Acute Coronary Syndromes

Question 1

Which drug should be used for pain relief as soon as possible in an acute coronary syndrome?

Answer 1

Glyceryl trinitrate (sublingual or buccal)

Sublingual (tablet): 1 tablet, dose may be repeated at 5 minute intervals if required (for treatment of angina)

Question 2

Apart of glyceryl trinitrate, what other medication can be used for pain relief in acute coronary syndrome (particularly acute MI)?

Answer 2

Morphine (for severe pain)

Acute pain (oral, subcutaneous injection, IM injection): Initially 10 mg every 4 hours (adult) 
Elderly: initially 5 mg every 4 hours

Question 3

In an acute coronary syndrome, a loading dose of (?) should be given as soon as possible.

Answer 3

aspirin 300 mg

Question 4

Should oxygen be routinely administered to patients with acute coronary syndromes?

Answer 4

NO

Monitor oxygen saturation and give supplemental oxygen if indicated

Question 5

All patients admitted to hospital with an acute coronary syndrome should be closely monitored for (metabolic derangement?)

Answer 5

Hyperglycaemia

Those with blood glucose concentration greater than 11.0 mmol/L should receive insulin

Question 6

What are the two options for coronary reperfusion therapy in a STEMI?

Answer 6

Primary PCI

Fibrinolysis

Question 7

What is the criteria for a patient to receive a primary PCI in the treatment of a STEMI? (2)

Answer 7

Present within 12 hours of symptom onset
AND
Within 120 minutes of the time when fibrinolysis could have been given

Question 8

Most patients with a STEMI or NSTEMI should be offered a second antiplatelet agent in addition to aspirin. What are the three options for the second antiplatelet agent?

Answer 8

Prasugrel
Ticagrelor
Clopidogrel

The choice of second antiplatelet depends on the planned intervention (PCI, fibrinolysis or conservative) and the patient’s bleeding risk

Question 9

Which second antiplatelet agent is preferred for most patients undergoing a primary PCI for a STEMI?

Answer 9

Prasugrel (oral)

• Initially 60 mg for 1 dose, then 10 mg once daily for up to 12 months (adult 18-74 years, body weight 60kg and above)
• Initially 60 mg for 1 dose, then 5 mg once daly usually for up to 12 months (adult 18-74 years, body weight up to 60kg; AND adult 75 years and over)

Unless the risk of bleeding outweighs its effectiveness (e.g. if taking an oral anticoagulant use clopidogrel)

Question 10

What drug should be used during a PCI with radial access for anticoagulation?

Answer 10

Heparin (unfractionated)

Question 11

What drug should be used during a PCI with femoral access for anticoagulation?

Answer 11

Bivalirudin (IV)
- Initially 750 micrograms/kg, followed immediately by 1.75 mg/kg/hour during procedure (IV infusion) and for up to 4 hours after procedure, then (by intravenous infusion) reduced to 250 micrograms/kg/hour for a further 4–12 hours if necessary.

Bivalirudin, a hirudin analogue, is a thrombin inhibitor

Question 12

What is the drug action of bivalirubin?

Answer 12

A hirudin analogue (thrombin inhibitor)

Question 13

Which drug can be used as rescue or bailout therapy to manage complications arising during PCI?

Answer 13

Glycoprotein (GP) IIb/IIIa inhibitors

Question 14

For patients undergoing fibrinolysis for a STEMI, what other drug class should be given at the same time?

Answer 14

Antithrombin agent

Question 15

If a patient with an NSTEMI does not have an immediate PCI planned and they do not have a high bleeding risk, which drug (in addition to antiplatelets) should be given?

Answer 15

Fondaparinux sodium (antithrombin therapy)

• Subcutaneous injection
• 2.5 mg once daily for up to 8 days (or until hospital discharge if sooner)

Question 16

A patient with an NSTEMI is given fondaparinux sodium, but then is scheduled for a coronary artery bypass graft surgery. How many hours prior to the surgery should the drug be stopped and how many hours after surgery should the drug be restarted?

Answer 16

Stopped: 24 hours before

Restarted: 48 hours post-operatively

Question 17

A patient has an NSTEMI and significant renal impairment is NOT undergoing an immediate coronary angiography and are not high bleeding risk, which antithrombin therapy should they receive?

Answer 17

Heparin (unfractionated)

Question 18

Following an acute coronary syndrome, all patients should be offered a cardiac rehabilitation programme. What 3 things does this include?

Answer 18

Lifestyle changes
Stress management
Health education

Lifestyle interventions include healthy eating, reducing alcohol, regular exercise, smoking cessation and weight management

Question 19

Is there a difference in the treatment for secondary prevention if the patient had a NSTEMI or STEMI?

Answer 19

NO

Clinical judgement is used in patients with unstable angina

Question 20

What drugs are offered as part of secondary prevention following an acute coronary syndrome? (4)

Answer 20

ACE inhibitor or ARB
Beta-blocker
Dual antiplatelet therapy
Statin

Question 21

When do you start a patient on an ACE inhibitor and beta-blocker after an acute coronary syndrome?

Answer 21

Once they are haemodynamically stable

Question 22

Following an acute coronary syndrome, how long does a patient need to take a beta-blocker if they have a reduced left ventricular ejection fracture?

Answer 22

Indefinitely

In those without reduced LVEF, it may be appropriate to discontinue beta-blocker therapy after 12 months

Question 23

Following an acute coronary syndrome, how long does a patient need to take a beta-blocker if they do NOT have a reduced left ventricular ejection fracture (LVEF)?

Answer 23

12 months minimum

Discontinue only after discussion with the patient and the potential benefits and risks of continuation are taken into account

Question 24

For secondary prevention after an acute coronary syndrome (ACS), which 2 drugs can be used as an alternative to beta-blocker therapy if the patient does NOT have pulmonary congestion or a reduced LVEF?

Answer 24

Diltiazem hydrochloride
- initially 60 mg 2-3 times a day (max. 360 mg per day)

Verapamil hydrochloride

Question 25

For secondary prevention following an acute coronary syndrome, how long should a patient take aspirin for?

Answer 25

Indefinitely

- 75 mg daily

Question 26

For dual antiplatelet therapy following an acute coronary syndrome, how long should a patient take the second antiplatelet drug (not aspirin)?

Answer 26

Up to 12 months unless contraindicated

Question 27

Following an acute coronary syndrome in patient with an aspirin hypersensitivity, which antiplatelet therapy should be used?

Answer 27

Clopidogrel monotherapy

- 75 mg daily (this is the dose with aspirin, can’t find dose if monotherapy)

Question 28

Following an acute coronary syndrome, when do you consider adding rivaroxaban as secondary prevention for atherothrombotic events?

Answer 28

ACS with elevated cardiac biomarkers

Rivaroxaban, in combination with either aspirin alone or aspirin and clopidogrel is also recommended as an option for preventing atherothrombotic events following an ACS with elevated cardiac biomarkers.

Question 29

Which two drugs do you offer if a patient has a STEMI but not a high bleeding risk if using medical management?

Answer 29

Ticagrelor
Aspirin

https://www.nice.org.uk/guidance/ng185/resources/visual-summary-stemi-pdf-8900623405

Question 30

Which two drugs do you offer if a patient has a STEMI and a high bleeding risk if using medical management?

Answer 30

Clopidogrel + aspirin
OR
Aspirin alone

Which two drugs do you offer if a patient has a STEMI but not a high blooding risk if using medical management?

Question 31

For dual antiplatelet therapy following an ACS and prior to PCI, what second antiplatelet (in addition to aspirin) do you give if they are NOT already taking an oral anticoagulant?

Answer 31

Prasugrel

• For people aged 75 and over, think about whether risk of bleeding with prasugrel outweighs its effectiveness; if so, offer ticagrelor or clopidogrel as alternatives
  https: //www.nice.org.uk/guidance/ng185/resources/visual-summary-stemi-pdf-8900623405

Question 32

For dual antiplatelet therapy following an ACS and prior to PCI, what second antiplatelet (in addition to aspirin) do you give if they are already taking an oral anticoagulant?

Answer 32

Clopidogrel (oral)
- Initially 300 mg, then 75 mg (NSTEMI up to 12 months, STEMI at least 4 weeks)

https://www.nice.org.uk/guidance/ng185/resources/visual-summary-stemi-pdf-8900623405

Question 33

What is the criteria to use fibrinolysis as reperfusion therapy after a STEMI?

Answer 33

Presents within 12 hours of symptoms and PCI not possible in 120 minutes

Give an antithrombin (fondaparinux) at the same time

https://www.nice.org.uk/guidance/ng185/resources/visual-summary-stemi-pdf-8900623405

Question 34

If you give fibrinolysis as reperfusion therapy following a STEMI, what do you need to do 60-90 minutes after?

Answer 34

ECG

https://www.nice.org.uk/guidance/ng185/resources/visual-summary-stemi-pdf-8900623405

Question 35

Is the patient has a high bleeding risk, which second antiplatelet drug is used as part of dual antiplatelet therapy?

Answer 35

Clopidogrel

- Initially 300 mg, then 75 mg (NSTEMI up to 12 months, STEMI at least 4 weeks)

Question 36

Is the patient does NOT have a high bleeding risk, which second antiplatelet drugs can be used as part of dual antiplatelet therapy?

Answer 36

Prasugrel (preferred if going to PCI)
- Initially 60 mg for 1 dose, then 10 mg once daily usually for up to 12 months (adult 18-74 years body weight 60 kg and above)

Ticagrelor (preferred if using fibrinolysis)
- Initially 180 mg for 1 dose, then 90 mg twice daily usually for up to 12 months.

Question 37

What is the mode of action of ticagrelor?

Answer 37

P2Y12 receptor antagonist that prevents ADP-mediated P2Y12 dependent platelet activation and aggregation

Question 38

What is the most common adverse effect of aspirin?

Answer 38

Gastrointestinal irritation

Question 39

What are the contraindications to the use of aspirin? (6)

Answer 39

Active peptic ulceration
Bleeding disorders
Children under 16 years (risk of Reye’s syndrome)
Haemophilia
Prevous peptic ulceration (analgesic dose)
Severe cardiac failure (analgesic dose)

Question 40

Which drugs may reduce the efficacy of clopidogrel?

Answer 40

CYP inhibitors
(e.g. omeprazole, ciprofloxacin, erythromycin…)

Clopidogrel is a pro-drug that requires metabolism by hepatic cytochrome P450 enzymes to its active form

Question 41

What should be monitored 1 months after initiation of ticagrelor in patient with acute coronary syndrome?

Answer 41

Renal function