ACS

Question 1

Three types of ACS

Answer 1

Angina
STEMI
NSTEMI

Question 2

Diagnosis of ACS

Answer 2

ECG, troponin ( biochemical cardiac markers

Question 3

What’s STEMI

Answer 3

ST elevation Myocardial Infarction
- ST elevation is a sign of heart attack
Full blown heart attack
Can lead to death

Question 4

Causes of ACS

Answer 4

Plaque ruptures from within a coronary artery
Causes partial or complete obstruction of that artery

Question 5

What’s STEMI

Answer 5

Worse form of ACS
Complete obstruction of coronary artery resulting in death of cardiac muscle

Question 6

Symptoms of Angina

Answer 6

Chest pain( tight, sharp, dull and heavy)
Spreads to left arm m neck, jaw or back)
Triggered by physical exertion or stress
Stop within a few minutes of resting
Nausea , fatigue and SOB
Sweating and diziness

Question 6

What’s NSTEMI

Answer 6

Partial heart attack
In between stable angina and STEMI
Partial obstruction of coronary artery
Some muscle cells die but can still survive

Question 7

Difference between stable and unstable Angina

Answer 7

Stable symptoms occur during exercise/ stress and stop on resting
Unstable symptoms occur while resting
Chest pain last longer and more severe pain

Question 8

Initial Management of ACS

Answer 8

GTN ( bucal or SL)/
IV morphine- ASAP for pain relief
Give Aspirin 300mg ASAP
Oxygen if needed
Insulin- if hyperglycaemic glucose > 11mmol/ ml

Question 9

Management of STEMI

Answer 9

Aspirin 300mg + clopidogrel/prasugrel/ticagrelor
Then
Heparin(unfractionated for renal impairment)
Or
Antithrombin agent for patients on fibronoylisis

Question 10

Secondary prevention of CV events following ACS

Answer 10

Cardiac rehabilitation ( lifestyle interventions)
ACEi/ARB
+
BB or Diltiazem or Verapamil
+ Dual Antiplatelet therapy( aspirin and Clopidogrel for 12 months
Or
Dual/Triple therapy with Anticoagulants( aspirin +Clopidogrel + Rivaroxaban)- those with very high troponin
+
Statins( for pts with clinical evidence of CVD)

Question 11

What are nitrates?

Answer 11

Useful role in angina
Potent coronary vasodilator but principal benefit is a reduction in Venous return which reduces left ventricular work

Question 12

Three most common forms of GTN

Answer 12

Tablet
Patch
Spray

Question 13

Side effect of Nitrates

Answer 13

Flushing
Headaches
Postural Hypotension
Arrythmias
Drowsiness
N and V
Cerebral Ischaemia

Question 14

Duration of action of GTN

Answer 14

Effects only last for 20-30mins

Question 15

State when long term prophylaxis of ACS is required when spraying GTN

Answer 15

If GTN spray is used more than twice a week

Question 16

GTN doses for prophylaxis of Angina(Sublingual Tablet)

Answer 16

Take One tablet before activity which is likely to cause Angina

Question 17

Treatment dose of Angina (SL tablet)

Answer 17

One tablet repeated at 5mins interval if required. If symptoms have not resolved after 3doses, medical attention should be sought

Question 18

Dose for GTN spray for tx or prophylaxis

Answer 18

Spray 1-2 doses under the tongue

Question 19

GTN (patches)

Answer 19

One patch changed every 24hrs

Question 20

Facts about Isorsobide dinitrate

Answer 20

Active sublingual and effective for pts requiring nitrates infrequently
Effective by mouth for prophylaxis(although slow onset of action)
Effect may persist for several hours)

Question 21

Facts about MR preparation of dinitrate

Answer 21

Duration of action up to 12hrs(give BD)
As the activity of dinitrate may depend on production of active metabolite

Question 22

Indication of isosorbide mononitrate

Answer 22

Licensed for angina prophylaxis
MR prep OD available

Question 23

State when IV GTN or isosorbide mononitrate used

Answer 23

Used for severe symptoms of Angina or when SL not effective

Question 24

What is the main caution with nitrates and how to overcome it

Answer 24

Tolerance
How to prevent it
Take MR isosorbide Once daily tablets( reduce tolerance)
For BD tablet, Take second dose after 6-8hrs not 12hours
Leave patch off for 8- 12hrs (usually overnight) in each 24hrs

Question 25

Strength of GTN SL tablets

Answer 25

300, 500 and 600mcg

Question 26

Prescribing and dispensing requirements for Nitrates

Answer 26

Tablets should be supplied in glass container of not >100 tablets
Close within a foil line cap
No cotton wool wadding
Discard after 8weeks
Rectal ointment should be Discarded after 8week of opening