ACS

Question 1

What is the difference between plaque, stable and unstable angina?

Answer 1

Plaque - test results are normal
Stable - atherosclerotic plaque
Unstable - thrombosis (rupture red cap)

Question 2

What is ACS?

Answer 2

Quick process due to sudden clotting and can occur randomly
Pain goes for longer than 10 mins and GTN doesn’t work
Includes unstable angina, MI (STEMI or NSTEMI)

Question 3

What is the difference in lab test between STEMI and NSTEMI

Answer 3

STEMI - high troponin and High CK
NSTEMI - high troponin but normal CK
In unstable angina - high risk stage - small troponin is detected because of small leak

Question 4

What are the normal levels of troponin and CK?

Answer 4

Troponin -

Question 5

When pt comes into the ED, what are the early managements they must go through?

Answer 5

Aspirin
Clopidogrel
Statin
Beta blocker (depends)
ACEI
Nicotine patch
GTN

Question 6

What happens to the patient if they were diagnosed with STEMI at the ED?

Answer 6

Give them heparin or LMWH before stent
Give second antiplatelet
Give reperfusion-thrombolysis (tPA rPA TNK-tPA) or PCI (stent) 
Statin
ACEI

Question 7

What are the contraindications of fibrinolytics?

Answer 7

Risk of bleeding (active bleeding / closed head or facial trauma within 3 months,peptic ulcer)
Risk of intracranial haemorrhage (any prior intracranial bleeding, ischaemic stroke within 3 months, cerebral vascular lesion)
Pregnancy

Question 8

What do we need to be aware about tPA?

Answer 8

It only breaks down the fibrin so it has no effect on platelet aggregation (need to use antiplatelet)
It does not prevent new fibrin generation (need to use heparin)

Question 9

What happens if the patient was diagnosed with NSTEMI in the ED?

Answer 9

Give second antiplatelet
If high risk, give heparin or LWMH
IF HIGH RISK, give G2B/3A INHIBITOR 
If high risk, PCI
Statin
Maybe ACEI

Question 10

Risk scores for NSTEMI is called what

And how can we use this

Answer 10

TIMI
3 or more traditional CAD risk factors (>65yo, 2 or more angina eps in last 24hrs, used aspirin in last 7 days, high enzyme…) –> PCI in 48 hours
Less than 3 –> drugs and exercise, maybe PCI

Question 11

What is the secondary prevention for ACS

Answer 11

Aspirin (good for secondary prevention but not primary)
- aspirin + licagrelor (NOT FOR STROKE ONLY PT)

Statin in high dose (fibrates are not rly good)

BB (Stable, STEMI, NSTEMI)
- metoprolol (NOT propranolol)

ACEI (in MI + HF or HF alone, not really MI alone)

Question 12

What meds should be avoided??

Answer 12

SNRI (venlafaxine) can put work on heart –> choose SSRI
TCA (amitriptyline) can risk MI –> choose SSRI
NSAIDs and cox2 inhibitors –> use naproxen
Oestrogen
Chemotherapy
Calcium

Question 13

The baseline risk of death and MI decreases with which combination?

Answer 13

Aspirin + ticagrelor + Statin + BB + ACEI