ACS initial management

Question 1

If a patient is negative for high-sensitivity cardiac troponins during initial evaluation can it be used to exclude ACS?

Answer 1

No, but in very low risk patients may justify early discharge.

Question 2

What criteria would signify a need for supplemental oxygen?

Answer 2

Signs of hypoxia, dyspnoea or heart failure.

Question 3

ECG Criteria for STEMI?

Answer 3

ST elevation of >0.1mV in 2 or more adjacent limb leads and/or >0.2mV in 2 or more adjacent chest leads or a new LBBB.

Question 4

Criteria for high-risk non-STEMI ACS?

Answer 4

Dynamic ECG changes
ST Depression.
Haemodynamic rhythm instability
Diabetes Mellitus.
High-risk scores (TIMI, GRACE)

Question 5

Which patient groups have unusual presentations of ACS?

Answer 5

Elderly female diabetic

Question 6

When should you measure troponin?

Answer 6

If patient presents within 6 hours of symptom onset: initial negative, repeat between 2-3hrs and up to 6 hours later.

Question 7

What are TIMI and GRACE used for?

Answer 7

They are risk stratification tools, used in conjunction with troponin levels to exclude ACS diagnosis.
(TIMI: Thrombolysis In Myocardial Infarction, GRACE: Global Registry of Acute Coronary Events)

Question 8

Talk through the algorithm - first part before differentiate STEMI/Non-STEMI ACS.

Answer 8

ECG -> Pain relief: nitroglycerin (if SBP >90) and morphine (3-5mg) -> Antiplatelet tx: 150-300mg aspirin or chewed or IV

Question 9

STEMI ->

Answer 9

PCI

Question 10

What are the signs of a posterior STEMI?

Answer 10

Right precordial leads should be recorded in all patients with inferior STEMI in order to detect right ventricular MI. Isolated ST- depression ≥0.05 mV in leads V1 through V3 represents STEMI in the inferobasal portion of the heart which may be confirmed by ST segment elevation in posterior leads (V7–V9).

Question 11

What can ECHO be used for?

Answer 11

Screening lower risk patients and identifying ddx: aortic dissection, pulmonary embolism, aortic stenosis, hypertrophic cardiomyopathy, pericardial effusion, or pneumoth- orax may be identified.

Question 12

What is MDCTA and what is it used for?

Answer 12

Multi-detector Computer Tomography Coronary Angiography.
Used for: ruling out obstructive CAD - screen very low risk patients to send home. Also, picks up low-risk patients who do have severe coronary lesions.

Question 13

22Why are NSAIDs avoided in ACS?

Answer 13

Fondaparinux indications?

Question 14

Prasugrel dose?

Answer 14

60mg loading

Question 15

Ticagrelor dose?

Answer 15

180mg loading

Question 16

Secondary prevention drugs?

Answer 16

• Beta-blockers: low and slow once stable.
• ACEIs/ARBs: oral within 24 hr.
• Statins within 24 hrs