ACS and Plavix, Statins, G2b3a Inhibitors

[waterski232002]

It is pretty clear that everyone uses typical MONA, BB, Heparin gtt for all patients with ACS in the ED. Just curious if everyone is also using Plavix, Statins, and/or G2b3a Inhibitors as well (in certain situations, or in consultation with cardiology).

I generally do the following...

UA - MONA, BB, Heparin gtt, +/- Plavix
NSTEMI - MONA, BB, Heparin gtt, Plavix
STEMI - MONA, BB, Heparin gtt, Plavix, Cath lab alert

I don't routinely administer statins acutely in the ED for ACS, although cardiology will often order it when they come down, and I also don't start G2b3a Inhibitors either. Do any of you?

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[Apollyon]

The IIb/IIIa that is used is dependent on whether the pt is going to the cath lab - there's good data about which one to use (like abciximab).

I never do IIb/IIIa without talking to cards, since they're the ones sticking the groin (or wrist).

 

[southerndoc]

I generally do the following...

UA - MONA, BB, Heparin gtt, +/- Plavix
NSTEMI - MONA, BB, Heparin gtt, Plavix
STEMI - MONA, BB, Heparin gtt, Plavix, Cath lab alert

The data for GP IIb/IIIa inhibitors prior to early cath isn't supportive of its use. It is, however, supported at stent deployment and with delayed cath (i.e., ACS managed medically and catheterized two days later).

Plavix is also not supported early on. At my institution, it is ONLY given when the stent is deployed. If you give it in the ED, a patient goes to cath, and then subsequently can't be stented and must go for an emergent CABG, then guess what? You're giving platelets. With a loading dose of 300 mg, about 55% of the platelets will be irreversibly inhibited within one hour. This effect lasts the lifetime of the platelet (7-10 days), and with additional doses, a steady state is reached whereby 90% of platelets are inhibited.

Resist the temptation to do everything possible in the ED. Aspirin, oxygen, nitrates and heparin are the mainstays of treatment for any ED physician. Morphine has recently been called into question as possibly associated with increased mortality, but no prospective study has ever examined this and it may be due to those requiring morphine having increased ischemia and therefore increased risk of death prior to even getting the morphine (since those with less ischemia may have relief with nitroglycerin).

The rush to give beta blockers in the ED is also being questioned since the majority of research supporting beta blockade in acute MI was done during the thrombolytic era and hasn't been well studied in the cath era. Patients receiving beta blockers and then subsequently undergoing heart catheterization have a higher rate of cardiogenic shock, increased requirement and prolonged duration of intraaortic balloon pump, and increased morbidity during the first 48 hours. Some cardiologists have suggested that beta blockers should not be given until post-cath day 1. However, this still remains a "core measure" that beta blockers be given within the first 24 hours, and preferably in the ED. This may change in the near future though.

 

[waterski232002]

At my institution, cardiology has insisted that we stock plavix in our pyxis for the sole purpose of ACS. Most of the cardiology research shows decreased morbidity and mortality with early Plavix loading within the first 6 hours. This was also highlighted in last months ACEP News article as well. The only caveat was if you suspect the patient may need an emergent CABG. In reality, the percentage of patients requiring emergent CABG is extremely low, partly b/c the vast majority of patients do not have 3 vessel disease on presentation, and partly b/c of the patients that DO, cardiology can stent the inciting lesion responsible for the immediate ischemia, and the CABG can be done semi-urgently. Plavix can then be discontinued well before the patient is taken to the OR. Based on this, they are encouraging us to use Plavix for ACS.

 

[southerndoc]

Most of the cardiology research shows decreased morbidity and mortality with early Plavix loading within the first 6 hours.

"Most" cardiology research has not supported its early use. Research supporting its use within 6 hours does not mean you have to give it within 5 minutes. ACE inhibitors for anterior wall MI and CHF patients has been beneficial if given 24 hours after presentation, but that doesn't mean you have to give it in the ED.

We need to resist the temptation of stocking every medicine in the ED and just throwing the kitchen sink at a patient. We must consider the consequences, and there should be clear indications for its use. In patients who are NOT undergoing immediate catheterization, then yes, it is indicated. In patients undergoing emergent PCI, then no, it is not indicated until stent deployment.

At my institution, 5% of patients go for emergent CABG for multi-vessel disease or proximal LAD lesions. Yes, this number is low, but these patients are operated on within 24 hours and would be unnecessarily exposed to blood products if given clopidogrel. Those who were given clopidogrel and who did not have multi-vessel disease would not have any statistically significant improvement in outcome.

FYI, the 2005 AHA/ACC guidelines recommended further reseach is needed to determine the optimal loading dose and timing before PCI. To my knowledge, there have been no trials examining clopidogrel use in emergent PCI. PCI-CURE, PCI-CLARITY, CREDO, ISAR-REACT, and ARMYDA-2 evaluated patients who were being medically managed prior to catheterization. Most had exclusion criteria of patients undergoing emergent PCI for acute MI, and most had catheterization after 2-5 days of ongoing ischemia or after thrombolysis.

PCI-CURE evaluated patients who received clopidogrel up to 6 days prior to catheterization -- not 6 hours. In fact, the shortest time evaluated was 48 hours of pre-treatment with clopidogrel. CREDO found that clopidogrel must be given a minimum of 15 hours prior to PCI to significantly impact peri-procedural events.

PCI-CLARITY demonstrated a significant reduction in mortality when acute MI patients were given clopidogrel concomitantly with thrombolysis. They were continued on clopidogrel for a minimum of 2 days prior to PCI.

Again, I am unaware of any research of clopidogrel use in ST-elevation MI or non-ST elevation MI that is going for immediate (emergent) catheterization. I could be missing the study by not having read a recent one, but I usually stay pretty current on acute MI stuff because of my risk factors (significant family history, genetic cholesterol disorder, high blood pressure, etc.).

Clopidogrel use in ACS/non-STEMI that is not going for emergent PCI may be indicated, but it is not indicated in STEMI or NSTEMI going for emergent PCI. (A significant portion of our NSTEMI's go for emergent PCI.)

 

[waterski232002]

Thanks southerndoc... it may be institutional bias leading to our liberal use of plavix in the ED. Nevertheless, if I don't write for it, cardiology will... they'll just wonder why I didn't give it in the first place.

 

[waterski232002]

So what about statins???? Does anyone write for these acutely in the ER?

 

[Apollyon]

So what about statins???? Does anyone write for these acutely in the ER?

Never have.

 

[southerndoc]

So what about statins???? Does anyone write for these acutely in the ER?

There is evidence to support its use in the first 24 hours. Patients who were started on statins within 24 hours of MI had a 4% mortality rate (5% for those who were continued on outpatient statins). Those who were not started on statins had a 15% mortality rate, and those who had a statin that was discontinued upon admission had a 16% mortality rate.

Although the data supports its use in the first 24 hours, it has never been evaluated when given in the ED. It is unlikely to have a significant mortality benefit when given in the ED. With so many interventions already being implemented and with a push to get patients to the cath labs quicker (60 minutes instead of 90 minutes), there is already enough pressure to get what meds have been shown to benefit mortality when given early. Throw in a few more meds, and you delay the ultimate intervention (PCI) and you increase the chances of an adverse drug event.

On another note, statin use in sepsis looks to be a promising trial. This is likely to be implemented in the ED since many ED's have long lengths of stay for patients admitted to an ICU. There is a clear benefit to patients who were already on a statin prior to arrival, and new research is underway right now to evaluate initiating statins in septic patients. At any rate, this is a topic for another day.

 

[Jeff698]

Just curious if everyone is also using Plavix, Statins, and/or G2b3a Inhibitors as well (in certain situations, or in consultation with cardiology).

For our low risk R/O patients, I give NTG, BB, ASA and fentanyl as needed to make them pain free.

NSTEMI's get the above plus either a heparin drip or lovenox depending on my mood. I generally prefer the drip.

STEMI's get rapid cath lab activation, NTG, BB, ASA, fentanyl as needed, heparin and integrilin. Our rate limiting step is usually reading the CXR prior to turning on the heparin and integrilin drips. Not that that is a long step (we're on a PACS system), just that cards is very responsive here and we get them out of the department pretty damn fast.

My best time so far was 8 minutes with prior EMS notification with field 12 lead. They sort of slowed down while we got a CXR and hung some drips before continuing on up to the lab. Cards was hanging out with us waiting on the patient, much like surgery with trauma alerts.

I've never given plavix in the ED.

Take care,
Jeff

 

[Apollyon]

I've never given Plavix in the ED.

Just keep in the back of your mind the 300mg of clopidogrel for the truly ASA-allergic (and some of the cards people I've known have pushed giving 600mg!).

 

[RuralMedicine]

The data for GP IIb/IIIa inhibitors prior to early cath isn't supportive of its use. It is, however, supported at stent deployment and with delayed cath (i.e., ACS managed medically and catheterized two days later).

Plavix is also not supported early on. At my institution, it is ONLY given when the stent is deployed. If you give it in the ED, a patient goes to cath, and then subsequently can't be stented and must go for an emergent CABG, then guess what? You're giving platelets. With a loading dose of 300 mg, about 55% of the platelets will be irreversibly inhibited within one hour. This effect lasts the lifetime of the platelet (7-10 days), and with additional doses, a steady state is reached whereby 90% of platelets are inhibited.

This is a very good point. The institution I trained at gave Plavix loading doses on the cath table after stents had been successfully placed. I also like GP IIb/IIIa inhibitors for ACS/NSTEMI with delayed cath. In STEMI you either should be thinking emergent cath or lytics (probably not a reality for anyone training because you probably have cath labs but we do not and if weather doesn't permit us to fly getting to cath <2hours may not be possible so we do use lytics sometimes). As far as statins I think on the admission orders is fine (although some of our gungho EM folks would give them along with Aspirin, BB where I trained) and they do show a mortality benefit but you're right about the 24 hour time period.