Clinical Pharmacology of Acute Coronary Syndrome

Question 1

Are acute coronary syndromes stable or unstable?

Answer 1

Unstable

Question 2

Describe unstable angina.

Answer 2

Unpredictable
No trigger

Question 3

What is NSTEMI?

Answer 3

Non-ST elevated myocardial infarction

Question 4

What is STEMI?

Answer 4

ST- elevated myocardial infarction

Question 5

Which is a clincial emergency- STEMI or NSTEMI?

Answer 5

STEMI

Question 6

Why does unstable angina occur?

Answer 6

A plaque has ruptured causing partial occlusion of the vessel.

Question 7

Describe pain felt in unstable angina patients.

Answer 7

Pain can occur at rest
Can progress rapidly over a short period of time

Question 8

What happens during a NSTEMI?

Answer 8

The plaque ruptures and thrombus formation causes partial occlusion of the vessel.
This results in injury an infarct to the subendocardial myocardium.

Question 9

What happens during a STEMI?

Answer 9

Complete occlusion to a vessel.
Results in transmural injury and infarction to the myocardium

Question 10

What is a STEMI reflected by?

Answer 10

An elevated ST segment
Rise in troponin

Question 11

What are the goals of therapy for unstable angina and NSTEMI?

Answer 11

Increase myocardial oxygen supply
Decrease myocardial oxygen demand

Question 12

How can therapy increase myocardial oxygen supply?

Answer 12

Coronary vasodilation
Correct hypoxaemia
Stop platelet aggregation

Question 13

How can therapy decrease myocardial oxygen demand?

Answer 13

Reduce heart rate
Reduce blood pressure (afterload)
Reduce preload
Reduce contractility and wall stress

Question 14

What is the pneumonic for remembering the drugs involved t=in the treatment of unstable angina/ NSTEMI?

Answer 14

M - Morphine
O – Oxygen
N - Nitrates
A - Aspirin
C/T/P - Clopidogrel/Ticagrelor/Prasugrel
+ Fondaparinux (OASIS-6 trial)

Question 15

Which drugs can decrease myocardial oxygen demand.

Answer 15

Bisoprolol (beta blocker)
Nitrates (not calcium channel blockers)
Ramipril (ace inhibitor)
Atorvastatin

Question 16

What are the three key antiplatelet drugs?

Answer 16

Aspirin
Clopidogrel/Ticagrelor/Prasugrel
Fondaparinux

Question 17

What does aspirin do?

Answer 17

Thromboxane-A2 inhibitor
Inhibit platelet activation and recruitment

Question 18

What do Clopidogrel/Ticagrelor/Prasugrel do?

Answer 18

Inhibits ADP activation of P2Y12 receptor

Question 19

What does fondaparinux do?

Answer 19

Reduces clots

Question 20

What is the goal of STEMI therapy?

Answer 20

To unclog the artery

Question 21

What are the two ways to unlock an artery when it comes to STEMI?

Answer 21

Emergency angioplasty
Thrombolysis

Question 22

RECAP- when should thrombolysis be used instead of angioplasty?

Answer 22

If you cannot get angioplasty in the next two hours.

Question 23

Which thrombolytic agent is often used?

Answer 23

Recombinant tissue plasminogen activator (rtPA)

Question 24

How does recombinant tissue plasminogen activator (rtPA) work?

Answer 24

Converting plasminogen to plasmin

Question 25

What does plasmin do?

Answer 25

Plasmin lyses clot by breaking down fibrinogen and fibrin within a clot

Question 26

What do fibrin specific agents do?

Answer 26

Catalyse conversion of plasminogen to plasmin in absence of fibrin

Question 27

Name two fibrin specific agents.

Answer 27

Alteplase
Tenecteplase

Question 28

Give an example of a non-fibrin specific agent.

Answer 28

Streptokinase

Question 29

What do non-fibrin specific agents do?

Answer 29

Catalyse systemic fibrinolysis

Question 30

What would contradict doing thrombolysis?

Answer 30

Prior intracranial haemorrhage
Known intracranial lesion
Ischaemic stroke within 3 months
Suspected aortic dissection
Active bleeding
Significant closed head trauma (<3 months)