Acute Coronary Syndrome

Question 1

what is ACS and what are the 3 clinical subtypes of it?

Answer 1

ACS encompass a spectrum of acute myocardial ischaemic states
1- Unstable Angina (UA)
2-Non-ST segment Elevation Myocardial Infarction (NSTEMI)
3-ST-segment Elevation Myocardial Infarction (STEMI)

Question 2

what is ACS triggered by?

Answer 2

atheromatous plaque disruption (rupture/ fissure/ erosion

Question 3

which ACS is only partial occlusion of artery?

Answer 3

UA or NSTEMI

Question 4

which ACS is sustained occlusion of artery?

Answer 4

STEMI

Question 5

what are the 3 characteristics of unstable Angina?

Answer 5

acceleration in frequency or severity of chest pain
new-onset anginal pain
anginal chest pain that abruptly occurs at rest

Question 6

which ACS shows enzymatic evidence of cell death

Answer 6

NSTEMI

Question 7

why is STEMI the most severe?

Answer 7

complete occlusion

ischaemia-induced electrical instability -can inc risk of sudden cardiac death

Question 8

how long after blood flow stops does cell death in nstemi and stemi cells occur?

Answer 8

20-40 min

2-3 hours =significant death

Question 9

what are the two phases of acute myocardial infarction?

Answer 9

phase of ischaemia(reversible injury)phase of infarction(irreversible injury)

Question 10

what are the 4 clinical features of ACS?

Answer 10

Pain & apprehension
Haemodynamic
Serial ECG changes
Serial Cardiac Biomarker changes

Question 11

What are the ECG changes in STEMI?

Answer 11

ST segment elevation

Pathological Q wave development

Question 12

what are the ECG changes in NSTEMI?

Answer 12

ST segment depression

T wave inversion

Question 13

what are the primary in diagnosis of ACS?

Answer 13

Confirm or rule out ACS secondary to obstructive CAD

low risk- UA/NSTEMI

Question 14

What do elevated, sustained troponin levels indicate?

Answer 14

STEMI

Question 15

how would you INITIAlLY manage ACS?

Answer 15

Analgesic & anti-ischaemic therapy

Question 16

what IMMEDIATE treatment would you use for ACS?

Answer 16

medication

asprin/bb/GNT/dimorphine or morphine/ anti-coagulants

Question 17

what are the main goals in the clinical management of STEMI?

Answer 17

1-establish & maintain patency of the infarct-related artery
2-limit the consequences of myocardial ischaemia
3-enhance myocardial healing & reduce the likelihood of recurrent events

Question 18

what is the open artery theory?

Answer 18

Prompt and complete restoration of flow in the occluded artery decreases infarct size, preserves left ventricular (LV) function, and improves survival rates

Question 19

what are the two strategies on the clinical management of STEMI? ( revascularisation/reperfusion)

Answer 19

1- mechanical- PCI

2-Pharmacological- thrombolytic or finbriotic therapy

Question 20

what are the two treatment pathways of UA and NSTEMI?

Answer 20

1-Initial Conservative Strategy (medical)-low risk

2-Early Invasive Strategy(medical or surgical reperfusion)-high risk

Question 21

what are the 3 types of agents used in antithrombotic therapy?

Answer 21

1 Thrombolytic / Fibrinolytic agents
2 Antiplatelet agents
3 Anticoagulants

Question 22

what does the thrombolytic therapy do?

Answer 22

Activation of the endogenous plasminogen fibrinolytic system- breakdown of clot

Question 23

what are the 2 thrombolytic agents?

Answer 23

1 Streptokinase (SK) 
2 Tissue-type plasminogen activators (t-PAs)

Question 24

is thrombolytic therapy first or second line?

Answer 24

second , PCI FIRST

Question 25

what are side effects of thrombolytic therapy?

Answer 25

haemorrhage allergic reactions (SK) hypotension reperfusion-induced arrhythmias

Question 26

what are the 3 types of anti-platelet agents?

Answer 26

1- Cyclooxygenase inhibitors –Aspirin 2- ADP receptor antagonists 3- GPIIb/IIIa receptor antagonists all decrease platelet aggregation

Question 27

what is the dose of aspirin?

Answer 27

150-300 mg loading dose; 75-100 mg/day maintenance dose

Question 28

what is the dose of Clopidogrel?

Answer 28

300-600 mg loading dose; 75 mg/day maintenance dose

Question 29

what is the dose of Prasugrel?

Answer 29

60 mg loading dose; 10 mg/d maintenance dose

Question 30

what is the dose of Ticagrelor?

Answer 30

180 mg loading dose; 90 mg bid maintenance dose

Question 31

what is the MOA of GPIIb/IIIa Receptor Antagonists

Answer 31

they bind to platlet receptors so fibrin cannot

Question 32

what is the MOA of aspirin?

Answer 32

Irreversible COX Enzyme Inhibitor

Question 33

what is the MOA of clopidogrel?

Answer 33

Irreversible ADP Receptor Antagonist-Binds to platelet P2Y12 ADP receptor -prevents ADP from binding

Question 34

what is the MOA of prasugrel?

Answer 34

Irreversible’ GPIIb/IIIa Receptor Antagonist

Question 35

what is the aim of the aim of anticoagulant therapy?

Answer 35

inhibit coagulation-driven thrombus formation in ACS | inactivate Factor IIa(thrombin) and/or FXa& FIXa

Question 36

what are the 3 indirect thrombin inhibitors?

Answer 36

UF Heparin –inactivation of thrombin (FIIa), FXa& FIXa LMW Heparins –inactivation of FXa Fondaparinux -inactivation of FXa

Question 37

name the direct thrombin inhibitor?

Answer 37

Bivalirudin- direct inactivation of thrombin (FIIa)

Question 38

what are the 5 treatments after ACS?

Answer 38

``` 1- aspirin 2- P2Y12 receptor antagonists 3- statins 4-b-blockers 5 angiotensin converting enzyme inhibitors ```