ACS and Angina

Question 1

What are the criteria for diagnosis of a STEMI?

Answer 1

ECG changes
ST-elevation

• 2 or more continous leads
• > 1mm (other than V2-3 where cutoffs are: >1.5 in women, >2 in men < 40 or >2.5 men >40)

No biochemical evidence needed, although cardiac enzymes (toponin) can be used to confirm diagnosis

Other more uncommon ECG changes

• Posterior STEMI: ST-depression in V1-3 + reciprocal changes
• New LBBB

Question 2

What is the initial management for patients with a STEMI?

Answer 2

1. Aspirin Loading dose (300mg) for ALL patients

Asessment for elegibility for reperfusion therapy

Question 3

How is decided which reperfusion therapy is used in patients with STEMI?

Answer 3

First line Coronary Angiography + PCI

• for all patients presenting within 12h of symptom onset if can be delivered within 120 minutes

If PCI cannot be delivered within 120 minutes but fibronolysis can: Fibrinolysis

Question 4

What is the medical management for all patients undergoing PCI for a STEMI?

Answer 4

1. Loading on prasugrel with aspirin if not on any oral anticoagulant
2. Clopidogrel with aspirin if taking other oral anticoagulant

If >75: weigh up risk of bleeding with prasugrel; alternative ticagrelor or clopidogrel

During Procesure: unfractionated heparin during procedure (radial access)

Question 5

What is the medical management for patiens with a STEMI undergoing fibrinolysis?

Answer 5

Also on double antiplatelets
1. Ticagrelor/Fundaparinox with aspirin or
2. clopidogrel with aspirin (or aspirin alone if high bleeding risk)

Question 6

What are the diagostic criteria for an NSTEMI?

Answer 6

ECG changes (normal in 30%)

• ST-depression (worse prognosis)
• Transient ST elevation not meeting STEMI criteria
• T-wave changes (e.g. inversion etc.)

Cardiac enzymes

• Troponin (generally peak after 12 h of ischaemic insult - often needs to be repeated)
• Drawn at 0 and 1h (sometimes + 3h if results inconclusive) + use 0/1 algorythm
• –> Positive for MI (Stetmi/NSTEMI)
• –> negative for unstable angina

Question 7

What is the initial management for NSTEMI/ Ustable angina?

Answer 7

1. 300mg Aspirin
2. Fondaparinux (unless high bleeding risk or immediate angiography) - if angiogram if likely to happen within the next days

• If Renal function impaired (creatinine >265: unfractionated heparin

3. Calculate GRACE score

Question 8

What is concidered a low GRACE score? How should patients with NSTEMI/ Unstable angina and low GRACE score be managed?

Answer 8

< 3% 6-month mortality

• Consider conservative management
• Ticagrelor with aspirin (if high bleeding risk Clopidogrel + aspirin)

PCI can still be considered if thought to be beneficial

Question 9

What is concidered a high GRACE score? How should patients with NSTEMI/ Unstable angina and high GRACE score be managed?

Answer 9

Predicted 6 month mortality >3%

1) If haemodynamically unstable: immediate Angiography +/- PCI within
2) If haemodynamically stable: Angiography +/- PCI within 72h
+ prasugrel (if PCI intended) /ticagrolor + aspirin

Question 10

What is the best choice of antiemetic in ACS management?

Answer 10

Question 11

What is the medical preventative management of stable angina?

Answer 11

1st line: Beta blocker (e.g. Atenolol)
2nd line:

• if Beta blocker not tolerated: Verapamil or Diltiazem (contraindicated with Beta blocker due to risk of Heart block)
• If addiotionally to Beta blocker: nifedipine

Question 12

What is the 3rd line preventative management option for stable angina if it is not controlled with Beta blocker + CCB or CCB alone?

Answer 12

□ Long-acting nitrates (e.g. ivabradine)

Question 13

What should be included in the discarge medication for people with ischaemic heart disease?

Answer 13

1. Dual antiplatelets (aspirin 75mg + clopidogrel/ ticagrelor or prasugrel)
2. ACEi
3. Beta-blocker
4. statin (high dose - secondary prevention)