1 - ACS and Hypertension Flashcards
1
Q
What is ACS and what is the aetiology of this?
A
STEMI/NSTEMI/Unstable Angina
Due to either plaque rupture, thrombosis or inflammation
2
Q
What are the signs and symptoms of ACS?
A
Signs: distress, anxiety, pallor, sweatiness, low grade fever, signs of heart failure (raised JVP, basal crepitations, 3rd heart sound)
Symptoms: acute central crushing chest pain lasting >20 minutes, nausea, sweating, dyspnoea, palpitations
3
Q
What is a silent ACS and what patients does this occur in?
A
ACS without the chest pain. May have syncope, pulmonary oedema, epigastric pain, vomiting, post op hypotension, oliguria, diabetic hyperglycaemia
Seen in the elderly and diabetics often
4
Q
What are some risk factors for ACS?
A
Non-Modifiable
- Age
- Male
- FHx
Modifiable
- Smoking
- Hypertension
- DM
- Hyperlipidaemia
- Obesity
- Cocaine use
5
Q
How are each of the three acute coronary syndromes diagnosed based on their investigation findings?
A
Triad of symptoms, ECG changes and hs-TnI levels
All will have cardiac sounding chest pain
STEMI:
- ST elevation (>1mm in limb leads and 2mm in chest leads) or new LBBB
- hs-TNI >100ng/L
- CK often raised over 400
NSTEMI
- ST depression, T-wave inversion or normal
- hs-TnI>100ng/L
Unstable Angina
- ST depression, T wave inversion or normal
- hs-TnI is normal
6
Q
What are the cardiac biomarkers used for a suspected MI and why?
A
- Trop I as high sensitivity as released from cardiomyocytes on necrosis.
- Begins to rise 3-4 hours after myocardial damage and remains high for 2 weeks
- Also check CK levels
- Need to see if falling, static or rising so take Trop I on admission then again in 3 hours to assess trend. Only need one result if onset of symptoms >3hours before presentation
7
Q
What can cause false positive elevation of hs-TnI, meaning the patient is not having an MI?
A
Common: advanced renal failure, PE, CPR, ablation therapy
Less common: severe congestive heart failure, myocarditis, prolonged tachyarrhythmia
Rare: aortic dissection, aortic stenosis, hypertrophic cardiomyopathy, malignancy, stroke, severe sepsis
ALWAYS TAKE SERIAL MEASUREMENTS AND LOOK AT THE TREND NOT THE VALUE OF TEST
8
Q
What ECG leads correspond to each area of the heart e.g anterior, septal etc?
VERY IMPORTANT
A
- Lateral: circumflex artery ( I, aVL, V5, V6)
- Septal: LAD (V1, V2)
- Anterior: LAD (V3, V4)
- Inferior: right coronary artery (II, III and aVF)
- Posterior (V7-V9): circumflex artery
9
Q
What are the immediate ECG changes in a STEMI? (excluding a posterior STEMI)
A
- ST elevation in 2 or more leads from the same zone e.g II, III, aVF.
- ST elevation >1mm in limb leads, >2mm in chest leads
- Presence of LBBB
- May have hyperacute tall T waves
10
Q
What are the sequential ECG changes following an STEMI?
A
Within hours: ST elevation and hyperacute T waves or LBBB
24 hrs: T wave inversion, ST normal
Few days: pathological Q waves that persist
11
Q
How does a posterior MI present on a 12 lead ECG, why is this and what should you do next?
IMPORTANT
A
- ST depression in leads V1-V4
- Reciprocal changes (upside down) due to looking at ischaemic myocardium from the other side
- Need to do 15 lead ECG (V7-V9 and RV4) in all STEMI patients, especially those with inferior STEMI or ST depression in V1-V4
12
Q
What are the ECG changes in an NSTEMI or unstable angina?
A
- ST depression or elevation
- T wave inversion (reperfusion waves) or flattening
- T wave pseudonormalisation
- Previously established ECG changes e.g old MI, LV hypertrophy
- Normal ECG
13
Q
What is T wave pseudonormalisation?
A
NSTEMIs often have T wave inversion that represents reperfusion of the area
On repeat ECG T waves may appear back to normal after firstly being inverted but this just means the artery is reoccluded
14
Q
Apart from an ECG and cardiac enzymes, what other investigations should you carry out for a patient who presents with cardiac chest pain ?MI?
A
CXR: look for cardiomegaly, pleural effusion, widened mediastinum
Bloods: FBC, U+Es, random glucose, lipid profile, HbA1c, cardiac enzymes (2 tests 3 hours apart)
ECHO: regional wall abnormalities
15
Q
What are some conditions that can mimic a STEMI on ECG?
A
- Early re polarisation: usually leads V1 or V2, often in younger athletic patients and sometimes Afro-Caribbeans
- Pericarditis: widespread ST elevation
- Brugada Syndrome (sudden death): looks like anterior STEMI
- Takotsubo Cardiomyopathy: emotionial stress reaction in middle aged females that is temporary
16
Q
What are some differential diagnoses for ACS?
A
- Stable angina
- Pericarditis
- Myocarditis
- Takotsubo cardiomyopathy
- Pneumothorax
- PE
- Oesophageal spasm/reflux
- MSK pain
17
Q
What is the immediate management of an acute STEMI when a patient arrives at A+E?
A
- Brief history and exam with ECG (take bloods and CXR)
- Gain IV access
- Morphine with antiemetic e.g metoclopramide or cyclizine
- Aspirin 300mg if not already given
- Oxygen if hypoxic, keep >94%
- Anticoagulate (see next flashcard)
- Restore coronary perfusion if <12h since onset
18
Q
Patients are given a loading dose of aspirin when they are having a STEMI. They also need to be further anticoagulated before reperfusion therapy, which drugs are used for this?
A
Prasugrel 60mg (inhibits ADP receptors)
If undergoing PPCI and are under 75 and weight more than 60kg and have not had prior TIA or stroke
Clopidogrel 600mg (inhibits ADP receptors)
If do not fufill criteria for prasugrel
Ticagrelor 180mg
If cannot have prasugrel or first line NSTEMI. Do not use if high bleeding risk
19
Q
How do doctors choose which reperfusion therapy to offer to a patient with an acute STEMI?
A
PPCI
- Used if <12h since onset and can be given PPCI within 120 minutes of first medical contact
Thrombolysis
- Used if <12h since onset but cannot get PPCI within 120 minutes. Given infusion (e.g alteplase TPA) then transferred to PCI centre
No reperfusion
- If presenting >12h, just given fondaparinux or enoxaparin
20
Q
What are some contraindications for treating a STEMI with thrombolysis?
A
- Previous intracranial haemorraghe
- Ischaemic stroke <6months ago
- Recent major head trauma/surgery
- Known bleeding disorders
- Liver biopsy or LP in past 24 hours
- Pregnancy
- GI bleeding
- Cerebral malignancy
21
Q
What blood tests are essential for a patient with a STEMI?
A
- Cardiac enzymes (TropI)
- FBC
- Lipid profile
- Random blood glucose
- HbA1c
22
Q
What medications are patients started on after an MI and for how long?
A
- Aspirin 75mg for life
- Ticagrelor (or another antiplatelet e.g Clopidogrel/Prasugrel) for 12 months
- ACEi or ARB for hypertension (checking renal function)
- Beta-blocker to lower heart rate (e.g Bisoprolol)
- Statin (e.g atorvastatin 80mg or rosuvastatin 5mg). Use ezetimibe if all statins have side effects
ATABS (also consider PPI for gastric protection with antiplatlets)
23
Q
How much do you want LDL cholesterol to be lowered by with a statin?
A
40% reduction in non-HDL cholesterol. Total cholesterol should be below 4
24
Q
After initial management of a STEMI and starting them on some cardioprotective medications, what are some other management principles you need to do for the patient?
A
CONTROL RISK FACTORS AND MANAGE ANY COMPLICATIONS
- Smoking cessation
- Control diabetes <7.5% Type 2 and <7% Type 1
- Control hypertension
- Encourage daily exercise with cardiac rehabilitation programme
- Advise diet low in saturated fats
25
If a patient is being anticoagulated for AF then has a STEMI and needs two more anticoagulants, what should you consider giving them?
Limit time on the drugs and give them a PPI
26
What are some complications of a STEMI and how are they managed?
**- Heart failure:** diuretics e.g Epleronone
**- Cardiogenic shock:** need inotropes and balloon pumps]
**- Valve damage** e.g Mitral Regurg: may present with pulmonary oedema, needs valve replacement
**- Ventricular Septal Defect**: pansystolic murmur that is diagnosed on ECHO and needs surgery
**- Pericarditis:** give NSAIDs
27
How long after an MI can a patient return to work and driving?
**Driving:** 1 week after successful angioplasty or 4 weeks after unsuccessfil angioplasty
**Work:** depends on clinical progress and nature of work. Should be encourage to modify work activities
28
How is an NSTEMI/Unstable angina managed immediately?
1. Pain relief with morphine
2. Aspirin 300mg
3. Start LMWH (Enoxaparin for 48h based on weight and creatinine)
4. Repeat ECG
5. Calculate if low or high risk with GRACE score
6. If high risk \>3% give Ticagrelor and offer angiography
7. Consider antianginals whilst waiting for angiography e.g nitrates, ranolazine, CCBs
29
What is the GRACE score?
Score that risk stratifies a patients 6 month mortality with ACS. If \>3% then high risk
Looks at age, heart rate, systolic BP, creatinine, abnormal cardiac enzymes, ST segment abnormalities
30
What medications should patients be placed on after an NSTEMI?
Same as with a STEMI, ATABS!!!!!
- Dual antiplatelet
- ACEi
- Beta blocker
- Statin
Make sure you address modifiable risk factors e.g hyperlipidaemia, diabetes, ACEi, statin
31
What is angina and how does it present?
Symptomatic reversible myocardial ischaemia causing chest discomfort
1. Constricting/heavy discomfort to chest, jaw, shoulders or arms
2. Symptoms brought on by exertion
3. Symptoms relieved within 5 mins of rest or with GTN
32
What are some associated symptoms with angina if it is severe, and what symptoms make the diagnosis of angina less likely?
**Associated symptoms**: fear, sweating, nausea, dyspnea
**Less likely to be angina:** pain that is continuous, pleuritic or worse with swallowing, palpitations, dizziness, tingling
33
Angina can be difficult to distinguish from other differentials e.g GORD, MSK pain, pulmonary disease. What makes a diagnosis of angina more likely?
Two or more risk factors for coronary artery disease means the chest pain is more likely to be due to angina:
- Smoking
- Hypertension
- Valvular heart disease
34
Apart from exercise, what are some other things that can precipitate angina?
- Emotion
- Cold weather
- Heavy meals
35
Angina is usually due to atheromas in the coronary arteries (coronary artery disease). What are some other conditions that can cause symptoms of angina in the absence of coronary artery disease?
- Aortic stenosis
- Hypertensive heart disease
- Hypertrophic cardiomyopathy
36
What is decubitus angina and variant (Prinzmetal) angina?
**Decubitus:** precipitated by laying flat
**Variant:** caused by coronary artery spasm, occurs at rest
37
What questions are important to answer in the history of a patient with suspected stable angina?
38
What are some things you should look at on examination of a patient with suspected angina?
- Height and weight for BMI
- Blood pressure
- Presences of murmurs (particularly aortic stenosis)
- Evidence of hyperlipidaemia
- Evidence of peripheral vascular diease or carotid bruits
39
What are some tests you should do as standard for all patients with suspected angina
- FBC, U+Es, TFTs HbA1c, Glucose
- Full lipid profile
- Resting 12 lead ECG
- Consider ECHO and CXR
40
Patients who have angina like pain are scored based on their estimated likelihood of CAD. What investigations should you offer for different likelihood scores?
**- 61-90%:** Invasive coronary angiography
**- 30-60%:** Functional imaging e.g stress MRI, echo or myoview
**- 10-29%**: CT calcium scoring. If zero likelihood is minimal. If 1-400 consider CTCA or stress perfusion imaging. If \>400 CTCA
41
What is the likelihood score for coronary artery disease in males and females over 70 presenting with angina symptoms?
**Male \>70:** \>90%
**Women \>70**: 61-90% unless women at high risk and typical symptoms then risk of \>90%
42
When should you not use an exercise ECG to diagnose or exclude stable angina?
People without known CAD
43
What are the principles of management in angina?
1. Address exacerbating symptoms e.g anaemia
2. Secondary prevention of CVD
3. PRN symptom relief
4. Antianginal medication
5. Revascularisation if all above fails
44
What medications are all patients with angina started on for secondary prevention of CVD?
**- Aspirin** 75mg (clopidogrel if cannot tolerate)
**- Statin**
- **ACEi** if diabetic
- Always address risk factors like smoking, hypertension, diabetic control
45
What medication are patients with angina given for symptomatic relief?
What are some common side effects?
- Sublingual GTN spray
- Take dose every 5 mins then after 15 mins call ambulance if not improved
- Can cause **headaches, dizziness and hypotension**
46
Rate limitation is the goal in patients with angina.
What antianginal medications are patients with angina started on?
**_1st Line_**
**B-Blockers**: Atenolol or bisoprolol
or
**NDHP CCB if above Cx**: Diltiazem or Verapamil
**_2nd Line_**
**- BB + CCB**
- If one of the above is Cx give one with **long acting nitrate isosorbibe mononitrate, nicorandil or ranolazine**
47
How do the following drugs act as anti-anginal medicine and when are they used?
- Nicorandil
- Ivabradine
- Ranolazine
Used 1st line as monotherapy if CCB and BB contraindicated or used in conjunction with one of them as 2nd line
**Nicorandil:** K+ channel activator. Can't use in pulomary oedema or hypotension
**Ivabradine:** Reduces HR without lowering BP by blocking sinus node. Do not give if HR\<70 or not in sinus rhythm, and do not coprescribe with CCB
**Ranolazine:** Inhibits late Na current. Caution in heart failure, elderly, \<60kg, eGFR\<30
48
Why do you need to be careful when prescribing long acting nitrates for angina?
Want to **avoid nitrate tolerance**. No point adding a nitrate if patient already established on nicorandil for example
49
What medicines are given to patients with angina?
- Aspirin
- Statin
- ACEi if diabetic
- BB +/ CCB
- Long acting nitrate, Ivabradine, Nicorandil, Ranolazine
50
When are patients with angina considered for revascularisation and what are the options for this?
When medical therapy is not providing symptomatic relief
**Percutaneous Coronary Intervention:** Balloon inflated in the vessel opening the lumen. Stent placed in. Dual antiplatelet therapy (aspirin and clopidogrel) for 12 months to reduce risk of in stent thrombosis
**CABG**: Less likely to need revascularisation but needs open heart surgery so slower recovery
51
When is a CABG carried out and what are the complications with this?
- Angina unresponsive to drugs
- Unstable angina
- Unsuccessful angioplasty
PCI is preferred as shorter recovery time and similar 5 year survival rates
52
What vessel is harvested for a CABG?
**- Saphenous vein**
OR
**- Internal mammary artery** (last longer but risk of chest wall numbness)
53
What are some non-cardiac causes of chest pain?
- Costochondritis
- Gastro-oesophageal
- Pneumonia
- PE
- Pleural effusion
- Pneumothorax
- Psychogenic
Often sharp localised pain, worse on inspiration
54
How do you take a cardiac history for an OSCE?
**HPC**: socrates, palpitations, dyspnoea, dizziness, blackouts, claudication
**PMHx**: ask about angina, any heart attacks/stroke, diabetes, hypertension, hypercholesterolaemia, past tests
**DHx and Allergies:** aspirin, GTN, statins, anticoagulants, ACEi
**FHx:** 1st degree relatives with cardio events especially \<60
**Social history:** alcohol, smoking, exercise
**Systems review and ICE**
55
What are some ischaemic heart disease risk factors?
56
How do you do a cardiovascular exam for an OSCE?
https://geekymedics.com/wp-content/uploads/2020/10/OSCE-Checklist-Cardiovascular-Examination-2.pdf
## Footnote
1. Wash hands, introduce, confirm identity, gain consent
2. Expose to waist then poisition at 45 degrees
3. General inspection
4. Hands
5. Pulses and Blood prssure
6. Neck JVP and carotids
7. Face
8. Inspect, Palpate, Auscultate
9. Look for sacral or peripheral oedema
10. Auscultate lung bases
11. Complete with . peripheral vascular examination, 12- lead ECG, urine dipstick, capillary blood glucose, fundoscopy, O2 sats, temp
57
How long is the treatment for PE?
- Cause known 3months
- Cause unknown 6months-1year
58
What are the signs on cardiovascular examination that would distinguish between right and left heart failure?
**Right:** raised JVP
**Left:** bibasal crepitations
59
When should BB and CCB not be used in the acute setting?
**BB:** acute pulmonary oedema or heart failure
**CCB:** as negative inotrope in acute setting
60
What are the different stages of hypertension?
**Stage 1:** 140/90 or 135/85 HBPM/ABPM
**Stage 2:** 160/100 or 150/95 HBPM/ABPM
**Severe/Stage 3:** Sys\>180 or Dia\>120
61
How is hypertension diagnosed?
If \>140/90 then offer ambulatory BP or home BP to check it is true before treating
If severe treat immediately with no ABPM/HBPM
62
What is malignant hypertension?
**Rapid rise in blood pressure to over 200/130**, leading to vascular and organ damage
Can causes **bilateral retinal haemorrhages**, headache, visual disturbances
Needs urgent treatment (BB or CCB)
63
Hypertension can be primary (90%) or secondary (10%). What are some secondary causes of hypertension?
- Renal disease: renal artery stenosis, polycystic kidneys
- Cushing's
- Phaeochromocytoma
- Pregnancy
- Drugs
- COCP
- Cocaine
64
What are some symptoms of hypertension?
- Usually **asymptomatic**
- Sweating, headache, palpitations and anxiety if phaeochromocytoma
- Muscle weakness or tetany in hyperaldosteronism
65
What are some signs on examination of a patient with hypertension?
- Retinopathy
- Palpable kidneys/renal bruits
- Radiofemoral delay in coarctation
- Signs of Cushing's
66
What other tests apart from BP are performed when a patient is newly diagnosed with hypertension?
- Urine dip
- Bloods
- Retinopathy
- ECG
- ECHO
**- Q Risk score**
67
How do you test for end organ damage in hypertension?
- Check for **proteinuria** or haematuria
- Check for **retinopathy**
- Do ECHO for **LV hypertrophy**
68
When should hypertension be pharmacologically managed?
**Stage 1:** if under 80 years old, diabetic, renal disease or QRISK >10%
**Stage 2 and above:** everyone should be offered
69
What are target blood pressures to bear in mind when treating hypertension?
- **Low-moderate risk:** \<140/90
**- Diabetic/Previous Stroke**: \<130/80 (keep below 85)
**- Elderly \>80:** \<150/90
Reduce slowly, can be fatal if lower too rapidly!
70
How is hypertension treated non-pharmacologically?
- Weight loss
- Stop smoking
- Reduce alcohol
- Reduce salt intake
- Aerobic exercise
71
How is hypertension treated pharmacologically?
ACD rule!
72
What are some side effects of the following antihypertensive drugs?
- Thiazides
- CCBs
- ACEi
- ARB
- BB
**Thiazides**: impotence, hypoK, hypoNa, cannot use in gout
**CCB**: ankle oedema, flushing, gum hyperplasia
**ACEi**: cough, hyper K, renal failure, angio-oedma
**ARB**: vertigo, urticaria, be careful in valve disease
**BB:** bronchospasm, cold peripheries, impotence
73
Why should you drop hypertension slowly?
Any sudden drops in BP increases stroke risk as cerebral autoregulation is poor
74
What is the definition of a hypertensive emergency?
Increase in BP which if sustained over the next few hours will cause irreversible end organ damage (encephalopathy, LV failure, aortic dissection, unstable angina, renal failure)
75
What is the difference between a hypertensive emergency and urgency?
**Emergency** - High BP with critical illness (AKI,MI, Encephalopathy). Will cause damage over hours
**Urgency** - High BP without critical illness at the moment, often accompanied by retinal damage. Will cause damage over days
76
How is a hypertensive emergency managed?
Aim to reduce diastolic BP to 110 in 3-12 hours (if emergency) or 24 hours (if urgency)
77
How is hypertensive urgency managed?
**Reduce diastolic gradually to \<100 over 48-72 hours using PO drugs**
Usually a combination of ACEi and CCB or Nifedipine AND Amlodipine for 3 days and then continue Amlodipine alone
- Amlodopine
- Diltiazem
- Lisinopril
78
What is the classic triad of symptoms for patients with a phaeochromocytoma?
- Episodic headache
- Sweating
- Tachycardia
with sustained/paroxysmal hypertension
79
How is phaeochromoctyoma diagnosed?
**24h urine collection:** measure urinary and plasma metanephrines and catecholamines
Can do MRI or CT abdo/pelvis to detect adrenal tumours
80
How is a phaeochromocytoma managed after diagnosis?
- **Surgical resection**
**- Whilst awaiting surgery hypertension control:** combined alpha and beta blockade. Start alpha blocker first ***_(phenoxybenzamine)_*** then add beta blocker when alpha blockade achieved. Never BB first
81
How do you diagnose Cushing's syndrome as the underlying cause of hypertension?
- Physical appearance
- Hyperglycaemia
- Elevated 24h urine cortisol
**- Diagnosis:** low dose dexamethasone suppression test
- Need to do adrenal CT
82
When should you suspect primary hyperaldosteronism as the cause of hypertension and how do you diagnose this?
**_Suspect:_**
- Low K+ and high/normal Na+
- FHx of premature hypertension
- Resistant hypertension
**_Diagnose:_**
- Aldosterone:renin ratio measured in the morning. Will be very high
- Adrenal CT
83
How does the RAAS system work?
84
What are some causes of postural hypotension?
- Hypovolemia
- Drugs e.g diuretics, nitrates, antipsychotics
- Autonomic neuropathy
- Hypopituitarism
85
How do you treat postural hypotension?
86
What are some signs of hyperlipidaemia?
- Xanthoma
- Xanthelasma
- Corneal arcus
87
What are the causes of the following pulses:
- Bounding pulse
- Collapsing waterhammer pulse
- Slow rising anacrotic pulse
- Jerky pulse
- Pulsus paradoxus
**Bounding:** sepsis, CO2 retention, liver failure
**Collapsing pulse:** aortic regurgitation, AV malformation, PDA
**Slow rising:** aortic stenosis
**Jerky pulse:** HCM
**Pulsus paradoxus:** severe asthma, pericardial constriction, cardiac tamponade
88
What does each part of the JVP wave form represent?
89
S1 is the closure of the mitral and tricuspid valve. S2 is closure of the pulmonary and aortic valve. What makes a loud S1, soft S1, loud A2 and loud P2?
Loud S1: Mitral stenosis
Soft S1: Mitral regurg
Loud A2: tachycardia, hypertension
Loud P2: pulmonary hypertension
90
When do you hear an opening snap?
Mid diastolic murmur of mitral stenosis usually due to calcification
91
What do the following murmurs indicate:
- Ejection-systolic
- Pansystolic
- Early diastolic
- Mid diastolic
**Ejection Systolic:** (Crescendo-Decresendo) aortic stenosis, pulmonary stenosis
**Pansystolic:** mitral regurgitation, tricuspid regurgitation
**Early diastolic:** aortic regurgitation
**Mid diastolic:** mitral stenosis, rheumatic fever, Carey Coombs
92
Which murmurs radiate and to where?
**Aortic stenosis:** carotids
**Mitral regurgitation:** axilla
93
Which murmurs can be heard best when leaning forward, left lateral positioned, expiring?
**- Leaning forward:** aortic regurg
**- Left lateral:** mitral stenosis
**- Expiring:** left sided murmurs as expiring increases blood follow to left side of heart
94
What are the following signs:
- De Mussets
- Corrigan's
- Muller's
- Quincke's
- Traubes'
All signs of aortic regurgitation
95
Why are transoesophageal echos better than transthoracic and what are they used for?
Closer to the heart so more sensitive
- Cardiac emboli
- Aortic dissections
- Assessing prosthetic valves
96
What is cardiac catheterisation used for and what are some complications of this procedure?
- Angioplasty
- Valvuloplasty
- Intravascular ultrasound or ECHO
97
What is used second line to treat hypertension for an Afro-Carribbean patient?
ARB e.g Valsartan
98
Which valve is the most commonly affected in infective endocarditis?
Mitral valve
99
What medication do you need to give a patient before PCI?
Dual antiplatelet therapy with aspirin and a P2Y12 antagonist
PLUS
Unfractionated Heparin
100
What is the difference between a STEMI and an NSTEMI?
STEMI is complete occlusion of the coronary artery but NSTEMI is only partial
Both result in tissue necrosis
101
How is hypertensive retinopathy graded?
1 - Tortuous arterterues with thick shiny walls
2 - AV nipping where arteries cross veins
3 - Flame haemorraghes and cotton wool spots
4 - Papilloedema
102
How should cocaine induced MI be managed?
Benzodiazepine plus GTN
103
What drug therapy should be used for a STEMI, prior to a PCI?
Furthermore, what drug therapy should be used if the STEMI is going to be medically managed?
PCI: **Aspirin + prasugrel** (swap prasugrel for clopidogrel if the patient is already taking oral anticoagulants)
Medically: **Aspirin + ticagrelor**
