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ACS Flashcards

1
Q

Name some of the possibilities of chest pain and their key characteristics (8):

A

Heartburn - triggered by eating, worse when lying down, felling full/bloated.

Sprain/strain - triggered by chest injury or excercise, worse on inhaling, eases on rest.

Panic attack - sharp continuous pain triggered by stress, increased HR, dizziness, sweating.

Pneumonia - worsens on inhale, green/yellow productive cough, fever.

Shingles - tingling feeling on skin, rash that turns to blisters.

Pericarditis - a sudden, sharp stabbing pain which worsens on lying down or deep breathing.

Angina - tight/dull/heavy or sharp stabbing pain which can radiate down the arms. Usually stops in a few minutes. Can also cause nausea, breathlessness or fatigue.

Heart attack - tight/dull/heavy or sharp stabbing pain which can radiate down the arms, jaw, neck, and back. Can cause breathlessness, nausea, anxiety, sweating. Persists for 15 minutes or more.

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2
Q

What would you ask someone to try identify the cause of their chest pain?

A

Site
Onset - how long, is it regular, any patterns or triggers.
Character - constant? dull ache, stabbing, sharp?
Radiation - does it spread anywhere else.

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3
Q

What are the other names for acute coronary syndrome?

A

Ischaemic heart disease
Coronary heart disease
Coronary artery disease

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4
Q

What is ACS?

A

A condition characterised by a decreased blood flow to part of the heart musculature usually caused by obstruction of the coronary artery due to thrombus formation, plaque rupture or erosion.

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5
Q

What is the clinical name for a lack of blood flow and oxygen to the heart?

A

Myocardial ischaemia

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6
Q

What can myocardial ischaemia result in?

A

Stable angina
Unstable angina pectoris
Myocardial infarction

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7
Q

What is angina?

A

Sudden onset of chest caused by myocardial ischaemia.

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8
Q

What is the difference between stable and unstable angina?

A

Stable angina - triggered by exertion, emotional stress, or cold environment. Can be alleviated by rest or use of sublingual nitro-glycerine.

Unstable angina - unpredictable with no clear trigger. Cannot be relieved with rest or nitro-glycerine.

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9
Q

What is a myocardial infarction?

A

Partial or complete obstruction of blood flow to the heart resulting in myocardial necrosis and suppression of cardiac function.

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10
Q

What is the difference in presentation between MI and unstable angina?

A

The presence of cardiac enzymes such as troponin which are triggered by myocardial necrosis.

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11
Q

What are the 2 types of MI?

A

STEMI (ST-elevation MI) - heart attack which presents with ST elevation on ECG. More serious as is caused by complete and prolonged occlusion of the epicardial coronary blood vessel.

NSTEMI (non ST-elevation myocardial infarction) - heart attack which does not present with ST elevation on ECG. Usually less serious as it is caused by complete occlusion of a minor artery or partial occlusion of a major artery (e.g., due to coronary artery narrowing or transient occlusion).

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12
Q

How is stable angina managed?

A

Secondary prevention of CVD plus:
1. Sublingual glycerol-trinitrate spray for relief.
2. Beta-blocker or CCB
3. If one poorly tolerated, try the other.
4. Both (but only using a dihydropyrodine CCB such as amlodipine, felodipine, nifedipine)
5. Monotherapy or addition of either a long acting nitrate, Ivabradine, Nicorandil, or Ranolazine.

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13
Q

What is used for secondary prevention of CVD?

A

Aspirin 75mg daily
ACE inhibitor (angina or diabetes)
Statin - Atorvastatin 80mg od first line.
Antihypertensives such as CCB.

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14
Q

What is the primary aim of statins in secondary prevention of CVD?

A

Reduce LDL cholesterol levels to <2.0mmol/L or non-HDL cholesterol levels to <2.6mmol/L.

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15
Q

How do nitrates work in angina?

A
  1. Nitrates converted in nitric oxide.
  2. Nitric oxide activates guanylyl cyclase.
  3. Guanylyl cyclase converts GTP to cGMP in vascular smooth muscle.
  4. cGMP activates protein-kinase dependent phosphorylation which causes extracellular calcium release and opend the calcium-gated potassium channel.
  5. This causes dephosphorylation of myosin light chains in smooth muscle fibres and leads to relaxation of smooth muscle in the blood vessels.
  6. This decreases resistance of blood flow and allows more blood/oxygen to the heart.
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16
Q

How should GTN spray be used?

A

Before exercise/exertion or upon symptoms of angina, use 1-2 sprays under the tongue. A second dose can be taken after 5 minutes if needed. If after another 5 minutes pain is persisting or intensifying, call ambulance for MI.

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17
Q

What is the difference between the use of short and long-acting nitrates?

A

Short acting nitrates are to be used for immediate prophylaxis or relief.
Long-acting nitrates are taken regularly to decrease the frequency and severity of anginal symptoms.

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18
Q

What are the 2 types of long-acting nitrates?

A

Standard release - use asymmetric dosing interval (usually 8am and 2pm) to maintain daily nitrate-free period of 10-14 hours.
Modified release - once daily modified release dose maintains a nitrate-low period.

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19
Q

Why is a nitrate-free/nitrate-low period required?

A

To prevent tolerance.

20
Q

When do modified release nitrates tend to be used?

A

Only when patients have poor compliance as they are more expensive than standard release.

21
Q

What are some side effects of nitrates?

A

Transient hypotension (dizziness, weakness, palpitations) which presents as postural hypotension and occurs shortly after drug administration.

Headache - very common at start of treatment but subsides after 1-2 weeks. Can be minimised by titration.

Burning, stinging, or tingling of mouth when using sublingual GTN tablets.

22
Q

Name 6 nitrate contraindications.

A

Acute MI with low filling pressure
Acute circulatory failure
Severe hypotension
Raised intracranial pressure
Anaemia
Glaucoma

Nitr-ate: MARGS

23
Q

Name 3 nitrates drug interactions.

A

PDE inhibitors - can cause hypotension and my precipitate MI.
Leave a gap between PDE inhibitor and nitrate: avanfil 12h, sildenafil 24h, tadalafil 48h, vardenadil don’t use.
If angina occurs during sex, do not use GTN spray. Stop sex and call 999 if pain doesn’t resolve in 10 minutes.

Riociguat - a guanylate cyclase stimulator which potentiates hypotension caused by nitrates.

Antihypertensives - potentiate hypotension.

24
Q

What monitoring is required for nitrates?

A

HR and BP.

25
Q

Name 2 short-acting nitrates.

A

Isosorbide mononitrate
Isosorbide dinitrate

26
Q

Name 3 non-nitrate drugs used for treating angina.

A

Ivabradine
Nicorandil
Ranolazine

27
Q

How does Ivabradine work?

A

HCN channel blocker which inhibits the cardiac pacemaker current which controls the spontaneous diastolic depolarisation in the SA node, in order to regulate heart rate.

28
Q

What are some side effects of Ivabradine?

A

Blurred vision
Hypotension/light headedness
Irregular heartbeat
Tiredness

29
Q

What is Ivabradine contraindicated in?

A

MI
Cardiogenic shock
Bradycardia

30
Q

What should be monitored when taking Ivabradine?

A

ECG - for AF
Heart rate - for bradycardia

31
Q

What is nicorandil?

A

A nitrate derivative which works in the same way as nitrates.

32
Q

What are the side effects if Nicorandil?

A

Headaches
Hypotension and dizziness
Nausea and vomiting
Gastric ulcers

33
Q

What is nicorandil contrindicated in?

A

Pulmonary oedema
Hypovolaemia
Shock

34
Q

How does Ranolazine work?

A

A piperazine derivative which inhibits the late inward sodium current in the heart muscles to reduce sodium overload and improve disturbed ion homeostasis.

35
Q

Name side effects of Ranolazine.

A

Headache
Vomiting
Fatigue
Constipation

36
Q

What is Ranolazine contraindicated in?

A

Low body weight
Heart failure
QT prolongation
Hepatic and renal impairment.

37
Q

How are unstable angina and NSTEMI treated?

A
  1. 300mg loading dose aspirin ASAP and fondaparinux 2.5mg SC (LMWH/unfractioned heparin if contraindicated).
  2. Following a diagnosis, perform GRACE assessment.
  3. If low risk - Ticagrelor 90mg bd + aspirin 75mg od/
    If high risk - perform angiography and assess need for percutaneous coronary intervention or oral anticoagulation.
  4. Assess for left ventricular dysfunction.
  5. Provide secondary prevention and lifestyle advice.
38
Q

What is the GRACE assessment?

A

Used in MI patients to assess 6-month mortality risk. Assesses full clinical history, physical examination (BP, HR), resting 12-lead ECG, and blood tests (troponin, creatinine, glucose, and Hb)

39
Q

What is an angiography?

A

X-ray which checks blood vessels using contract agent which is injected into blood.

40
Q

What is a percutaneous coronary intervention (PCI)?

A

Non-surgical procedure to open narrow/blocked sections of artery.

41
Q

What is given for secondary prevention of MI (and other cardio events)?

A

ACE inhibitor or ARB (titrate up every 12-24 hours before discharge, take baseline renal function and monitor).

Dual antiplatelet therapy (aspirin + 1 other) - assess bleeding risk

Beta-blocker (ASAP when patient haemodynamically stable. Titrate up to target dose according to the person’s response and HR control at rest and during exercise).

A statin.

42
Q

What lifestyle advice should be given after MI?

A

Mediterranean diet (more bread, fruit, veg, and fish, less meat, butter, and cheese).

Lower alcohol consumption.

Regular physical activity

Smoking cessation

43
Q

How does fondaparinux work?

A

ATIII-mediated selective inhibition of Factor Xa. Binds to natural anticoagulant factor ATIII which potentiates the neutralising action of ATIII on factor Xa 300x, thus decreasing the conversion of prothrombin to thrombin, and subsequent conversion of fibringogen to fibrin, preventing clotting.

44
Q

What are some side effects of fondaparinux?

A

Anaemia, bleeding, haemorrhage

45
Q

What should fondaparinux not be taken with?

A

Blood thinning drugs such as SSRIs, NSAIDs, DOACs, clopidogrel.

46
Q

What is fondaparinux contraindicated in?

A

Bleeding disorders
Bacterial endocarditis
Surgery

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