Acute Coronary Syndrome

Question 1

What 3 conditions fall under ACS?

Answer 1

Unstable angina
NSTEMI - Non-ST elevation myocardial infarction
STEMI - ST elevation myocardial infarction

Question 2

What are some modifiable & non-modifiable risk factors of ACS?

Answer 2

Modifiable - lifestyle changes, smoking, diet, exercise

Non-modifiable - age, gender, ethnicity, genetics

Question 3

What are the differences between unstable angina, STEMI & NSTEMI?

Answer 3

NSTEMI:

1. Increased frequency of chest pains (>20mins)
2. Slight troponin increase
3. No GTN spray relief
4. T wave inversion present
5. Less cardiac damage present

Unstable angina:

1. No troponin/ECG changes
2. No GTN spray relief
3. Increased frequency of chest pains (>20mins)

STEMI:

1. Most severe
2. High troponin levels
3. ST elevation due to K+ ions
4. Evaluate for cardiac reperfusion intervention

Question 4

What is the difference between troponin I & troponin T?

Answer 4

Troponin I - is a specific CV bio marker
Troponin T: is not a CV bio marker

(Creatine kinase is also a specific CV bio marker)

Question 5

What 4 things should be given during pre-hospital management of an ACS event?

Answer 5

REMEMBER MONA 
M - morphine 5-10mg IV for pain 
O - oxygen if levels are <94% 
N - nitrates, GTN sublingual (not for a STEMI)
A - aspirin 300mg loading dose

Question 6

What is the immediate treatment for a STEMI in hospital?

Answer 6

PCI (percutaneous coronary intervention) is administered using a catheter to place a stent to widen blood vessels narrowed by atherosclerosis.

Antiplatelets (e.g aspirin/clopidogrel/ticagrelor) + anticoagulants given (e.g low molecular weight heparin, bivalirudin)

Question 7

What are some examples of fibrinolytic agents given during a STEMI?

Answer 7

Alteplase, streptokinase, tenectaplase

They are tissue plasminogen activators (TPA’s)

Question 8

What is the immediate treatment for UA/NSTEMI?

Answer 8

1. Aspirin 300mg loading dose

2. Antithrombin therapy - fondapurinix, unfractioned heparin

Question 9

What is the GRACE score and what is it used for?

Answer 9

It is a scoring system used to predict the mortality of patients who are at risk of a CV event.

1. Patients with <6 months: dual anti platelet therapy (aspirin + clopidogrel). Anticoagulant e.g bivalirudin also given.
2. Low risk patients: dual anti platelet therapy only

Question 10

How is aspirin given for any ACS event and which patients should you take care with when giving it?

Answer 10

300mg loading dose, then 75mg lifelong

It can cause bronchospasms & GI irritation so take care in patients with asthma & peptic ulcers.

Question 11

How is clopidogrel given for any ACS event?

Answer 11

300mg loading dose, then 75mg lifelong.
Can be used as mono therapy for those not tolerated to aspirin.
Used as dual therapy for 12months.

Question 12

How is ticagrelor given in any ACS event?

Answer 12

180mg immediately, then 90mg BD
Used with aspirin if patient is at high risk.
Mostly used for STEMI/NSTEMI patients.

Question 13

What are the 4 options available during long term management of ACS?

Answer 13

REMEMBER ABAS

A - Dual anti platelet therapy (aspirin + other antiplatelet)
B - B blockers (bisoprolol 10mg OD)
A - ACE inhibitors (ramipril, perindopril)
S - Statins (atorvastatin 80mg)

Question 14

How are ACEI, b-blockers & statins given?

Answer 14

ACEi: induces cardiac remodelling, titrated till target dose.
B-blockers: reduces infarction size, take care in asthmatics as it can cause bronchospasms. Can also cause night terrors & coldness.
Statins: high dose atorvastatin given (80mg), stabilises plaques, & avoid grapefruit juice.

Question 15

Why is lansoprazole also given to all ACS patients?

Answer 15

To avoid GI irritation (gastro protection)

Lansoprazole 30mg OD is given.