Acute Coronary Syndromes 2 Flashcards

1
Q

Initial drug therapy for unstable angina & NSTEMI (anti platelet & antithrombin)

A
  • Aspirin ASAP (single loading dose 300mg) to all people and continue indefinitely unless contraindicated by bleeding risk/aspirin hypersensitivity
  • Offer fondaparinux to people who do not have high bleeding risk unless they are undergoing immediate coronary angiography
  • Consider unfractionated heparin with dose adjustmentt guided by monitoring of clotting function as an alternative to fondaparinus for people with significant renal impairment (creatinine >265 micro moles/litre)]
  • Do not offer dual anti platelet therapy to people with chest pain before diagnosis of unstable angina/NSTEMI is made
  • Carefully consider choice & dose of antithrombin for people who have higher risk of bleeding associated with advanced age, known bleeding complications, renal impairment, low body weight
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2
Q

Risk assessment for unstable angina & NSTEMI once diagnosis has been made and aspirin and antithrombin therapy has been offered

A
  • Formally assess individual risk of future adverse CV events using an established risk scoring system that predicts 6 month mortality (e.g. GRACE)
  • Use risk assessment to guide clinical management and balance benefit of a treatment against any risk of related adverse events
  • Use predicted 6 month mortality to categorise the risk of future adverse CV events
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3
Q

What factors should you include in the formal risk assessment for risk of adverse events in unstable angina and NSTEMI

A
  • full clinical history (age, PHx MI, PCI, CABG)
  • physical exam (BP, HR)
  • resting 12-lead ECG, looking for dynamic or unstable patterns that indicate MI
  • blood tests e.g. troponin I or T, creatinine, glucose, Hb
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4
Q

Predicted 6 month mortality and risk of further adverse CV events categories

A
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5
Q

What do you need to offer to pt with unstable angina or NSTEMI if their clinical condition is unstable

A
  • immediate coronary angiography
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6
Q

When would you consider offering coronary angiography to pt with unstable anigna or NSTEMi

A
  • immediate coronary angiography to pt whose clinical condition is unstable
  • consider (with follow on PCI if indicated) within 72h of first admission in pt with intemriediate-oigher risk of adverse CV events (predicted 6 month mortality >3%) and no contraindications to angiography (e.g. active bleeding, comorbid)
  • Consider (with follow on PCI indicated) in pt initially assessed to be at low risk of adverse events (3% or less) if ischaemia is subsequently experienced or demonstrated by ischaemia testing
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7
Q

benefits and risks of early invasive treatment (coronary angiography with follow on PCI if needed) compared to conservative management for pt with unstable angina/NSTEMI

A
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8
Q

anticoagulation to offer to people with unstable anigna or STEMI who are undergoing PCI

A

Offer systematic unfractionated heparin in the cardiac catheter laboratory to people whether or not they have received fondaparinux

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9
Q

anticoagulation to offer to pt who are having coronary angiography

A
  • prasugrel or ticagrelor (dual anti platelet therapy with aspirin)) if no separate indication for ongoing oral AC
  • if using prasugrel, only give it once coronary anatomy has been defined and PCI intended
  • use maintenance dose in prasgurel SoPC
  • pt 75 and over think about risk of bleeding with prasugrel vs effectiveness
  • give clopidogrel + aspirin dual therapy is separate indication for ongoing oral AC
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10
Q

what to give is stenting is indicated to people undergoing vevascularisation by PCI

A

drug-eluding stent

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11
Q

management of NSTEMI/unstable angina when PCI not indicated, including AC

A
  • consider conservative management w/o early coronary angiography for pt with low risk of adverse CV events (3% or less)
  • offer ticagrelor with aspirin to people when PCI not indicated unless higher bleeding risk
  • consider clopidogrel + aspirin or aspirin alone for people whom PCI is not indicated for, if they have high bleeding risk
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12
Q

tests before discharge

A
  • consider ischaemia testing before discharge in pt who have been managed convervatively and have not had coronary angiography, to detect and quantify inductible ischaemia
  • assess LV function in all pt who has NSYEMI
  • consider assessing LV function in pt with unstable angina
  • record measured LVF in pt care record, and in correspondence with primary HCT and the pt
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13
Q

managing hyperglycaemia in patients within 48h of ACS

A
  • keep BG levels below 11mmol/L, while avoiding hypoglycaemia
  • in the first instance consider dose-adjusted insulin infusion with regular monitoring of BG levels
  • do not routinely offer intensive insulin therapy (IV infusion of insulin + glucose w or w/o potassium) to manage hyperglycaemia in people admitted to hospital or an ACS unless clinically indicated
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14
Q

Process for identifying people with hyperglycaemia after Acs who are at high risk of developing diabetes

A

offer all pt with hyperglycaemia after ACS and w/o known diabetes tests for:
- HbA1c levels before discharge
- FBGT no earlier than 4 days after onset of ACS
- these tests should not delay discharge

Do not routinely offer OGTT to people with hyperglycaemia after ACS and w/o known diabetes if HbA1c and FBG levels normal

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15
Q

Advise people without known diabetes that if they have had hyperglycaemia after an ACS, they

A
  • increased risk developing T2D
  • see GP if experience symptoms e.g. frequent urination, excessive thirst, weight loss, fatigue
  • they should be offered tests for diabetes (HbA1c or FBG) at least annually by their GP
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16
Q

secondary prevention for pt who have had MI

A
  • ACEi
  • dual anti platelet therapy (unless separate indication for platelet therapy
  • statin
  • BB
17
Q

ACEI for secondary prevention - when to give & titration in hosp/out of hospital

A
  • Offer to pt who present with acute MI as soon as haemodynamically stable and continue indefinitely
  • titrate dose upwards at short intervals e.g. every 12-24h before pt leaves hospital until max tolerated/target dose achieved
  • if it is not possible to complete titration during this time, ensure it is completed within 4-6 weeks of hosp discharge
18
Q

ACEI (or ARB) for secondary prevention: monitoring

A
  • renal, serum electrolytes and BP before starting ACEi (or ARB)
  • measure again within 1-2 weeks of initiation
  • more freq monitoring may be required in pt at risk of deterioration in renal function
  • chronic HF: once stable, monitor each month for 3 months, then at least every 6 months & when acutely unwell
19
Q

Offer an ACEi to people who have had an MI >12 months ago…

A

…and titrate dose to max tolerated/target dose over 4-6 week period and continue indefinitely
- if intolerant to ACEI, give ARB instead

20
Q

anti platelet therapy secondary prevention after MI

A
  • offer to all pt after MI to continue indefinitely unless intolerant or if they have an indication for anticoagulation
  • offer to all people who have had an MI >12 months ago and continue indefinitely
  • consider dual anti platelet therapy for up to 12 months after MI unless contraindicated
  • aspirin hypersensitive and MI: consider clopidogrel monotherapy
21
Q

When to offer clopidogrel and MR dipyridamole instead of aspirin

A
  • clopidogrel monotherapy instead of aspirin if allergy
  • clopidogrel instead of aspirin to pt who also have other clinical vascular disease
  • MR dipyridamole for prevention of occlusive vascular events and who have had MI and stopped anti platelet therapy / or have had MI >12 months ago
22
Q

Beta blockers as secondary prevention after MI

A
  • offer ASAP after MI when pt is haemodynamically stable
  • titrate BB up to max tolerated or target dose
23
Q

BB as secondary prevention after MI - pt with reduced LVEF vs people without reduced LVEF

A
  • consider continuing for up to 12 months after MI for people without reduced LVEF
  • discuss potential benefits and risks of stopping or continuing BB beyond 12 months after an MI for people without reduced LVEF
  • there is lack of evidence on relative benefits and harms of continuing beyond 12 months, and some pt experience adverse effects
  • do not offer in pt without reduced LVEF of HF who have had an MI >12 months ago unless there is additional clinical indication for a BB
  • continue indefinitely in people with reduced LVEF
  • offer all pt who have had MI >12 months ago who have reduced LVEF whether or not they have symptoms
24
Q

Use of CCBs after MI

A
  • do not routinely offer CCBs to reduce CV risk after MI
  • if BBs contraindicated or need to be discontinued, consider RL-CCBs instead in people without pulmonary congestion or reduced LVEF
  • for people whose condition is stable after an MI, CCBs can be used to treat hypertension and/or angina
  • for people with HF and REF, amlodipine is the only CCB that can be used!! avoid all others
25
Q

Aldosterone antagonists in pt with HF and reduced LVEF and monitoring

A
  • start an AA that is licensed for post-MI treatment (eplerenone) within 3-14 days of the MI, pref after ACEi therapy
  • Start it in pt who have had acute MI and how have symptoms/signs of HF and reduced LVEF
  • pt who have recently had acute MI and have clinical HF with reduced LVEF and are already being treated with AA for a concomitant condition (e.g. chronic HF), should continue with the AA or an alternative licensed for early post-MI treatment
  • monitor renal function and serum potassium before and during treatment
  • if hyperkalaemia is a problem, half dose of AA or stop drug