum requirement of what you wanna take away
as just one example of each of antiplatelet and anticoagulant therapy.