ACS

Question 1

What is the initial treatment for acute coronary syndrome with ST elevation?

Answer 1

ROMANCE

Reassure
Oxygen - if sats <95% or breathless or acute LVF
Morphine - 5-10mg IV repeat after 5 mins if necessary
Aspirin 300mg PO
Nitrates - if patient Is hypertensive or in acute LVF
Clopidogrel 300mg (not used anymore)
Enoxaparin - 2.5mg (not preferred)

Aim is to PCI within 120 mins

Question 2

What should be given with the first dose of morphine in acute coronary syndrome?

Answer 2

Anti-emetic

1st line - 10mg metoclopramide
2nd line 50mg cyclizine

Question 3

What is now recommended ahead of the use of clopidogrel?

Answer 3

Ticagrelor 180mg

Prasugrel 60mg - if no history of stroke/TIA and <75yo

Question 4

What is the preferred anticoagulation to use in acute coronary syndrome?

Answer 4

Bivalirudin

Question 5

How is right ventricular infarction confirmed?

Answer 5

ST elevation in rV3/V4 and or shown on Echo

rV3/V4 is where pad is placed on right 5th intercostal space, mid clavicular line

Question 6

How is a right ventricular infarct managed?

Answer 6

Treat hypotension and oliguria with fluids

Avoid nitrates and diuretics

Assess for early signs of pulmonary oedema

May req. inotropes and intensive monitoring

Question 7

What is the ECG criteria for diagnosing a STEMI?

Answer 7

ST elevation >1mm in 2+ adjacent limb leads or >2mm in 2+ adjacent chest leads

New found LBBB

Posterior changes - deep ST depression and tall R waves in v1-3

Question 8

When is primary PCI (primary percutaneous intervention) offered?

Answer 8

Within 12 hours of symptom onset

Question 9

What should be done if a patient can’t be offered primary percutaneous intervention (PCI) within 120 mins?

Answer 9

Thrombolysis and transfer to primary PCI centre ideally before 12 hours

Question 10

When should you aim to thrombolyse a patient with a ?STEMI by?

Answer 10

Within 30 mins of admission

Use >12 hrs post symptom onset req. specialist advice

Question 11

When should you not thrombolyse a patient with ?ACS?

Answer 11

ST Depression alone
T wave inversion alone
Normal ECG

Question 12

How do you thrombolyse patients with ?ACS?

Answer 12

Tissue plasminogen activators - tenecteplase

Question 13

Give some contraindications for thrombolysis in ?ACS?

Answer 13

Previous intracranial haemorrhage

Ischaemic stroke <6 months

Cerebral malignancy or AV malformation

Recent major trauma/surgery/head injury (<3 wk)

GI bleed <1month

Known bleeding disorder

Aortic dissection

Non-compressible punctures <24hr - liver biopsy/lumbar puncture

Question 14

What are the relative contraindications for thrombolysis in ?ACS?

Answer 14

TIA <6months
Anticoag therapy
Pregnancy or <1wk post partum
Refractory hypertension (>180/110)
Advanced liver disease
Infective endocarditis
Active peptic ulcer
Prolonged/traumatic resuscitation

Question 15

How should patients with STEMI who do not receive repercussion managed?

Answer 15

Fondaparinux

Enoxaparin/unfractionated heparin if not available

Question 16

What things in the history may indicate a diagnosis of acute coronary syndrome (NSTEMI)?

Answer 16

Previous angina
Relief with rest or nitrates
History of CVS disease
Risk factors for IHD

Question 17

What is the aim of management of an NSTEMI?

Answer 17

Control pain

Initiate anti-ischaemic and antiplatelet therapy

Question 18

What oral anti-platelet therapy is initiated for an NSTEMI?

Answer 18

Aspirin 300mg PO followed by 75mg OD

If confirmed ACS - give second antiplatelet:

• clopidogrel 300mg PO then 75mg OD
• ticagrelor 180mg PO then 90mg BD (preferred)
• Prasugrel 60mg PO then 10mg OD - if undergoing PCI

Question 19

What anticoagulation is indicated in a patient with a ?NSTEMI?

Answer 19

Fondaparinux 2.5mg OD

If unavailable then LMWH (enoxaparin 1mg/kg/12h) or unfractionated heparin (aim for APTT 50-70s) until discharge

Question 20

What other medications are offered for a patient with an NSTEMI?

Answer 20

Beta blockers (if no CI)
Nitrates - recurrent chest pain
ACE inhibitors - unless CI
Statins - atorvastatin 80mg OD

Question 21

When should you not use beta blockers in NSTEMI management?

Answer 21

With verapamil as it can precipitate asystole

Question 22

What is the prognosis for an NSTEMI?

Answer 22

~1-2% risk of death

~15% risk of refractory angina

Question 23

How is risk stratified in patients post NSTEMI?

Answer 23

GRACE score

Question 24

Which factors are associated with a high risk post NSTEMI?

Answer 24

History of unstable angina

ST depression or widespread t wave inversion

Raised troponin (except patients with STEMI)

Age >70yo

General co-morbidities - previous MI, poor LV function, diabetes

Question 25

What further measures should be taken for patients with an NSTEMI?

Answer 25

Wean GTN infusion once stabilised on oral drugs

Continue fondaparinux until discharge

Observe cardiac monitor or telemetry in case of dysrhythmia

Check serial ECG’s and troponin 12h post pain

Address modifiable RF - smoking, HTN, hyperlipidaemia, T2DM

Gentle mobilisation

Ensure dual antiplatelet therapy

Question 26

If a patient with an NSTEMI has a recurrence of symptoms, what should you do?

Answer 26

Refer to cardiologist for urgent angiography and PCI/CABG