Cardiology: Ischaemic Heart Disease II Flashcards
A patient presented with an MI following a 1st-degree heart block. Where is the MI most likely to have taken place? [1]
MI has most likely affected the inferior leads (right coronary arteries also provide blood supply to the AV node).
What investigations should you conduct for ACS? [2]
ECG:
- STEMI
- NSTEMI
- T wave inversion
- R/LBBB
Troponin levels
Label A & B
What are the criteria or ECG changes to be classified as a STEMI [4]
Cinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of:
-
2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years
or - ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years
- 1.5 mm ST elevation in V2-3 in women
- 1 mm ST elevation in other leads
- new LBBB (LBBB should be considered new unless there is evidence otherwise)
USE THE J POINT TO WORK OUT IF ACS IF OCCURRING
Asides from ST elevation / ST depression (STEMI & NSTEMI), what other ECG changes may indicate ACS? [1]
How can this change help ID where ischaemia is? [1]
T wave inversion may be a feature of myocardial ischaemia, T wave inversion
T wave inversion even in the absence of ST changes.
Generally relates to the territory of the coronary artery affected by ischaemia.
What does fixed vs dynamic T wave inversion indicate in ACS? [1]
T wave inversion may be fixed, which is usually associated with a previous ischaemic event and associates with Q waves.
Alternatively, T wave inversion may be dynamic, which is associated with& acute myocardial ischaemia.
Name 5 differentials for causes of troponin rises [5]
Myo/pericariditis
CKD
PE
Cardiomyopathy
Afib / tachyarythmais
What indicates a patient is suffering unstable angina c.f STEMI or NSTEMI?
Unstable angina is diagnosed when there are symptoms suggest ACS, the troponin is normal, and either:
A normal ECG
Other ECG changes (ST depression or T wave inversion)
Describe how ST changes occur in a STEMI [3]
Firstly get tall tented / hyperacute T wave
This then moves to J point meeting the increased T wave
Then a Q wave will develop
Describe how ST changes occur in a NSTEMI [2]
In patients presenting with symptoms of acute coronary syndrome, the initial management can be remembered with the “[]” mnemonic
What is the immediate pain relief and management for ACS? [5]
“CPAIN” mnemonic:
C – Call an ambulance
P – Perform an ECG
A – Aspirin 300mg
I – Intravenous morphine for pain if required (with an antiemetic, e.g., metoclopramide)
N – Nitrate (GTN)
Oxygen should only be given if the patient has oxygen saturations < 94% in keeping with British Thoracic Society oxygen therapy guidelines
Describe the management for a STEMI
Immediately assess eligibility for coronary reperfusion therapy. There are two types:
Primary coronary intervention:
- Offered if the presentation is within 12 hours of onset of symptoms AND PCI can be delivered within 120 minutes of the time when thrombolysis could have been given
- Prior to PCI: ‘dual antiplatelet therapy’, i.e. aspirin + another drug.
if the patient is not taking an oral anticoagulant: aspirin & prasugrel;
if taking an oral anticoagulant: aspirin & clopidogrel
- During PCI: patients with radial access:
unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
- During PCI: patients with femoral access:: bivalirudin with bailout GPI
Thrombolysis:
- should be offered within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when thrombolysis could have been given
- streptokinase, alteplase and tenecteplase.
How do you determine which drugs to give if prior to PCI based on their current medication? [2]
Prior to PCI: ‘dual antiplatelet therapy’, i.e. aspirin + another drug.:
If the patient is not taking an oral anticoagulant:
- prasugrel
If taking an oral anticoagulant:
- clopidogrel
How do you determine which drugs to give if during to PCI based on their access? [2]
patients with radial access:
- unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
Patients with femoral access:
- bivalirudin with bailout GPI
What is the treatment regimen for NSTEMI? [6]
B – Base the decision about angiography and PCI on the GRACE score
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel if high bleeding risk, or prasugrel if having angiography)
M – Morphine titrated to control pain
A – Antithrombin therapy with fondaparinux (unless high bleeding risk or immediate angiography)
N – Nitrate (GTN)
Also condiser anti-emetic such as ondansetron
Ticagrelor works by which MoA? [1]
Name two more drugs that work this way [2]
P2Y12 inhibitor: inhibit the platelet activation and aggregation by antagonizing the platelet P2Y12 receptor.
clopidogrel
prasugrel
What do you need to consider with regards to blood glucose levels with STEMI & NSTEMI? [1]
Manage hyperglycaemia by keeping blood glucose levels < 11 mmol/L
What is the medication used following NSTEMI as seconary prevention? [6]
6 As AAAAAA
- Aspirin 75mg once daily indefinitely
- Another Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months
- Atorvastatin 80mg once daily
- ACE inhibitors (e.g. ramipril) titrated as high as tolerated
- Atenolol (or another beta blocker – usually bisoprolol) titrated as high as tolerated
- Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
Why do you need to monitor renal function with secondary prevention of NSTEMIs? [2]
Taking ACE inhibitors and aldosterone antagonists
Both can cause hyperkalaemia (raised potassium).
What is the name of the score used to calculate risk assessment / 6 month predicted 6‑month mortality for patients with ACS? [1]
Global Registry of Acute Coronary Events (GRACE)
State the different risk stratifications based of GRACE scores [5]
How do you determine if an NSTEMI patient needs coronary angiography (with follow-on PCI if necessary):
Immediately [1]
Within 72 hours [1]
immediate:
- patient who are clinically unstable (e.g. hypotensive)
within 72 hours:
- patients with a GRACE score > 3% i.e. those at immediate, high or highest risk
coronary angiography should also be considered for patients is ischaemia is subsequently experienced after admission
What drug therapy should be given to patients with NSTEMI undergoing PCI? [2]
unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not
further antiplatelet (‘dual antiplatelet therapy’, i.e. aspirin + another drug) prior to PCI:
If the patient is not taking an oral anticoagulant:
- prasugrel or ticagrelor
if taking an oral anticoagulant:
- clopidogrel
How do you decide which PY12 inhibitor should give for conservative managament of unstable angina / NSTEMI based off their risk of bleeding? [2]
if the patient is low-risk of bleeding:
- ticagrelor
if the patient is at a high-risk of bleeding
- clopidogrel
