Acute Coronary Syndrome

Question 1

Whats is ischaemic heart disease all about

Answer 1

plaque formations from fatty streaks

If these rupture then they can cause thrombosis

Question 2

What symptoms/effects can people get if arteries start to narrow?

Answer 2

• TIA’s
• Angina
• leg ischaemia

Question 3

What happens if a plaque ruptures?

Answer 3

• platelets clump together to cause a sudden partial or total occlusion of the artery and an acute coronary syndrome develops.

Question 4

what risk assessment tool do we use for CHD?

What does it assess?

Answer 4

QRISK2

10 year CVD risk

Question 5

What modifiable risk factors do we have for ACS

Answer 5

• diet
• smoking
• exercise
• HTN - each 2mmHg rise incurs a 7% increase in CHD and a 10% increase in stroke risk.
• alcohol
• lipid control - offer 20mg atorvastatin to patients with QRISK score > 10%.

Question 6

How can we monitor for primary preventions?

Answer 6

Keep reassessing the QRISK2 score

Question 7

What do we check when starting statins?

- primary prevention

Answer 7

• baseline lipids
• LFT’s
• No secondary cause of dyslipidaemia e.g. thyroid disease
• repeat after 3 months and check compliance side/effects
• Aim for >40% reduction in HDL cholesterol.
• Consider increasing dose again if not maximal effect
• Repeat LFT’s 12 months but not again unless indicated

Question 8

What do we check if statin antihypertensives?

- primary prevention

Answer 8

• Bloods: albumin creatinine ration (ACR), blood sugar, u&E, eGFR, lipids
• ace/arb - U&E’s, eGFR 1-2 weeks after dose titration and then annually unless indicated.
• diuretics - recheck (u&e, eGFR) 4-6 weeks then annually
• check BP response to treatment and compliance/side effects

Question 9

Is QRISK2 score used for primary or secondary prevention?

Answer 9

Primary

All patients that have had an event are high risk. All modifiable/non-modifiable lifestyle factors are still relevant in secondary prevention.

Question 10

Patients with CHD who feel pain on exertion because the heart required more oxygen but this resolves on rest and GTN spray can be diagnosed with….

Answer 10

Angina

It is important to note that this resolves on rest because if it doesn’t and the patient feels pain on rest then they could be having an ACS

Question 11

Management of Angina….

Answer 11

• diet & lifestyle
• education on what it is, what provokes it (cold, stress, exertion)
• aspirin 75mg OD (clopidogrel if aspirin is C/I)
• Evaluate bleeding risk and start PPI omeprazole 20mg to cover for long term aspirin
• rationalise medicines - try to avoid NSAIDS for example.
• Start atorvastatin 80mg regardless of lipid levels. 20mg in CKD.
• antihypertensives if high BP
• GTN spray - monitor frequency of use and if still symptomatic add in

1) BB or rate limiting CCB (verapamil or diltiazem)
2) BB + CCB (switch to non rate limiting)
3) nicorandil, ISMN, ranolazine, ivabradine (lowers HR with little effect on pulse)

Question 12

How do we treat post-MI

Answer 12

• CVD risk factor modification
• diet/lifestyle advice
• antiplatelets (aspirin + clopidogrel, ticagrelor or prasugrel) Usually dual therapy for 12 months then mono.
• ace-inhibitor - start low and up titrate
• beta-blocker - start low and up titrate
• atorvastatin 80mg
• GTN spray
• rationalise meds - avoid NSAIDS
• minimise bleeding risk > 65 years offer PPI e.g., concurrent steroids or SSRIS. Ensure second anti platelet is stopped at the correct time.
• cardiac rehab - recommended to start 10 days post discharge

Question 13

What is the difference between an NSTEMI (non ST elevation myocardial infarction|) and a STEMI. (ST elevation myocardial infarction)

Answer 13

STEMI - total occlusion of an artery - ECG picks up ST wave elevation and troponin rise is evident.

NSTEMI - partial occlusion of artery. ECG shows ischemic changes ( T wave inversion and ST segment depression) and troponin rise is evident

Question 14

How do we treat a STEMI

Answer 14

1) PPCI - primary percutaneous coronary intervention (angioplasty) treatment of narrowed arteries. Favoured over thrombolysis due to more effective revascularisation, lead re-occlusion, less bleeding, decreased length of stay.
2) Thrombolysis - not used as much due to PPCI but may be needed if ‘delay to balloon time’
3) oxygen - hypoxic
4) morphine/diamorphine to relieve pain or anxiety
5) metoclopramide
6) GTN
7) Aspirin 300mg stat - if PPCI then further 300mg stat then loading dose of clopidogrel, ticagrelor or prasgruel.
8) IV beta-blocker (optional)
9) parenteral anticoagulation (heparin) if giving thrombolysis.

Question 15

Treatment of NSTEMI

Answer 15

Review the GRACE score

Question 16

What does a GRACE score predict?

Answer 16

Predicts the mortality risk due to CVD

Question 17

Some facts about ivabridine?

Answer 17

• it has minimal effect on BP (only really effects HR)
• It should be avoided inpatients with AF as only works on sinus node (sinus rhythm)
• It should be avoided with clarithromycin.

Question 18

What can be used to treat a STEMI but not an NSTEMI

Answer 18

tenectaplase

Question 19

Facts about fondaparinux

Answer 19

• dose is 2.5mg daily

- studies have shown a lower bleeding risk compared to enoxaparin

Question 20

A patient has an NSTEMI on the background of AF - how do we treat

Answer 20

Anticoagulation plus aspirin for 12 months then anticoagulation long term.

Question 21

Which of the following is no longer recommended post STEMI

Answer 21

omacor

Question 22

Can amitiptyline be used post MI?

Answer 22

No - contraindicated

Question 23

Digoxin should not be used in the management of paroxysmal AF because it has a negative chronotropic effect ?

Answer 23

True