ACS

Question 1

initial treatment for STEMI

Answer 1

300mg aspirin
if going to receive PCI-> prasugrel or clopidogrel if already on anticoagulant

during PCI
radial access: UFH with glycoprotein IIb/IIIa inhibitor (eptifibatide and tirofiban)

femoral access: blilvardin with same glycoprotein thing

Question 2

if not treating STEMI with PCI

Answer 2

ticagrelor as dual treatment with aspirin

if high bleeding risk -> clopidogrel

Question 3

treatment for MI

Answer 3

Initial: MONA
	• Morphine 
	• Oxygen (If SPO2 < 94%)
	• Nitrate : GTN spray 
	• Antiplatelet (aspirin and P2y12 inhibitor) & antiemetic 

After: BASH
	• Beta blocker 
		○ Calcium channel if asthma 
	• ACE inhibitor  
	• Statin 
	• Heparin if NSTEMI: 3 days 
	• + aspirin and clopidogrel 
		○ Clopidogrel continues for a year
		○ Aspirin forever

Question 4

NSTEMI

Answer 4

B – Beta blockers unless contraindicated

A – Aspirin 300mg stat dose

T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative)

M – Morphine titrated to control pain

A – Anticoagulant: Low Molecular Weight Heparin (LMWH) at treatment dose (e.g. enoxaparin 1mg/kg twice daily for 2-8 days)

N – Nitrates (e.g. GTN) to relieve coronary artery spasm

Give oxygen only if their oxygen saturations are dropping (i.e. <95%).

Question 5

which Ca channel blocker for those with reduced EF post MI

Answer 5

amlodipine dont use verapamil, diltiazem and short acting dihydropyridine agents

Question 6

Complications of MI

Answer 6

(Heart Failure DREAD)
D – Death

R – Rupture of the heart septum or papillary muscles

E – “Edema” (Heart Failure)

A – Arrhythmia and Aneurysm

D – Dressler’s Syndrome

Question 7

factors that affect prognosis of MI

Answer 7

• Comorbidities such as hypertension, chronic kidney disease, anaemia, and diabetes
  
  • Site of the infarction. For example, a STEMI in the anterior part of heart has a less favourable prognosis than one in the inferior part of the heart
  • Depression, particularly treatment-resistant and insufficiently treated depression
  • Older age and female sex

Question 8

MI can cause impairment of NA-K ATPase due to impaired ATP production

Answer 8

○ Increased intracellular Na → intracellular edema
○ Increased extracellular K → alteration in transmembrane potential → electrical instability and susceptibility to arrhythmias
○ Increased intracellular Ca → activation of degradative lipases and proteases → tissue necrosis

Question 9

secondary prevention

Answer 9

6A's
aspirin 
antiplatelet
Atorvastatin 
ACE inhibitor 
atenolol 
aldosterone antagonist (for clinical heart failure - eplerenone)