ACS (Oxford Handbook of Clinical Pharmacy 2e)

Question 1

The prehospital management of a STEMI consists of [4]

Answer 1

1. GTN spray 400micrograms s/l, repeat after 5 min (max 2 doses) if available to take.
2. GTM tablet 500micrograms s/l, maximum 1500, if availble.
3. Supplemental oxygen.
4. If Dr present: Morphine 2.5-5mg IV repeat as necessary. (think about laxatives, anti-emetics later on).

Question 2

What does the immediate and early hospital management of STEMI consist of? [4]

Answer 2

1. ECG: if STEMI diagosed:
2. Aspirin 300mg chewed or dissolved before swallowing plus 02 therapy.
   - NB: patients with severe obstructive airway disease could underventilate with 02 therapy and retain C02 becoming drowsy.
3. For chest pain: GTN 500micrograms s/l, repeat ater 5 mins if pain persists and SBP >95mmhg.
4. For persisting chest pain: Morphine 2.5-5mg IV PRN plus reperfusion therapy.

Question 3

What is PCI?

Answer 3

This is the reperfusion therapy of choice.

Adjuvant therapy for PCI includes aspirin/clopidogrel and heparin. Some patients need a glycoprotein IIb/IIIa inhibitor.

Question 4

What does adjuvant therapy for PCI consist of? [3]

Answer 4

Adjuvant therapy for PCI includes aspirin/clopidogrel (1) and heparin (2). Some patients need a glycoprotein IIb/IIIa inhibitor (3).

Question 5

In the management of STEMI, when is fibrinolytic therapy indicated? (2)

Answer 5

Prolonged ischaemic chest pain that has begun within the previous 12 hours (1) in the presence of ST segment elevation (2) or left bundle branch block.

Question 6

Patients who cannot have fibrinolytic therapy for STEMI should have what?

Answer 6

PCI

Question 7

For STEMI patients who can have fibrinolytic agents, what can be used?

Answer 7

1. Alteplase
2. Reteplase
3. Streptokinase
4. Tenecteplase

The plasminogen activators: alteplase, reteplase and tenecteplase are superior to streptokinase but considerably more expensive.

Question 8

Why is there a risk of allergic reactions in patients having a second treatment of streptokinase within 1 year of the previous treatment?

Answer 8

Antibodies are generated for streptokinase - it should not be used again beyond 4 days of first administration.

Question 9

How can we reverse heparin?

Answer 9

Protamine. Dosage depends on level of anticoagulation.

Question 10

The routine management of patients with acute MI with magnesium

Answer 10

NOPE

Question 11

What does subsequent management of patients with STEMI consist of? [5]

Answer 11

1. Coronary angiography normally to investigate and then initiation of aspirin 75-300mg daily or if intolerant clopidogrel 75mg oral daily.
2. B-Blocker therapy: Atenolol 25-100mg oral daily etc. titrate to maximum tolerated dose, do not allow SBP <95mmHg or heart rate <55.
3. ACEi therapy or ARB if ACEi intolerance
4. Statin therapy: atorvastatin.
5. CCB: this should be reserved for those who have post-MI angina and CIs to BB.

Question 12

When would CCB be used post STEMI?

Answer 12

When cannot tolerate BB or post-MI angina occurs.

Question 13

What does intitial therapy for high-risk unstable angina and NSTEMI patients consist of? [6]

Answer 13

1. Hospitalisation
2. ECG
3. Platelet inhibition
4. Antithrombin therapy
5. BB therapy
6. Potentially glycoprotein IIa/IIIb inhibitors and revascularisation

Question 14

For UA/NSTEMI patients who are nable to use BB, what can be used?

Answer 14

Non-dihydropyridine CCB
Dilitiazem 30-120mg oral, tds.
Diltiazem controlled release 180-360mg oral, daily.
Verapamil etc.

Question 15

For patients in whom UA has not be controlled with a BB alone what can be added?

Answer 15

A NON-RL CCB:
NOT DILT or VER
Nifedipine or amlodipine

Question 16

Patients who have undergone revascularisation procedures including a coronary stent must be on what drugs and for how long?

Answer 16

Aspirin AND clopidogrel for at least 1 month.

If using drug-eluting stent: at least 3 months.

Question 17

In the management of NSTEMI/UA what does platelet inhibition take the form of?

Answer 17

Aspirin 75-300mg oral, daily and clopidogrel 75mg oral, daily with an initial stat dose of 300mg (sometimes 600???)

Question 18

In the management of NSTEMI/UA what does antithrombin therapy take the form of?

Answer 18

UFH or LMWH in addition to the Aspirin that the patient will be initiated onto.

UFH/LMWH should be used for at least 3 das and possibly longer.

LMWH advantages: subcut, no constant monitoring.
Disadvantages: cannot be easily reversed.

For patients on UFH, the APTT should be checked initially every 6h, with a target range of 60-80s and shold be checked daily after therapy has been stabilised.

Question 19

What BB should we use in people with UA/NSTEMI

Answer 19

Atenolol or metoprolol are recommened (according to this book - might be out of date)

Question 20

When would the use of GP IIb/IIIa inhibitors occur in UA/NSTEMI management?

Answer 20

1. PAtients might be treated in the coronary care unit (with tirofiban only) for a number of hours before undergoing investigation and PCI, if needed.
2. PAtients might be treated with abiciximab at the time of procedure.

They are recommended for people who are at high risk and have abnormal ECG or a positive tropinin test.

Question 21

What is tirofaban? [3]

Answer 21

Non-peptide antagonist of GP IIb/IIIc receptors.
Approved for use in combination with heparin for patients with UA who are being treated medically and for those undergoing PCI.
When administered IV, more than 90% of platelet aggregation is inhibited.

Question 22

What is Abciximab? (3)

Answer 22

1. Chimeric human-murine monoclonal antibody
2. Elective, urgent or emergent PCI
3. Binds to receptor with high affinity and reduces platelet aggregation 80%.

Question 23

What is Eptifibatide?

Answer 23

1. Antagonist of the platelet glycoprotein IIb/IIIc eceptor which reversibly prevents von Willebrand factor, fibrinogen and other adhesion ligands from binding to the receptor.
2. Used for preventon of early MI in patients with unstable angina or NSTEMI with last episode of chest pain within 24h.