ACS Therapy Flashcards
What is immediate treatment for UAP + NSTEMI
Morphine / analgesia
Oxygen
GTN - give with aspirin prior to hospital or IV nitrates
Aspirin + dual anti platelet with Clopidogrel / Trisagrelol
IV access for blood
12 lead ECG
Anti-emetic
What therapy do you give for UAP and NSTEMI
Anti-platelet - aspirin / clopidogrel - dual therapy Anti-coagulant - LMWH until discharge Statins ACEI - if hypertensive but way up risks BB Decide risk Revascularisation if high risk
What therapy if there for STEMI
If PCI available in 2 hours give GP IIB/ IIA antagonist
If unavailable = thrombolysis then transfer
Alteplase (fibrin specific)/ streptokinase (no-fibrin specific)
What are the CI of thrombolysis
Haemorrhage stroke CNS damage Major trauma < 3 weeks / operation GI bleeding Aortic dissection Low platelet Low glucose High BP Pregnant Anti-coagulant
What do you use in combination with thrombolysis
Aspirin
What do you give post STEMI / ACS
4 therapy Aspirin 75mg Tisagruel or clopidogrel 75mg Dual anti-platelet BB Atenolol 50-100mg ACEI 2.5mg - renin angio causes fibrosis Statin 80mg
Maybe give
Aldosterone antagonist (eplenerone) if evidence of HF
Anti-arrythmia
GTN
What do you never use in ACS
CCB
When do you do coronary revasculiration (CABG / PCI)
If high risk of STEMI with UA or NSTEMI
Normally keep in hospital after NSTEMI for CABG to prevent
Look at legs for scars (saphenous)
What are new approaches to NSTEMI / UAP
Trimetazidine - metabolic modulation
Ivabradine - inhibit sinus node
Ranolazine - Na inhibitor
When is there an increased risk of bleeding from anti-thrombotic (Heparin)
High BP Age >75 Stroke Bleeding tendency Labile INR >4 Abnormal renal / liver Drugs - aspirin / NSAID / alcohol
Low body weight
CKD
When do you do CABG
3 vessel disease
Left main stem disease
Disease not amendable to PCI
What does CABG require
Adequate lung / hepatic function
Ascending aorta
Distal coronary targets
LV EF >20%
What can you use for CABG
Revered long saphenous vein
Internal mammary arteries / radial (if varicose vein surgery)
Artery or veins connected to LAD artery
What is needed during CABG procedure
Heart / lung bypass machine
Anti-coagulant
Hypothermia
What are post-op problems
Cardiac tamponade - prevents atria filling
Increased JVP, tachy, muffled HS and low BP
Death - stroke / MI
What does aspirin do
Inhibits thromboxane A2 production and platelet aggregration by blocking enzyme cyclooxygenase
Anti-Platelet
Reduce MI mortality
Risk of GI bleed so low dose
What does a statin do
Lower cholesterol
What are the SE of statin and when is it CI
Myopathy - check CK Rhabdomyolysis (check CK) if develop Liver impairment - discontinue if 3x - measure baseline and at 3 + 12 months CI pregnancy / macrolide use Type II DM Haemorrhagic stroke = very rare
Who is given statin + aspirin
All patients with CVD as secondary prevention or
>10% ris as primary prevention
Think if elderly do they still need
What is the action of clopidogrel / tisagrelor / prasagurel
Inhibits ADP receptor which stops activation of GB IIa / IIb
Stops aggregation of platelet
What is 1st line in ACS
Tisagrelor (CI previous stroke)
What is used if already on anti-coagulant or will need anti-coagulation or TIA or peripheral arterial disease
Clopidogrel
What are risks
Bleeding - don’t give if CABG
Lower risk of GI bleed than aspirin
Caution asthma / COPD
What do BB do
Block sympathetic
Decrease HR and contractility
Improves perfusion
What can sudden cessation of BB do
Cause Mi
What are the indications for BB
Angina Post MI HF Arrythmia - drug of choice in AF Thyrotoxicosis / anxiety
What are the SE of BB
Bronchospasm Cold periphery Fatigue Sleep Erectile dysfunction Insulin resistance / decreased awareness of hypo
When are BB CI
Asthma / COPD Heart block Verapamil use If in cariogenic shock Peripheral vascular Raynauds Uncontrolled HF Bradycardia Verapamil use Cocaine Vasospasm Shock
What do nitrates do
Relax all smooth muscle
Symptomatic Rx by reducing afterload and preload (dilate vein)
What are averse effects of nitrates
Headache Hypotension - CI BP <90 Flushing Myalgia Rhabdomyolysis
What anti-coagulants are there
LMWH
Fondaparinux
Warfarin
DOAC
When should you not give anti-coagulant
If angiogram within 72 hours
When are anti-coagulants indicated
VTE
Valve disease
AF
When are anti-coagulants indicated post ACS
6 months post MI as risk of aneurysm / embolism
Anti-platelets have a much stronger indication so do risk vs benefit
What does Ivabradine so
Inhibits sinus node
Slows diastolic depolarisation reducing HR and O2 demand
Only use if HR >70 and if can’t tolerate BB
What does Ranazoline do
Late Na current inhibition
What does Trimetazadine do
Metabolic modulation in ischaemic tissue
Who should receive a statin
Anyone with CVD disease
>10% risk
Type 1 DM Dx 10 years ago or >40 or nephropathy
What dose of statin
20mg if primary prevention
80mg if secondary
What should you do before putting on a statin
LFT baseline the 3 months then annual
How do you manage DM in CCU
Change drugs to insulin infusion sliding scale
What should you do if on statin and need macrolide
Stop statin
What is the action of thrombosis
Converts plasminogen to plasmin which degrades fibrin and helps break up thrombi
When is Diclofenac CI
IHD
PAD
CVS
Congestive HF 2-4
What should you do
Switch to naproxen or Ibuprofen
What should you never use in ACS
CCB
