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Pre Reg Pharmacy > Chapter 2 - ACS > Flashcards

Chapter 2 - ACS Flashcards

1
Q

What syndromes does ACS include?

A

Unstable angina
NSTEMI
STEMI

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2
Q

What is the pathophysiology of ACS?

A

Build up of fatty deposits on the walls of coronary arteries
Plaque ruptures
Blood clot forms

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3
Q

How is ACS diagnosed?

A

Symptoms
Angiography
ECG
Troponin blood enzyme assay

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4
Q

What are the symptoms of ACS?

A 
SOB
Pain or discomfort in the chest that may radiate to the arm, jaw, neck, stomach, back
Sweating
Nausea
Dizziness 
Lightheadedness
Palpitations 
Feeling of impending doom

May also be indicated by stable angina that suddenly worsens, or prolonged angina at rest

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5
Q

Is there myocardial necrosis in unstable angina, NSTEMI, and STEMI?

A

UA - no
NSTEMI - yes (though less significant than STEMI)
STEMI - yes, irreversible

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6
Q

What is the initial management of unstable angina and NSTEMI?

A

300mg aspirin
Heparin

If needed:
O2
Pain relief (nitrates (buccal or IV, IV morphine or diamorphine)
Metoclopramide

Assess for angiography and possibly PCI

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7
Q

How are patients with unstable angina or NSTEMI assessed for angiography and PCI?

A

Assess the 6-month risk of mortality due to future adverse cardiovascular events

E.g. GRACE score

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8
Q

When is angiography and PCI carried out in unstable angina or NSTEMI?

A

If the patients condition is unstable - immediately

If the 6-month mortality is >3% - within 72 hours

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9
Q

What dual antiplatelet therapy should be given if PCI is carried out in unstable angina or NSTEMI?

A

Ticagrelor and prasugrel - if there is no separate indication for oral anticoagulation

Clopidogrel - if there is a separate indication for oral anticoagulation

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10
Q

What dual antiplatelet therapy should be given if PCI is not indicated in unstable angina or NSTEMI?

A

Ticagrelor - if there is a low risk of bleeding

Clopidogrel- if there is a high risk of bleeding

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11
Q

What is the initial management of STEMI?

A

300mg aspirin

Assess the patient for coronary reperfusion therapy (PCI or fibrinolysis)

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12
Q

How do you decide whether to do PCI or fibrinolysis?

A

Presenting with symptoms within 12h of onset and PCI available within 120 mins - PCI

Presenting with symptoms within 12h of onset and PCI NOT available within 120 mins - fibrinolysis

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13
Q

What dual antiplatelet therapy should be given if PCI is indicated?

A

Prasugrel - if there is no separate indication for oral anticoagulation

Clopidogrel - if there is a separate indication for oral anticoagulation

If the patient is over 75, dont use prasugrel, offer ticagrelor or clopidogrel

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14
Q

What treatment should be given if PCI is indicated in STEMI?

A

Dual antiplatelet therapy

Glycoprotein IIb/IIIa inhibitor (tirofiban or eptifibatide) plus:
Heparin if there’s radial access
Bivalirudin if femoral access is needed

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15
Q

What needs to be done 60-90 minutes after fibrinolysis in STEMI?

A

ECG

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16
Q

What other treatments might need to be considered if needed in STEMI?

A

Oxygen
Pain relief (nitrates (buccal or IV), or IV morphine/diamorphine
Metoclopramide (or cyclizine)

17
Q

What drugs are used for the long term management of ACS?

A

Dual antiplatelet therapy
Beta blocker
ACEI/ARB
Statin

18
Q

How long is dual antiplatelet continued for after ACS?

A

12 months

Then continue aspirin indefinitely

19
Q

How long should beta-blockers be used for after ACS?

A

12 months

Unless there are other indications for beta-blockers e.g. HFrEF

20
Q

What can be given as an alternative to beta-blockers for the long term management after ACS?

A

Verapamil

Diltiazem

21
Q

How quickly should the dose of ACE Inhibitors be titration after ACS

A

Quickly - every 12-24h

The maximum tolerated dose should be reached by the time the patient leaves the hospital

22
Q

What statin should be used after ACS?

A

Atorvastatin 80mg

23
Q

What is the mechanism of action of aspirin?

A

It inhibits COX-1 enzymes

COX-1 enzymes are responsible for the production of thromboxane A2, which is a powerful promoter of platelet activation

It also reduces prostaglandin production, and so has an irritant effect on the stomach (may need a PPI)

24
Q

What must be controlled before aspirin is initiated?

A

Blood pressure

25
Q

What are the indications of aspirin?

A

Secondary prevention of CVD - 75mg OD
Treatment of TIA/ischaemic stroke - 309mg OD for 14 days
Treatment of angina, nSTEMI r STEMI - 300mg

Pain - 300-900mg every 4-6 hours, maximum 4g daily
Bypass surgery - 75-150mg OD
Precention of Pre-eclampsia in pregnancy in women at moderate to high risk - 75mg OD from 12 weeks gestation until birth

26
Q

What are the contraindications of aspirin?

A

Active or history of a GI ulcer
Bleeding disorders
<16 years

Cautioned in asthma and hypertension

27
Q

What are some side effects of aspirin?

A 
Haemorrhage 
Menorrhagia 
Dyspepsia 
Dyspnoea
Rhinitis
28
Q

What are the indications of clopidogrel?

A

TIA/ischaemic stroke

After ACS alongside aspirin - initially 300mg then 75mg daily

29
Q

Do clopidogrel, prasugrel or ticagrelor need to be discontinued before surgery?

A

Yes

Discontinue clopidogrel and prasugrel 7 days before surgery

Discontinue ticagrelor 5 days before surgery

30
Q

What is the brand name of ticagrelor?

A

Brilique

31
Q

How do fibrinolytics work?

A

They activate plasminogen to form plasmin

Which degrades fibrin and so breaks up the thrombus

32
Q

How soon should antifibrinolytics be given after STEMI?

A

12 hours, although ideally within 1 hour

33
Q

When is bivalirubin used?

A

This is a thrombin inhibitor

It is used as an anticoagulant for those undergoing ACS

34
Q

In unstable angina/NSTEMI, if angiography and PCI are not planned in the next 24h, which heparin can be used?

A

Fondaparinux

Less than 24h - LMWH or UFH

35
Q

What can rivaroxaban be used for in ACS?

A

Prophylaxis of atherothrombotic events following ACS with elevated cardiac biomarkers

Can be combined with aspirin or clopidogrel

Pre Reg Pharmacy (36 decks)

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