ABCDE: STEMI & NSTEMI Flashcards
Classification of STEMI vs NSTEMI?
STEMI –> ST-segment elevation + elevated biomarkers of myocardial damage
NSTEMI –> ECG changes but no ST-segment elevation + elevated biomarkers of myocardial damage
Initial drug therapy in all patients with ACS?
1) Morphine –> if in extreme pain
2) Nitrates (useful if ongoing chest pain or HTN) –> if not hypotensive
3) Aspirin 300mg
What is the ECG criteria for a STEMI?
Clinical symptoms consistent with ACS (≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of:
1) 2.5 mm ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm in men over 40 years
2) 1.5 mm ST elevation in V2-3 in women
3) 1mm ST elevation in other leads
4) new LBBB
What is next question once STEMI has been diagnosed?
Is PCI possible within 120 minutes of the time when fibrinolysis could have been given AND is the presentation within 12 hours of the onset of symptoms?
If patients with STEMI are eligible for PCI, what is the next step?
Give additional antiplatelet (i.e. aspirin + another drug).
What 2nd antiplatelet is given prior to PCI:
a) if the patient is not taking an oral anticoagulant
b) if taking an oral anticoagulant
a) prasugrel
b) clopidogrel
What additional drug therapy is required DURING PCI?
a) patients undergoing PCI with radial access
b) patients undergoing PCI with femoral access
a) unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
b) bivalirudin with bailout GPI
What 2 other procedures should be considered during PCI?
1) thrombus aspiration, but not mechanical thrombus extraction, should be considered
2) complete revascularisation should be considered for patients with multivessel coronary artery disease without cardiogenic shock
What stents are used in PCI?
Drug-eluting stents
Is radial or femoral access in PCI preferred?
Radial
If PCI cannot be delivered within 120 minutes in a STEMI, what is the management?
Fibrinolysis
What should patients undergoing fibrinolysis be given?
An antithrombin drug eg. UH, LMWH, fondaparinux
What investigation should be done following fibrinolysis in a STEMI?
An ECG should be repeated after 60-90 minutes to see if the ECG changes have resolved.
If patients have persistent myocardial ischaemia following fibrinolysis then PCI should be considered.
What are 2 examples of GP IIb/IIIa inhibitors?
1) tirofiban
2) eptifibatide
What is given after fibrinolysis?
Ticagrelor
If an NSTEMI/unstable angina is identified, what is the next step? (aspirin 300mg has already been given)?
Fondaparinux
This should be given to all patients who are NOT high bleeding risk and do NOT have immediate PCI planned.
If immediate PCI is planned in NSTEMI, what should be given?
UH
In what 3 situations would fondaparinux not be given in NSTEMI treatment?
What should be given instead?
1) High risk of bleeding
2) Having immediate PCI
3) Creatinine >265 µmol/L
Give UH instead.
What is the tool used for risk assessment in NSTEMI?
GRACE score
What is next step after giving aspirin & fondaparinux in NSTEMI?
Calculate the GRACE score
What are the 2 key GRACE scores?
> 3% –> high risk
≤3% –> low risk
How does the GRACE score determine management in NSTEMI?
GRACE ≤3% –> conservative managemnet
GRACE >3% –> PCI
What does the GRACE score take into account? (6)
1) age
2) HR, BP
3) cardiac (Killip class) and renal function (serum creatinine)
4) cardiac arrest on presentation
5) ECG findings
6) troponin levels
Mx of patients with NSTEMI with GRACE ≤3%?
Conservative management –> ticagrelor or clopidogrel
What antiplatelet is given in conservative management of NSTEMi?
If high risk of bleeding –> clopidogrel
If not high risk of bleeding –> ticagrelor
Mx of patients with NSTEMI with GRACE >3%?
Refer for PCI.
If unstable e.g. hypotensive –> immediately
If stable –> within 72 hours
What further drug therapy in indicated in patients with NSTEMI having PCI?
1) UH –> given regardless of whether the patient has had fondaparinux or not
2) Further antiplatelet (i.e. dual antiplatelet) prior to PCI:
- if taking oral anticoag –> clopidogrel
- if not taking oral anticoag –> prasugrel or ticagrelor
