ACS & STABLE ANGINA Flashcards
Initial management of all ACS cases?
MONA
5-10mg morphine IV (2.5-5mg for frail pt)
O2 if sats <94
GTN sublingual 1 tablet, can be repeated at 5 minute intervals
Loading dose of 300mg oral aspirin
Management of a STEMI if presenting within 12 hours of Sx and PCI unit is within 120 mins away?
Coronary angiogram followed by immediate PCI
Give prasugrel (or clopidogrel if already taking an anticoagulant)
If radial access then give unfractionated heparin with bailout GP2b/3a inhibitor
If femoral access give bivalirudin and GPI
Management of a STEMI if not presenting within 12 hours of Sx or if PCI unit is not 120 mins away?
Fibrinolysis with alteplase
Give an antithrombin agent such as fondaparinux
After give ticagrelor (or clopidogrel if high bleeding risk!)
Do an ECG 60-90 mins after thrombolysis and if failed then do an angiogram and follow on PCI
What tool do we use to help decide management of an NSTEMI?
GRACE tool
How does the GRACE tool help decide on NSTEMI management?
If <3% 6 month mortality risk = conservative Tx
If >3% = coronary angiogram within 72 hours with follow on PCI
Management of a pt with an NSTEMI and GRACE score of <3%?
Ticagrelor loading dose 180mg followed by ticagrelor 90mg TD for 12 months & aspirin 75mg OD lifelong (clopidogrel with aspirin or aspirin alone if bleeding risk)
Antithrombin therapy with fondaparinux can be offered if PCI is not immediately indicated and no high bleeding risk
Management of a pt with an NSTEMI and a GRACE score of >3%?
Coronary angiogram within 72 hours (immediately if unstable) followed by PCI.
Give prasugrel and unfractionated heparin as you would in a STEMI!
Secondary prevention non-medications for ACS?
Lifestyle - smoking cessation, healthy eating, exercise, alcohol reduction, weight management
Annual influenza vaccine
Optimise management of conditions e.g. diabetes
Cardiac rehabilitation programme
Secondary prevention for ACS: medical management?
BASIC (all for indefinite use except for second antiplatelet)
BB
Aspirin 75mg OD
Statin - atorvastatin 80mg ON
inhibitor (ACEi) or ARB if ACEi not tolerated
Clopidogrel/prasugrel/ticagrelor for up to 12 months
Management of stable angina?
AAABCN
Aspirin 75mg OD
Atorvastatin 80mg ON
ACEi if they have diabetes, HF or CKD
Sublingual GTN for a final attacks
BB or CCB
If monotherapy fails increase to max tolerated dose and then use the other either BB or CCB as well
If this fails or is not tolerated then use long acting nitrates, ivabradine, nicorandil or ranolazine. Note you should only add a third drug whilst awaiting PCI or CABG
Whats the aim with statin Tx?
To have a reduction of non-HDL cholesterol concentration of >40%
In the Tx of stable angina, if using monotherapy of CCB what should you use?
Rate-limiting/non-dihydropyridines CCBs e.g. verapamil or diltiazem
Why can Dihydropyridine CCBs and BB not be used in combination?
As this can cause excessive suppression of the AVN leading to complete heart block or bradycardia
Example of a long-acting nitrate?
Isosorbide nitrate
SE of isosorbide nitrate?
Tolerance
Hypotension
Tachycardia
Flushing
Headache
SE of ivabradine?
Headache
Bradycardia
Heart block
Visual effects
When is nicorandil CI?
In left ventricular failure
SE of nicorandil?
Headaches
Flushing
Skin, mucosal, eye ulcerations - be careful in pts with IBD or PUD due to GI ulcerations
Who is ranolazine best for?
Pts with DM as seems to help lower HBA1c
Adverse effect of ranolazine?
Prolonged QT interval
What should you do if medical treatment is not controlling symptoms in stable angina?
Offer coronary angiogram to guide treatment strategy. Options are:
- PCI - has faster recovery, lower rates of strokes as complications, high rate of requiring repeat revasculisation
- CABG - best for severe stenosis
How can we prevent nitrate tolerance?
Asymmetric dosing interval to maintain a daily nitrate-free interval of 10-14 hours
MOA of ivabradine for angina?
It acts on the If (‘funny’) ion current which is highly expressed in the sinoatrial node, reducing cardiac pacemaker activity = reduces heart rate
MOA of nicorandil
It is a potassium-channel activator and activates guanylyl cyclase which results in increase cGMP = vasodilation
MOA of nitrates in angina?
nitrates cause the release of nitric oxide in smooth muscle, activating guanylate cyclase which then converts GTP to cGMP, which in turn leads to a fall in intracellular calcium levels
in angina they both dilate the coronary arteries and also reduce venous return which in turn reduces left ventricular work, reducing myocardial oxygen demand
BB or CCB as first line for a pt with stable angina and asthma?
CCB - BB can cause bronchospasm
BB or CCB as first line for a pt with stable angina and peripheral vascular disease?
CCB - BB can worsen PVD by causing vasoconstriction
BB or CCB as first line for a pt with stable angina and HF?
BB - definitely avoid rate-limiting CCBs!
The dihydropyridines affect peripheral vascular smooth muscle more than the myocardium so dont result in worsening of HF but they do still cause ankle swelling
Is verapamil or diltiazem more negatively inotropic?
Verpaamil so should never be given with BB as can cause heart block
But diltiazem should still be used with caution in pts taking BB or have HF - they can still cause hypotension, bradycardia, HF and ankle swelling
Which CCB can cause reflex tachycardia?
Shorter acting dihydropyridines e.g. nifedipine as they cause peripheral vasodilation!
This may increase angina symptoms
Which CCBs are most likely to have Vasodilatory adverse efefcts e..g flushing, headaches, postural hypotension and ankle swelling?
Dihydropyridine CCBs
(Note these adverse effects usually reduce in severity with continued treatment but the ankle swelling often persists)
