ACS summaries using NICE graphs Flashcards
STEAMI - immediate management
300mg loading dose of aspirin ASAP and continue indefinitely unless CI
Do not offer routine GPIs or fibrinolytic drugs before arrival at catheter lab if primary PCI planned
What to do after you have given loading dose of 300 aspirin in STEMI
immediately assess eligibility for reperfusion therapy
if eligible, offer reperfusion therapy ASAP
otherwise offer medical management
You have given aspirin 300mg loading dose to patient. You then assessed reperfusion eligibility. They are not eligible so you offer medical management - what is it?
ticagrelor + aspirin unless high bleeding risk
if high bleeding risk, clopidogrel + aspirin or aspirin alone
You have given medical management (dual antiplatelet therapy to pt depending on their bleeding risk, or aspirin alone) in a pt with STEMI who was not suitable for reperfusion therapy. What is next?
(3)
offer cardiology assessment
then assess LV function
then cardiac rehabilitation and secondary prevention
you have given loading dose aspirin 300mg to pt with STEMI. You have assessed eligibilty and they are suitable for reperfusion therapy. What are the 2 options
angiography with follow on primary PCI or fibrinolysis
for people who are eligible for reperfusion therapy, the options are either angiography with follow on primary PCI or fibrinolysis.
when would you give them fibrinolysis and what does it involve?
(STEMI)
if present within 12h symptom onset and PCI not possible in 120 mins
give antithrombin at the same time
offer ECG 60-90 mins after fibrinolysis
for people who are eligible for reperfusion therapy, the options are either angiography with follow on primary PCI or fibrinolysis.
when would you offer them angiography with follow on primary PCI and what does this involve?
(STEMI)
if presenting within 12h symptom onset and PCI can be delivered within 120 mins
consider if presenting >12h after symptoms and they have a continuing MI or cardiogenic shock
radial access in preference to femoral!
You have given someone fibrinolysis, given them antithrombin at the same time and have done ECG 60-90 mins after fibrinolysis.
What is next?
(STEMI)
drug therapy: ticagrelor + aspirin unless high bleeding risk. if so, clopidogrel + aspirin or aspirin alone
if ECG indicates, do not repeat fibrinolysis - offer immediate angiography with following PCI
seek specialist advice for recurrent MI and offer angiography with follow on PCI if appropriate
consider angiography during same admission if they are stable after successful fibrinolysis
assess LV function
then give cardiac rehabilitation and secondary prevention
You have given someone angiography with follow on primary PCI. What is drug therapy, including for radial and femoral access?
(STEMI)
drug therapy for primary PCI
- prasugrel + aspirin if not already taking oral AC
- clop + aspirin if already taking oral AC
- UFH + bailout GPI for radial access
- bivalirudin with bailout GPI if femoral access needed
if 75 and over, think about whether bleeding risk with prasugrel outweighs effectiveness; if so give ticag or clopid instead
You have offered someone angiography with follow on primary PCI and administered necessary drug therapy after STEMI
Stenting and revascularisation?
And after?
if stenting indicated, give a drug eluding one
offer complete revascularisation (consider doing this in index admission) if multivessel CAD and no cardiogenic shock
consider culprit only during index procedure for cardiogenic shock
Then assess LV function, then cardiac rehabilitation and secondary prevention
immediate management for NSTEMI/unstable angina
(antiplatelet, antithrombin)
300mg loading dose aspirin
continue indefinitely unless CI
initial antithrombin: fondaparinux unless high bleeding risk or immediate angiography. think about choice and dose of antithrombin if high bleeding risk (e.g. elderly, bleeding complications, RI, low body weight).
if creatinine >265, consider UFH with dose adjusted to clotting function
nstemi/unstable angina.
what do you do after you have given initial antiplatelet and antithrombin
use established risk scoring system e.g. GRACE to predict 6 month mortality and risk of CV events
include the following in the risk assessment: clinical history, physical examination, resting 12 lead ECG and blood tests
balance possible benefits of treatment against bleeding risk
NSTEMI/unstable angina.
You have given inital antiplatelet & antithrombin therapy. And also have used established risk scoring system to predict 6 month mortality and risk of CV events.
the patient has low risk (predicted 6 month mortality less than or equal to 3%).
what do you do?
consider conservative management w/o angiography but be aware that some younger people may benefit from early angiography
offer T + A unless high bleeding risk. if so, consider C + A or A alone for high bleeding risk.
Consider testing ischaemia before discharge
If it develops or is shown on testing, consider angiography with follow on PCI if indicated
Assess LV function for NSTEMI, and consider assessing for unstable angina.
Then cardiac rehab and secondary prevention
NSTEMI/unstable angina.
You have given inital antiplatelet & antithrombin therapy. And also have used established risk scoring system to predict 6 month mortality and risk of CV events.
the patient has intermediate or high risk (predicted 6 month mortality more than 3%).
what do you do?
- if clinical condition unstable, immediate angiography
- otherwise consider angiography with follow on PCI if indicated within 72h if no CI e.g. active bleeding, comorbids
- if no separate indication for AC, offer P or T with aspirin.
- if separate indication for AC, offer C + A.
- only give prasugrel once PCI intended.
- offer systemic UFH in catheter lab if having PCI
- drug eluding stent if stenting indicated
- if follow on PCI not done, consider angiography findings, comorbids, and risks and beenfits when discussing management strategy with cardiologist, cardiac surgeron and pt.
- then assess LVF for NSTEMI and consider assessment for unstable angina
- then cardiac rehab and seocndary prevention
