CV: Acute coronary syndromes

Question 1

ACS includes what?

Answer 1

Unstable angina, myocardial infarction with or without ST-segment elevation.

Question 2

Unstable angina and ST-segment elevation myocardial infarction (STEMI) are related acute coronary syndromes. Why do they usually occur?

Answer 2

As a result of atheromatous plaque rupture, and are often characterised by stable angina that suddenly worses, recurring or prolonged angina at rest, or new onset of severe angina.

Question 3

Patients with unstable angina differ from those with NSTEMI how?

Answer 3

Unstable angina = no evidence of myocardial necrosis, whereas in NSTEMI, myocardial necrosis (less significant than with STEMI) will be evident.

Question 4

What five drugs/drug classess are used in the initial management of ACS?

Answer 4

Oxygen if evidence of hypoxia, pulmonary oedema.

Nitrates to relieve ischaemic pain, if sublingual is not effective, intravenous or buccal glycerl trinitrate or IV isosorbide dinitrate is given.

Diamorphine hydrochloride or morphine can be given by slow IV injection; an antiemetic such as metoclopramide should also be given.

Aspirin (chewed or dispersed in water) is given for its antiplatelet effect. Clopidogrel as well should be given. Also heparin, LMWH or fondaparinux sodium.

Patients without contra-indications should receive beta-blockers which should be continued indefinitely.

Question 5

When is oxygen administered in the treatment of ACS?

Answer 5

If there is evidence of hypoxia, pulmonary oedema, or continuing myocardial ischaemia. Caution with COPD.

Question 6

Why are nitrates used in ACS management? What different ones should be used?

Answer 6

Used for ischaemic pain.

If sublingual glyceryl trinitrate is not effective then IV or buccal routes or IV isosorbide dinitrate.

Question 7

What form of isosorbide is used in the management of ACS?

Answer 7

Dinitrate

Question 8

When are opioids used in ACS?

Answer 8

If pain continues despite nitrates, diamorphine or morphine can be given by slow intravenous injection; an antiemetic such as metoclopramide should also be given.

Question 9

What drugs should be given for their antiplatelet effects in ACS?

Answer 9

Aspirin (Chewed or dispersed in water) should be given and so should clopidogrel.

Question 10

What is an alternative to clopidogrel in certain patients undergoing PCI?

Answer 10

Prasugrel.

Question 11

When would eptifibatide or tirofiban be used for unstable agina or for NSTEMI?

Answer 11

When patients at a high risk of either MI or death.

Glycoprotein IIb/IIIa inhibitors.

Eptfibatide must be used with heparin (unfractionated) and aspirin.

Tirofiban must be used with heparin (unfrac), aspirin and clopidogrel.

Question 12

What must the glycoprotein IIb/IIIa inhibitor Eptfibatide be used in combination with?

Answer 12

Heparin (unfrac) and aspirin.

Question 13

What must the glycoprotein IIb/IIIa inhibitor Tirofiban be used in combination with?

Answer 13

Heparin (unfrac), aspirin and clopidogrel.

Question 14

In ACS, patients without contra-indications should receive beta-blockers which should be continued indefinitely. In patients without left ventricular dysfunction and in whom beta blockers are inappropriate, what can be given?

Answer 14

Rate-limiting CCBs diltiazem and verapamil.

Question 15

What is the main difference between the treatment of STEMI of UA/NSTEMI?

Answer 15

Because a STEMI is sudden complete blockage of a heart artery, the patency of the occluded artery can be restored by PCI or by giving a thrombolytic drug.

PCI is preferred and patients undergoing PCI chould be given either heparin (unfrac) or a LMWH; bivalirudin is an alternative to the combination of a glycoprotein IIb/IIIa inhibitor plus a heparin.

Question 16

What is the difference between NSTEMI and STEMI?

Answer 16

STEMI is caused by a sudden complete (100%) blockage of a heart artery.

An NSTEMI is caused by a severely narrowed artery but the artery is not normally completely blocked.

Question 17

In patients recieving treatment for STEMI who cannot be offered percutaneous coronary within 90 minutes, what should be offered?

Answer 17

A thrombolytic drug should be administered along with either heparin (unfrac) (for a maximum of 2 days), a low molecular weight heparin or fondaparinux sodium.

Question 18

Patients with STEMI who do not reveive reperfusion therapy (with percutaneous coronary intervention or a thrombolytic) should be treated with what?

Answer 18

Either fondaparinux sodium, enoxaparin sodium, or heparin (unfrac).

Question 19

ACEi and ARB (if ACEi not tolerated) should be started within how many hours of STEMI and continued for how long?

Answer 19

Within 24 hours, continued for at least 5-6 weeks.

Question 20

Following an STEMI, what drugs should ideally be started in a patient with no previous regular medicines or contra-indications/intolerances to medicines?

Answer 20

Aspirin + the addition of clopidogrel.

Beta-blockets such as acebutolol, metoprolol, propranolol and timolol. For patients with left ventricular dysfunction: carvedilol, bisoprolol or a long-acting metoprolol may be appropriate.

ACE inihbitor or ARB if ACEi intolerant at high doses.

Nitrates if angina.

A statin ideally.

Question 21

Prevention of cardiovascular events in patients with unstable angina or NSTEMI is comprised of what?

Answer 21

Clopidogrel is given, in combination with aspirin, for up to 12 months (most benefit during first 3 months) alongside an ACEi.

Prasugrel or ticagrelor are alternatives to clopidogrel in certain patients.

Question 22

Which NOAC in low-doses, in combination with aspirin alone or aspirin and clopidogrel, is licensed for the prevention of atherothrombotic events following an acute coronary syndrome with elevated cardiac biomarkers.

Answer 22

Rivaroxaban.