ACS

Question 1

what is NSTEMI

Answer 1

partial or intermittent blockage of coronary artery
usually myocardial necrosis ( = increased troponin)
ST segment depression, T wave inversion, or normal

Question 1

what is STEMI

Answer 1

complete and persistent blockage of coronary artery
myocardial necrosis (= increased troponin)
ST segment elevation

Question 2

what is unstable angina

Answer 2

partial or intermittent blockage of coronary artery
no myocardial necrosis (= normal troponin)
ST segment depression, T wave inversion, or normal

Question 3

MI, aka

Answer 3

heart attack

Question 4

initial management of ACS

Answer 4

pain relief: GTN buccal or sublingual, IV opioids e.g. morphine esp if suspected acute MI

loading dose 300mg aspirin

monitor O2 saturation and offer supplementary O2 if needed (not routinely given)

Question 5

what do you need to monitor all pt admitted for?

Answer 5

hyperglycaemia (>11) and give insulin if indicated

Question 6

what does ACS result from

Answer 6

from the formation of a thrombus on an atheromatous plaque in a coronary artery

Question 7

summarise management of STEMI

Answer 7

1. 300mg aspirin ASAP
2. assess for reperfusion therapy. options include angiography with follow on PCI or fibrinolysis
3. give DAT
4. assess LV function
5. cardiac rehabilitation and secondary prevention

Question 8

STEMI reperfusion therapy - PCI. what other medicine to give alongside e.g. DAT?

Answer 8

give angiography with follow on PCI if <12h symptom onset and can be delivered in 120 mins

radial access preferred: UFH + bailout GP
if femoral access: bivalirudin + bailout GP

give DAT:
- P + A preferred.
- If already taking AC or high risk of bleeding, give C + A.

Question 9

STEMI reperfusion therapy - fibrinolysis. what other medicine to give alongside?

Answer 9

Give if <12h symptom onset and PCI can’t be given within 120 mins.

Give DAT:
- T+A
- if high bleeding risk, C+A or A alone

Also give antithrombin e.g. heparin

ECG 60-90 mins after fibrinolysis - if residual ST elevation, do not repeat fibrinolysis. Offer immediate angiography with follow on PCI if indicated.

Question 10

Medical management of STEMI if reperfusion therapy not appropriate

Answer 10

DAT

• T + A
• if high bleeding risk, C + A or A alone

Question 11

summarise management of NSTEMI and unstable angina

Answer 11

1. 300mg aspirin asap. Also give antithrombin UNLESS high bleeding risk or immediate angiograph: fondaparinux, or UFH if sifnificant RI
2. predict 6 month mortality rate and risk of CV events e.g. with GRACE
3. manage according to results of above (low risk = <3% and high risk = >3%)
4. assess LV function in NSTEMI, consider assessing it for unstable angina
5. cardiac rehabilitation and secondary prevention

Question 12

NSTEMI & unstable angina - management once you have predicted 6 month mortality rate and risk of CV events and result comes back as intermediate to high risk. What drugs to give?

Answer 12

intermediate to high risk (>3%)
- if unstable, offer immediate angiograph
- otherwise, consider angiography with follow on PCI if indicted if within 72 hours and no CI
- If PCI indicated, give UFH radial access
- DAT: P (if doing PCI) or T + A
- DAT if already taking AC: C + A

Question 13

NSTEMI & unstable angina - management once you have predicted 6 month mortality rate and risk of CV events and result comes back as low risk. What drugs to give?

Answer 13

low risk = <3%

• consider conservative management but be aware that some younger people may benefit from angiography

DAT: T+A but if high bleeding risk give C+A or A alone

Question 14

summarise what drugs you would give for secondary prevention (4)

Answer 14

ACE
BB
DAT
Statin

Question 15

who would you give secondary prevention to

Answer 15

All pt with STEMI and NSTEMI
clinical judgement for unstable angina

Question 16

How long should you continue BB for secondary prevention

Answer 16

Continue indefinitely for patients with a reduced LVEF.
In those without reduced LVEF, it may be appropriate to discontinue BB therapy after 12 months; this should be discussed with the patient and the potential benefits and risks of continuation taken into account.

Question 17

What can be given as alternative to BB for secondary prevention following ACS

Answer 17

Diltiazem hydrochloride or verapamil hydrochloride may be considered as an alternative to beta-blocker therapy in patients who do not have pulmonary congestion or a reduced LVEF.

Question 18

How long to continue DAT secondary prevention for

Answer 18

Aspirin: continue indefinitely.
Dual antiplatelet therapy (aspirin with a second antiplatelet) should be continued for up to 12 months unless CI. Clopidogrel monotherapy should be considered as an alternative to aspirin in patients who have aspirin hypersensitivity.

Question 19

2 options recommended as an option for preventing atherothrombotic events following an ACS with elevated cardiac biomarkers.

Answer 19

Rivaroxaban + aspirin
or
Rivaroxaban + aspirin + clopidogrel