0730 - Management of Angina and ACS - RM

Question 1

What are the short-term aims of treatment in STEMI (3)?

Answer 1

1. Lyse the thrombus
2. Keep the plaque stable
3. Decrease heart demand in the short term.

Question 2

What is the definition of stable angina?

Answer 2

Chest discomfort that occurs predictable and reproducibly at a certain level of exertion and is relieved with rest or nitroglycerin.

Question 3

What are the goals of treatment for stable angina?

Answer 3

Prevent/minimise ischaemia and improve survival by:

• Reduce plaque progression
• Stabilise plaque
• Prevent thrombosis if plaque rupture occurs.

Minimise or abolish symptoms over the longer term.

Question 4

What percentage of an artery needs to be occluded to cause symptoms of haemodynamic compromise?

Answer 4

70% if a single lesion.

50% if lesion is in left mainstem, or if multiple lesions.

Question 5

What pharmacological management is used to improve the prognosis of stable angina?

Answer 5

Prevent thrombus - Antiplatelet (low-dose aspirin or clopidogrel)
Reduce plaque progression - Lipid-lowering therapy (statins for all, fibrates for high-risk) to get LDL <2mmol/L
Reduce myocardial demand - Beta blockers (reduce HR and contractility)
Reduce Myocardial demand - ACE Inhibitors (particularly for those with comorbidities - hypertension, heart failure, diabetes etc)
Angiotensin-II receptor blockers (if in heart failure or have previous MI)
Annual Fluvax

Question 6

What prescription and advice should be provided to patients with stable angina?

Answer 6

Advice to lower risk factors and aid rehabilitation (stop smoking, exercise, eat right etc).

Sublingual nitrates and rest in the event of an acute attack.

Seek medical advice if symptoms persist for more than 10-20 minutes, as they will require ECG and blood test, with possible angiogram.

Question 7

What are the key principles of treatment for a patient with stable angina? (Key concept)

Answer 7

General advice (lose weight, stop smoking, moderate alcohol, exercise, lower BP, manage comorbidities etc).

Pharmacological therapy (particularly regular antiplatelet, statin, and beta-blocker, with sublingual nitrate as required).

Consider revascularisation if SI still limiting activities despite drug treatment - Percutaneous coronary intervention (if only 1 or 2 vessels diseased, or unfit for surgery), or CABG (if left main artery diseased, or more than 3 vessels).

Question 8

What are the key aims of early management of patients with Acute Coronary Syndromes?

Answer 8

Relieve Ischaemic pain
Assess haemodynamic state and correct abnormalities
Reperfuse with primary PCI (or fibrinolysis if unavailable) to save the myocardium - Emergency CABG if this fails and patient in cardiogenic shock/life-threatening arrhythmias.
Antithrombotic therapy (prevent rethrombosis or acute stent thrombosis)
Beta-blocker (lower myocardial demand - prevent recurrent ischaemia and ventricular arrhythmias)

Question 9

What is the pharmacological management of acute coronary syndromes?

Answer 9

Oxygen
Sublingual nitrates (IV if pain persists after 3 tablets)
Antiplatelets (aspirin unless contraindicated)
Anticoagulants for most (generally heparin, sometimes direct thrombin inhibitors)
Morphine
Beta blocker (unless contraindicated)

Question 10

What is the long-term pharmacological treatment for ALL patients post-STEMI (unless personal contraindications)?

Answer 10

Antiplatelets and anticoagulants (aspirin for life, also others for periods up to several years)
Beta-blockers
ACE-inhibitor (or angiotensin-II receptor blocker (ARB) if not tolerated)
Statins
Fluvax annually

Question 11

What three conditions fall under Acute Coronary Syndromes?

Answer 11

STEMI
Non-STEMI
Unstable Angina