ACS & STABLE ANGINA

Question 1

Initial management of all ACS cases?

Answer 1

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

Question 2

Management of a STEMI if presenting within 12 hours of Sx and PCI unit is within 120 mins away?

Answer 2

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

Question 3

Management of a STEMI if not presenting within 12 hours of Sx or if PCI unit is not 120 mins away?

Answer 3

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

Question 4

What tool do we use to help decide management of an NSTEMI?

Answer 4

GRACE tool

Question 5

How does the GRACE tool help decide on NSTEMI management?

Answer 5

If <3% 6 month mortality risk = conservative Tx
If >3% = coronary angiogram within 72 hours with follow on PCI

Question 6

Management of a pt with an NSTEMI and GRACE score of <3%?

Answer 6

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

Question 7

Management of a pt with an NSTEMI and a GRACE score of >3%?

Answer 7

Coronary angiogram within 72 hours (immediately if unstable) followed by PCI.
Give prasugrel and unfractionated heparin as you would in a STEMI!

Question 8

Secondary prevention non-medications for ACS?

Answer 8

Lifestyle - smoking cessation, healthy eating, exercise, alcohol reduction, weight management
Annual influenza vaccine
Optimise management of conditions e.g. diabetes
Cardiac rehabilitation programme

Question 9

Secondary prevention for ACS: medical management?

Answer 9

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

Question 10

Management of stable angina?

Answer 10

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

Question 11

Whats the aim with statin Tx?

Answer 11

To have a reduction of non-HDL cholesterol concentration of >40%

Question 12

In the Tx of stable angina, if using monotherapy of CCB what should you use?

Answer 12

Rate-limiting/non-dihydropyridines CCBs e.g. verapamil or diltiazem

Question 13

Why can Dihydropyridine CCBs and BB not be used in combination?

Answer 13

As this can cause excessive suppression of the AVN leading to complete heart block or bradycardia

Question 14

Example of a long-acting nitrate?

Answer 14

Isosorbide nitrate

Question 15

SE of isosorbide nitrate?

Answer 15

Tolerance
Hypotension
Tachycardia
Flushing
Headache

Question 16

SE of ivabradine?

Answer 16

Headache
Bradycardia
Heart block
Visual effects

Question 17

When is nicorandil CI?

Answer 17

In left ventricular failure

Question 18

SE of nicorandil?

Answer 18

Headaches
Flushing
Skin, mucosal, eye ulcerations - be careful in pts with IBD or PUD due to GI ulcerations

Question 19

Who is ranolazine best for?

Answer 19

Pts with DM as seems to help lower HBA1c

Question 20

Adverse effect of ranolazine?

Answer 20

Prolonged QT interval

Question 21

What should you do if medical treatment is not controlling symptoms in stable angina?

Answer 21

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

Question 22

How can we prevent nitrate tolerance?

Answer 22

Asymmetric dosing interval to maintain a daily nitrate-free interval of 10-14 hours

Question 23

MOA of ivabradine for angina?

Answer 23

It acts on the If (‘funny’) ion current which is highly expressed in the sinoatrial node, reducing cardiac pacemaker activity = reduces heart rate

Question 24

MOA of nicorandil

Answer 24

It is a potassium-channel activator and activates guanylyl cyclase which results in increase cGMP = vasodilation

Question 25

MOA of nitrates in angina?

Answer 25

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

Question 26

BB or CCB as first line for a pt with stable angina and asthma?

Answer 26

CCB - BB can cause bronchospasm

Question 27

BB or CCB as first line for a pt with stable angina and peripheral vascular disease?

Answer 27

CCB - BB can worsen PVD by causing vasoconstriction

Question 28

BB or CCB as first line for a pt with stable angina and HF?

Answer 28

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

Question 29

Is verapamil or diltiazem more negatively inotropic?

Answer 29

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

Question 30

Which CCB can cause reflex tachycardia?

Answer 30

Shorter acting dihydropyridines e.g. nifedipine as they cause peripheral vasodilation!
This may increase angina symptoms

Question 31

Which CCBs are most likely to have Vasodilatory adverse efefcts e..g flushing, headaches, postural hypotension and ankle swelling?

Answer 31

Dihydropyridine CCBs
(Note these adverse effects usually reduce in severity with continued treatment but the ankle swelling often persists)