Cardio - Acute Coronary Syndrome

Question 1

What is acute coronary syndrome

Answer 1

Constellation of symptoms due to myocardial ischemia

Question 2

Name 3 groups of patient which may have UA

Answer 2

i) New onset (<2 months) angina - Severe (Canadian Cardiovascular Society Angina Classification class 3) and/or frequent (>3 episodes/day)
ii) Accelerated angina - previously chronic stable angina which bcomes more frequent, severe, prolonged, or precipitated by less exertion than before.
iii) Angina at rest (> 20 min)

Question 3

What are the symptoms of ACS?

Answer 3

TYPICAL

Chest pain/discomfort retrosternal, central or left chest, may radiate to jaw or down upper limb

Crushing, pressing or burning in nature

Severity of pain is variable

ATYPICAL

Unexplained fatigue, shortness of breath, epigastric dscmfort, nausea and vomitting

Question 4

What to do to investigate of ACS

Answer 4

ECG

• ST depression >0.05 mv
• T wave inversion > 0.2 mv symetrical T wave inversion particularly in precordial lead

Troponin, cardiac enzymes (CKMB, AST, LDH)

Echocardiography

CXR, FBC, PT, PTT, LFT, Creatinine, BUSE, glucose and lipid profile

Question 5

Whats the different between UA and NSTEMI?

Answer 5

If no ST elevation, no cardiac biomarkers = UA

If no ST elevation, but got biomarkers = NSTEMI

Question 6

What is the criteria for high risk of Death or MI?

Answer 6

1) Patient with ecg abnormalities:
- dynamic ST segment changes >0.05 MV, prticularly ST depression
- transient ST elevation
- patho Q
- BBB new or presumed new
- sustained VT

2) Patients with elevated troponin
3) Patient with LV dysfunction & LVEF <40%

Question 7

What is the criteria for low risk of death or MI

Answer 7

• No recurrence of chest pain within observational period
• Patient without ST segment depression or elevation but rather negative T, flat T or normal ECG.
• Without elevated trop or cardiac biomarkers

Question 8

Describe algorithm for ACS mnagement

Answer 8

Aspirin + Clopidogrel
Heparin +/- IV GP IIb/IIIa antagonist
IV Nitrate
Statin
B Blocker (if contraindicated gv Ca antagonist)

If not controlled after 24Hrs - cnsider coronary angio

If controlled - cnsider exercise ECG

Then proceed with medical therapy

Question 9

What are the general measures for ACS?

Answer 9

▪Admit CCU. Monitor cardiac rhythm for 24-48 hrs. Encourage report if pain recur
▪Bed rest, sedation and analgesics. Morphein if for recurrent or persistent symptoms. Bolus 2-5 mg with IV anti emetic (maxolon 10 mg)
▪BP every 15-30 mins for few hr, then every 1-2 hrs
▪ IV line for drug
▪ Oxygen via NP
▪ Serial ECG and cardiac enzymes to detect AMI or silent recurrent ishaemia
▪Treat risk factor (DM, cholesterol) and precipitating factor (anaemia, etc)

Question 10

Give antithrombotic therapy algo for low risk and high risk UA/NSTEMI

Answer 10

Low risk

ASA + Clopidogrel + SC LMWH or IV UFH

If high risk: Add IV platelet group iiB/iiiA antagonist

Question 11

Name antiplatlet of choice and its dose.

Answer 11

Choice:
▪Cyclooxygenase inhibitors: Aspirin
▪Adenosine diphosphate receptor antagonist (thienopyridines): Clopidogrel, ticlodipine, prasugrel

Dose:
▪Aspirin: 300 mg chewed and swallowed then 75-150 mg OD
▪Clopi: 300 mg stat followed by 75 mg OD
▪Ticlodipine: 250 mg in patient with aspirin hypersnse/ intolerence
▪Prasugrel: 60 mg stat followed by 10 mg OD (5mg if body weight <60kg)

Question 12

Name 3 anticoagulant and its dose.

Answer 12

UFH - 5000U then 1000 U per hour
LMWH - dalteparin, nadroparin (fraxiparine), enoxaparine (clexane)
Factor Xa inhibitor (Fondaparinux)

Question 13

Give 3 names of IV GP iiB/iiiA receptor antagonist.

Answer 13

Abciximab (Reopro)
Eptifibatide (Integrilin)
Tirofiban (Aggrastat)

Question 14

How B Blockers work?

Answer 14

Reduce myocardial oxygen demand by inhibiting increase in HR and myocardial contractility

Question 15

Give 2 b blockers that we use and its dose.

Answer 15

Propanolol - 20-80 mg tds (120-140 mg/day)

Metoprolol - 50 mg bd and titrate to achieve HR between 55 - 60

Question 16

When to withhold B blockers?

Answer 16

If systolic BP <100mmHg or PR <50/min.

Question 17

What is the contraindication of B blocker?

Answer 17

▪Severe heart block
▪History of bronchospasm
▪AV nodal block
▪Severe peripheral vascular disease
▪Marked resting bradycardia (HR <50-55 bpm)

Question 18

Nitrates are the first line agents for angina

Give names for nitrates and its dose.

Answer 18

i) Sublingual nitrates (glyceryl trinitrate) - 0.3-0.5 mg
Max 3 tab at 5 mins interval.

ii) IV nitroglycerin - (50 mg in 250 ml of NS or D5% = 200 ug/ml ; 10 ug/min = 3ml/hr)

Increase by 5-10 ug/min every 5-10 min, up to 100-200 ug/min

Titer to eliminate chest pain but no lower systolic pressure >10-15% or to <100 mmHg

Question 19

Whats the alternative to IV or sublingual nitrate?

Answer 19

IV Isoket (Isosorbide Dinitrite) - 2-10 mg/hr

Question 20

Whats the dose for Isoket, Nitrate ointment, Patch and mononitrate?

Answer 20

IV Isoket - 5-40 mg tds
2% nitroglycerin ointment - 0.5-2.0 in 4-5 hrly
Sustained-release GTN patches - 5-10 mg OD
Isosorbide mononitrate - 30-120 mg daily

Question 21

CCB is usually the third line agents. Name the usual meds and its dose.

Answer 21

Verapamil - 40-120 mg tds
Verapamil SR - 120-180 mg OD
Diltiazem - 30-120 mg tds
Diltiazem SR - 100-360 mg OD
Nifedipine SR - 30-90 mg OD
Amlodipine - 2.5-10 mg OD
Felodipine - 5-10 mg OD

Question 22

What is the contraindication of verapamil and diltiazem?

Answer 22

▪Sinus node disease
▪Bradycardia
▪AV Block
▪Heart failure
▪Left ventricular dysfunction

*shouldnt be given in acute infarction