ACS Flashcards
What are Acute
Coronary Syndromes (ACS)?
- Unstable Angina
- NSTEMI (“Heart attack)
- STEMI (“Serious Heart attack”)
What is the difference between stable angina and UNSTABLE angina?
- Both occur as a result of restricted blood flow to the heart
- Stable angina occurs due to physical activity/exertion
- Whilst in UNSTABLE angina, symptoms occur at rest or during very little activity
NSTEMI
- Non ST segment elevation MI
- ST segment is not elevated on ECG
- Partial blockage
Difference between NSTEMI and unstable angina
- Unstable = partial block which can = NSTEMI/STEMI. But heart muscles are preserved
- NSTEMI = some cardiac necrosis (heart damaged)
- STEMI = more cardiac necrosis
A partial block of the coronary artery is…
NSTEMI OR Unstable angina
STEMI
- Complete blockage of artery
- ST zone of ECG is elevated
Complications
- Arrythmias
- HF
Diagnosis
- Full clinical history
- Physical examination e.g. BP and HR
- ECG (12-lead)
- Blood tests (including Troponin I and T)
MAIN ONE! - Creatinine
Troponin
- Protein found in heart muscles
- When damage occurs, it is released into the blood treat
- High levels of troponin = NSTEMI/STEMI
What are the steps involved in the initial
management of
NSTEMI and UA?
- Pain relief: GTN +/- IV morphine
- Aspirin 300mg loading dose
- fondaparinux sodium
- if bleeding risk is NOT high
and
- NOT undergoing immediate coronary angiography - Monitor for
Hyperglycaemia
- Give insulin if necessary - Oxygen
- Only if hypoxia is suspected
Which drugs are given to manage pain in the initial management of
NSTEMI and Unstable angina?
- GTN
- IV Morphine
What if the patient has already administered an aspirin 300mg
loading dose before admission to the hospital?
Inform medical team
Why is fondaparinux sodium administered to patients with
NSTEMI or UA in the initial management?
- anti-thrombin
- NSTEMI and UA occur as a result of thrombus restricting blood flow to the heart
- prevents thrombus formation
What is an alternative to fondaparinux
sodium if patients have renal impairment?
Heparin (unfractionated)
What are the revascularisation procedures used in
NSTEMI and UA?
- PCI
- CABG
PCI
Percutaneous coronary intervention
- coronary angioplasty (baloon that inflates to expand blood vessels and stents)
- minimally invasive procedure
CABG
Coronary artery bypass graft (CABG)
- Taking blood vessels from other parts of the body
- These new blood vessels (graft) are used to deliver blood to the heart and bypasses the blocked or narrowed arteries
If patient is undergoing a PCI, which anticoagulant should be administered to them?
Does it matter if they have already received anti-thrombin treatment
e.g. fondaparinux?
- Patients undergoing PCI should be administered
Heparin (unfractionated) - Regardless of whether or not they have received fondaparinux
Dual-antiplatelet therapy
Following diagnosis, initial management and whether or not revascularisation procedures are given, patients will need a second antiplatelet in addition to aspirin
- Prasugrel
- Ticagrelor
- Clopidogrel
In summary, when is Prasugrel offered as a second anti-platelet?
ONLY when PCI is indicated!!
P for PCI and Prasugrel
What if patient has a high bleeding risk, can they take dual-antiplatelet therapy?
Patients can take Aspirin as monotherapy (no dual anti-platelet therapy)
What if patients cannot take Aspirin due to hypersensitivity,
which anti-platelet can you offer?
- Clopidogrel monotherapy
How long is dual-antiplatelet therapy given for?
- Dual antiplatelet given for 12 months
- Aspirin should be taken for life
What is the dose of Aspirin in ACS?
- On symptom onset (during
initial management) = 300mg
loading dose - Secondary prevention of CVD
= 75mg OD
Which oral anticoagulant may be considered in combination with anti-platelets for the
prevention atherothro mbotic events following ACS?
- Rivaroxaban 2.5mg BD
- Taken in combination with Aspirin AND Clopidogrel (or in combination with Aspirin alone)
In summary, if patient is already taking an anti-coagulant for another condition, which anti-platelet do you offer in
combination with Aspirin?
Clopidogrel
DO NOT OFFER TICAGRELOR OR PRASUGREL IF PATIENT IS
TAKING ORAL
ANTICOAGULANT
What should be performed
IMMEDIATELY
following a STEMI?
- PCI (PREFERRED)
or - Fibrinolysis
- Via fibrinolytic drugs e.g.
Streptokinase
How do you determine whether to give PCI or fibrinolysis for reperfusion treatment following STEMI?
- PCl is most preferred method and should be offered within 120 minutes if presented to hospital within 12 hours of symptom onset
- Offer Fibrinolysis if PCI cannot be offered within 120 minutes if presented to hospital within 12 hours of symptom onset
Patients should also recieve dual-antiplatelet therapy following STEMI, which antiplatelet do you offer in addition to aspirin?
PCI
- P + A or T + A
Fibrinolysis
- T + A or C+A
What are the long-term treatments for secondary prevention of CVD following ACS?
- Dual anti-platelet therapy
- for 12 months - ACE-Inhibitors
- ARB if ACE intolerated - Beta-Blocker
- May be discontinued after 12m in pt w/o LVEF - Statins
- ato 80mg
