ACS Management

Question 1

STEMI Management?

Answer 1

Aspirin 300mg
- PCI (drug-eluting stent) - prasugrel + unfrac heparin + bailout glycoprotein IIb/IIIa inhibitor
OR
- Fibrinolysis - antithrombin + ticagrelor. Repeat ECG after 60-90mins, if ongoing ischaemia = PCI

Question 2

Substitute drugs for STEMI if high bleeding risk + on oral anticoagulants?

Answer 2

High bleeding risk = swap prasugrel for ticagrelor. swap ticagrelor for clopidogrel
Oral anticoagulant = swap prasugrel for clopidogrel

Question 3

Site of access for ACS management?

Answer 3

RADIAL access

Question 3

NSTEMI management?

Answer 3

Aspirin 300mg + PCI if unstable OR Fondaparinux (if no immediate PCI)
Estimate 6-month mortality (GRACE)
≤3% risk - conservative + ticagrelor
>3% risk - PCI (drug-eluting stent) within 72 hrs + prasugrel OR ticagrelor + unfrac heparin

Question 4

Substitute drugs for NSTEMI if high bleeding risk + on oral anticoagulants?

Answer 4

High bleeding risk - swap fondaparinux for alternative antithrombin/dose, swap prasugrel for ticagrelor, swap ticagrelor for clopidogrel
Oral anticoagulants - swap prasugrel/ticagrelor for clopidogrel

Question 5

Tool for risk assessment in ACS + metrics it calculates?

Answer 5

Global Registry of Acute Coronary Events (GRACE)
Calculates 6-month mortality stratifying from Lowest, Low, Intermediate, High, Highest with ≤1.5%, 1.5-3.0%, 3.0-6.0%, 6.0-9.0%, >9.0% risk.

Question 6

General management rules for all ACS patients?

Answer 6

Aspirin 300mg
O2 given if <94% sats
Morphine only if severe pain
Nitrates sublingual/IV if ongoing chest pain + hypertension, don’t use if hypotensive

Question 7

ECG criteria for STEMI?

Answer 7

Men >40 - ≥2.0mm ST elevation in leads V2-3
Men <40 - >2.5mm ST elevation in leads V2-3
Women - ≥1.5mm ST elevation in V2-3
AND/OR
- 1mm ST elevation in other leads
- New LBBB