Acute Coronary Syndromes and Stable Angina

Question 1

What is acute coronary syndrome?

Answer 1

Any group of syndromes attributed to the obstruction of the coronary arteries. 
This includes
- NSTEMI
-STEMI
- Unstable Angina

Question 2

What is myocardial infarction?

Answer 2

Caused by a blood clot which stops the blood flowing to a part of the heart muscle. Common form is blood clot in the coronary artery or one of its branches

Question 3

What are the 2 types of myocardial infarction?

Answer 3

• ST Elevated: this means that there is an elevation of the ST segment in ECG
• Non ST elevated: No change in ECG

Question 4

What are the risk factors of myocardial infarctions?

Answer 4

• Smoking
• High Cholesterol
• High BP
• Physical inactivity
• Obesity
• Diabetes
• Increased Age
• Male
• Race

Question 5

What are the symptoms of myocardial infarction?

Answer 5

• Sudden crushing chest pain that originates at the centre of the chest then radiates to the arms neck or jaw.

Question 6

What is the treatment of STEMI?

Answer 6

• Aspirin 300mg
• Coronary reperfusion therapy
• Either primary percutaneous coronary intervention with additional antiplatelet agent e.g. Ticagelor or pasgruel or fibrinolytic eg. reteplase, tenecteplase
• Pain relief, anti emetics and glycaemic control

Question 7

What are the secondary preventions of STEMI?

Answer 7

• Aspirin at low dose - lifelong
• If patient has a stent, dual antiplatelet therapy may be required e.g. ticagelor and aspirin or clopidogrel and aspirin
• PPI to relieve GI side effects of antipatelet
• Beta blockers
• Lipid lowering treatment
• ACEi
• Alodesterone antagonists

Question 8

What is the treatment of NSTEMI and unstable angina?

Answer 8

• Aspirin 300 mg
• Ticagelor 180mg
• Glycoprotein 2B3A inhibitor - eptifibatide and tirofiban who will undergo coronary angroplasty or abciximab asan adjunct to PCI or coronary artery bypass graft (CABG)
• Pain relief and anti-emetics

Question 9

What is the secondary prevention of NSTEMI and unstable angina?

Answer 9

• Dual antiplatelet therapy
• Lipid lowering medication: statins
• ACEi
• Beta Blockers

Question 10

What is the treatment of stable angina?

Answer 10

• GTN for rapid symptom relief
• First line treatment: Beta blocker or calcium channel blocker
• If symptoms not controlled consider switching to another option
• If patients symptoms not controlled or not toelrated then:
  
  • Use long acting nitrate
  • Ivabradine
  • Ranolazine
• If using a CCBs with a BBs or Ivabradine, consider a slow release nifedipine, amlodipine or felodipine. If patient cannot tolerate BBs or CCBs then consider monotherapy with:
• A long acting nitrate
• Ivabradine
• Ranolazine

Question 11

How do nitrates work?

Answer 11

• mimic endogenous NO causing vasodilation which improves coronary blood flow and reducing preload - dilating veins and afterload - dilating arteries.
• Nitrates relax the vascular smooth muscle

Question 12

What is the prevention method of tolerance to nitrates?

Answer 12

• Nitrate free period

- Should be done at lowest risk at night

Question 13

What is contraindicated with nitrates?

Answer 13

Slidenail (Viagra)