Acute coronary syndromes Flashcards
3 acute coronary syndrome conditions
- Myocardial infarction (heart attack) with ST-segment-elevation (STEMI)
- Myocardial infarction without ST-segment-elevation (NSTEMI)
- Unstable angina
→ formation of thrombus on atheromatous plaque in coronary artery
STEMI
COMPLETE and PERSISTENT blockage of artery = necrosis = ST-segment elevation on ECG
NSTEMI & unstable angina
PARTIAL or INTERMITTENT blockage of artery = myocardial necrosis (ONLY IN NSTEMI !!!)
→ Troponin used to differentiate between NSTEMI and unstable angina
Non-drug tx for Acute coronary syndromes (STEMI/ NSTEMI / Unstable angina)
→ Revascularisation procedures i.e. percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG)
Initial management of ACS
~ supportive care + pain relief
1. GTN (sublingual / buccal)
2. IV opioids (Morphine) if MI suspected
3. Loading dose of Aspirin (300mg) ASAP
4. Monitor ALL pt for hyperglycaemia !! … consider dose-adjusted insulin if BG > 11 mmol/l
STEMI tx
- Coronary reperfusion therapy (either primary PCI or fibrinolysis) ASAP
- Primary PCI (if within 12 hours of symptom onset & within 120 minutes of time when fibrinolysis could have been given) = preferred
- Aspirin + 2nd antiplatelet agent (prasugrel, ticagrelor, or clopidogrel). Aspirin alone appropriate if high bleeding risk not undergoing PCI.
For patients undergoing primary PCI with radial access, heparin (unfractionated) also given. If femoral access needed, bivalirudin considered [unlicensed]. Bailout glycoprotein IIb/IIIa inhibitor given if indicated during PCI.
For patients undergoing fibrinolysis, antithrombin agent given at same time.
STEMI tx, who would prasugrel preferred as 2nd anti-platelets
Preferred for pt undergoing primary PCI, unless risk of bleeding outweighs its effectiveness
Unstable angina tx
- Aspirin + 2nd antiplatelet. Aspirin alone = if high bleeding risk
- fondaparinux sodium, unless patient undergoing immediate coronary angiography, or high bleeding risk.
- Heparin (unfractionated) = if significant renal impairment.
- Patients undergoing PCI = offered heparin (unfractionated) in cardiac catheter laboratory [unlicensed], regardless of whether or not already received fondaparinux.
secondary prevention of CVD events in following STEMI / NSTEMI
initiated in ALL
1. ACE inhibitor, beta-blocker, DAPT (unless separate indication for anticoagulation), & statin
2. ACE inhibitor, beta blocker started once haemodynamically stable & continued indefinitely.
Beta-blocker continued indefinitely for patients with reduced LVEF. In those without reduced LVEF, it may be appropriate to discontinue beta-blocker therapy after 12 months;
* Diltiazem hydrochloride / verapamil hydrochloride considered as alternative to beta-blocker therapy in patients who do not have pulmonary congestion or reduced LVEF.
Tx with aspirin continue indefinitely. DAPT aspirin with second antiplatelet) continued for up to 12 months unless contraindicated. Clopidogrel monotherapy considered as alternative to aspirin in patients who have aspirin hypersensitivity. Rivaroxaban, in combination with either aspirin alone or aspirin & clopidogrel also recommended as option for preventing atherothrombotic events following ACS with elevated cardiac biomarkers.
IF ongoing separate indication for anticoagulation, duration & type (dual or monotherapy) of antiplatelet therapy in 12 months following ACS considered, taking into account their bleeding, thromboembolic, & CV risks.
STATIN= recommended if clinical evidence of CVD.
Steps of management of ACS (NSTEM, STEMI and unstable angina)
Hypoxic
- oxygen
Ischaemic pain
- GTN / IV isosorbide dinitrate
- IV diamorphine / morphine + metoclopramide
Reperfusion
- Aspirin 300mg + Clopidogrel 300mg
- PCI or thrombolytic (Alteplase, streptokinase (within 12h - avoid 4 days)
Prevention re-occlusion systemic & embolization
- parenteral anticoagulants
Long-term management = SAAB (statin, ACEi, Aspirin (Forver), beta blocker)
- clopidogrel (4 weeks in STEMI, 12 months = NSTEMI/Unstable angina)
PCI
~ can be given with glycoprotein IIa/IIb inhibitor
- DAPT
— Aspirin (forever) + Clopidogrel
Clopidogrel in PCI
elective = 1 month
bare metal stent = 12 month
drug-eluting stent = 12 months +
Medical emergency in community - unstable angina/ NSTEMI
- Dispersible / chewable ASPIRIN 300mg stat
- GTN prn S/L (0.3-1mg) or spray (1-2)
Medical emergency in community - STEMI
- Dispersible / chewable ASPIRIN 300mg stat
- GTN prn S/L (0.3-1mg) or spray (1-2)
- IV diamorphine / morphine + Metoclopramide
