Acute Coronary Syndrome

Question 1

How are unstable angina and NSTEMI often characterised

Answer 1

Stable angina that suddenly worsens
Recurring or prolonged angina at rest
or new onset of severe angina

Question 2

Differential Diagnosis:

Unstable angina vs NSTEMI

Answer 2

Patients with unstable angina have NO EVIDENCE of myocardial necrosis, whereas in NSTEMI myocardial necrosis will be evident (less significant than with STEMI though)

Question 3

What is the risk to patients with unstable angina or NSTEMI?

Answer 3

Progression to STEMI or sudden death

Particularly in patients who experience pain at rest

Question 4

Initial management for unstable angina and NSTEMI

Answer 4

Aim is to provide supportive care, pain relief during the attack and prevent further cardiac events and death

• supportive care -
  OXYGEN - if evidence of hyperoxia, pulmonary oedema, or continuing myocardial ischaemia ( avoid hypoxia and take care in pts with COPD
• Pain Relief -
  NITRATES
  (GTN or isosorbide dinitrate) if pain continues diamorphine or morphine IV; and an antiemetic such as metoclopramide should be given.
• Prevention -
  ANTIPLATELETS (Aspirin and clopidogrel (for 12 months - most benefit during first 3 months). Prasugrel is an alternative in patients undergoing percutaneous coronary intervention. Ticagrelor is also an alternative to clopidogrel)

BLOOD THINNER
heparin or LMW heparin or fondaparinux (as unstable angina and NSTEMI usually occur as a result of atheromatous plaque rupture)

BETA BLOCKER
indefinitely - except in pts without left ventricular dysfunction and in whom bb are inappropriate - diltiazem or verapamil

ACEi

Question 5

management for high/intermediate risk patients with unstable angina and NSTEMI

Answer 5

Eptifibatide + heparin + aspirin
or
Tirofiban + heparin + aspirin + clopidogrl

(for patients at high risk of either MI or death

Question 6

What is a STEMI?

Answer 6

An acute coronary syndrome where plaque ruptures lead to thrombosis and myocardial ischaemia with IRREVERSIBLE necrosis of the heart muscle

Question 7

Apart from plaque ruptures, what are some other cause of STEMI?

Answer 7

Coronary spasm 
Coronary embolism 
Arteritis 
Spontaneous thrombosis
Sudden severe elevation in BP

Question 8

Initial management of STEMI

Answer 8

Aims of management are to provide supportive care and pain relief, to promote reperfusion and to reduce mortality

• supportive care -
  OXYGEN if there is evidence of hypoxia, pulmonary oedema or continuing myocardial ischaemia (avoid hyperoxia - especially in pts with COPD)
• Pain Relief -
  NITRATES
  for ischaemic pain.
  iv diamorphine or morphine and an iv antiemetic - metoclopramide (of if ventricular function not compromised, cyclizine)
• Promote reperfusion -
  ANTIPLATELETS
  Aspirin and clopidogrel. Prasugrel is an alternative in patients undergoing percutaneous coronary intervention. Ticagrelor is also an alternative to clopidogrel)

BLOOD THINNER
heparin or LMW heparin

BETA BLOCKER
early administration has been shown to be of benefit

ACEi
can be started within 24hrs of the MI and continued fir at least 5-6 weeks

Question 9

Long term drug treatment of STEMI

Answer 9

Aspirin (indefinitely)
+ Clopidogrel (shown to reduce morbidity and mortality)
+ Beta Blockers (diltiazem or verapamil can be considered if a BB cant be used)
+ ACEi or ARB(a relatively high dose my be required to produce benefit)
+ Nitrate (if pt has angina)
+ Eplerenone (if has left ventricular dysfunction and evidence of heart failure)
+ Statin (to prevent recurrent CV events

Question 10

Diabetic with stable angina

Answer 10

+ ACEi