ACS Management

Question 1

What ix to include in assessment of ACS

Answer 1

12 lead ECG - then cardiac monitoring

Bloods - FBC, U&E, LFT, CRP, glucose, high-sensitivity troponin, magnesium, phosphate, lipids

CXR - LVF signs, other causes

Question 2

1. When does high-sensitivity troponin peak after pain onset?
2. What is used in NSTEMI patients to look for significant change for diagnosis of MI
3. When is HS troponin usually done
4. When can troponin be used to rule out MI

Answer 2

1. 12 hours after pain onset but value will be rising before this
2. Interval testing
3. Usually at presentation and 3 hours after
4. A normal value over 6 hours from pain onset

Question 3

What are the types of ACS

Answer 3

STEMI - ST elevation or new LBBB

NSTEMI - raised troponin but no ECG changes

UAP - ACS without ECG changes or raised troponin

Question 4

What is included in the initial mx of ACS

Answer 4

M - morphine 10mg in 10ml slow IV titrated to pain + 10mg metoclompramide IV

O - oxygen if sats below 94%

N - nitrates: sublingual GTN if not hypotensive (then PRN) - IV infusion can also be given

A - aspirin 300mg PO loading dose (then 75mg OD)

Question 5

Further medications to consider in ACS

Answer 5

P2Y12-receptor inhibitors - cardiologist will start during PCI

• prasugrel - 1st line but highest bleeding risk
• ticagrelor - if higher bleeding risk
• clopidogrel - if already anticoagulated

ACS-dose anticoagulation - fondaparinux or LMWH or unfractionated heparin for 5 days

• cardiologist will start during PCI in STEMI patients or patients having immediate PCI
• start before PIC if low bleeding risk in NSTEMI patient not having immediate PCI

Question 6

What early long-term medications would you consider in ACS

Answer 6

B-blocker
ACEi - once haemodynamically stable
Statin

Question 7

When would you consider PCI in NSTEMI patient

Answer 7

Immediately - unstable clinical condition

• haemodynamically unstable
• acute heart failure
• arrhythmia
• ischaemic changes
• ongoing / recurrent pain
• mechanical complications

Within 72 hours - intermediate/high risk GRACE score

Low-risk GRACE score - non-invasive testing may be more appropriate i.e. stress ECHO

Question 8

What does the GRACE score measure and consider

Answer 8

The probability of ACS mortality at 6 months:

• age
• heart rate
• SBP
• creatinine
• presence of ST deviation
• troponin
• cardiac arrest or LVF

> 3% = intermediate-high risk

<3% = low risk

Question 9

What should all patients have to assess LV function

Answer 9

ECHO

Question 10

What should you check regularly in hospital

Answer 10

Electrolytes and cardiac monitoring

Question 11

When can patients usually be discharged from hospital after ACS

Answer 11

STEMI patients with complete revascularisation - 2-3 days

low-risk NSTEMI patients with complete revascularisation - within 24 hours

Question 12

What is included in the long-term management of ACS

Answer 12

Antiplatelet therapy - give with PPI if bleeding risk

• No AF - aspirin (life) + tica/pras/clop (1 year)
• AF - DOAC (life) + clop (1 year) + aspirin (1 week)

CV risk reduction

• BP control - ACEi (life), b-blocker (if LV dysfunction - 1 year if not), aldosterone antagonist (if LV dysfunction)
• Statin
• lifestyle modifications/cardiac rehab, smoking cessation