ACS/AMI

Question 1

back to basics for ASCVD

Answer 1

atherosclerotic cardiovascular disease (ASCVD) -> coronary artery disease -> atherosclerosis -> chronic coronary syndrome (stable ischaemic heart disease, angina), acute coronary syndrome (STEMI, N-STEMI)

Question 2

pathophysiology of ACS/AMI

Answer 2

clot break off -> emoblise to left ventricle -> travel to aorta -> travel to coronary vessel -> occlude coronary vessel -> AMI

Question 3

clinical presentation of ACS

Answer 3

• chest pain that radiate to arm, shoulder, neck, jaw, upper abdomen
• SOB, cold clammy skin, lightheaded

Question 4

clinical presentation of AMI

Answer 4

3 cardinal sign
1) ECG
2) high troponin levels
3) clinical symptoms (chest pain, difficulty breathing, widespread pain across epigastric region)

Question 5

diagnose ACS/AMI

Answer 5

1) ECG

• ST elevation within 10 mins = STEMI
• ST depression/normal within 10 mins = NSTEMI

2) differential diagnosis

• GERD, PUD
• hypoglycaemia
• pneumonia
• CHF

Question 6

high bleeding risk (HBR) criteria meanings

Answer 6

high bleeding if 1 major criterion or 2 minor criterion

Question 7

major criterion for HBR

Answer 7

1) probably long term anticoagulation
2) severe/end stage CKD
3) spontaneous bleeding requiring hospi/transfusion
4) mod/severe baseline thrombocytopenia
5) liver cirrhosis w portal HTN
6) active malignancy within past 12 month (exclude nonmelenoma skin cancer)
7) previous spontaneous ICH (any time) or traumatic ICH (within 12 months)
8) mod - severe ischaemic stroke within past 6 months
9) nondeferrable majory surgery on DAPT
10) recent major surgery/major trauma within 30d before PCI

Question 8

minor criterion for HBR

Answer 8

1) age ≥ 75
2) moderate CKD
3) Hb 11 - 12.9 for men and 11 - 11.9 for women
4) spontaneous bleeding blah blah but dont fulfil major criterion
5) long term NSAID/steroid
6) any ischaemic stroke not meeting major criterion

Question 9

treatment for pt since the beginning

Answer 9

1) suspected ACS (acute MI occur) otw to hospital on ambulance

• load aspirin (100mg if take before, 300mg if never take)

2) at A&E

• confirm ACS/MI through 3 cardinal sign
  ** load ticagrelor 180mg
  ** if CI then clopidogrel 600mg

3) primary angioplasty (PCI)

• IV UFH/LMWH +/- IV GPIIb or GPIIa to prevent clot from forming

4) warded

• start DAPT

5) send patient home

• counselling
• monitoring and follow up: FBC, bleeding (dark tarry stool), adherence, dyspnoea (for ticagrelor)
• secondary prevention

Question 10

aspirin for ACS/AMI

Answer 10

• SAPT/DAPT
• 300mg PO loading dose + 100mg PO lifelong

Question 11

ticagrelor for ACS/AMI

Answer 11

• DAPT w aspirin
• 180mg PO loading dose + 90 mg PO lifelong
• why preferred over clopidogrel?
  ** clopidogrel got CYP3C19 polymorphism
  ** use ticagrelor for ACS, clopidogrel for CCS
• stop ticagrelor 2 - 3 days before surgery
• CI: severe liver impairment

Question 12

clopidogrel for ACS/AMI

Answer 12

• DAPT w aspirin
• ACS but CI with ticagrelor or CCS: 600mg PO loading dose + 75mg lifelong
• receiving thrombolysis: 300mg loading dose
• stop 5 days before surgery
• CYP2C19 polymorphism
  ** if 2/3 then loss of function -> use ticagrelor
  ** if 17* then gain of function

Question 13

dipyridamole for ACS/AMI

Answer 13

• DAPT w aspirin with high bleeding risk
• 25 - 150 mg PO TDS

Question 14

duration of DAPT

Answer 14

1) ACS: 12 month DAPT + lifelong SAPT
2) CCS: 6 month DAPT + lifelong SAPT
3) high bleeding risk: 3 month DAPT -> lifelong SAPT