IC6 Flashcards
what are the symptoms of ACS
main: chest pain that radiates to the neck, jaw, back, abdomen
others: SOB, cool/clammy skin, nausea, light-headedness.
Differential Diagnosis for ACS
PUD = pain at the epigastric region.
- reflux? burping?
Hypoglycaemia = sweating (characteristic), unwell, pale
- skip meals?
pneumonia? may present with fever and cough. check FBC (CRP, WBCs, procalcitonin, urinary antigen tests, gram stain and culture from sputum or LRT, blood cultures) and imaging (CT scan = consolidates).
pneumothorax? check SPO2? imaging
ACS MI should be widespread and not at a single point.
algorithm for confirmation of ACS MI
1) clinical setting symptoms and vital signs
- is it widespread or at a single area?
2) ECG
- any ST elevation or depression?
3) troponin at 0h and any changes (in 1,2,3h)
- presence of troponin could be a sign of myocardial injury (sensitive but not specific; could be associated with other stress states)
if troponin increase is not high (and st depression) = observe = possible unstable angina, other cardiac problems…
what is the treatment algorithm for suspected ACS?
treat with aspirin 100 or 300mg (300mg if newly initiated)
ECG on ambulance
confirmed STEMI = initiate 180mg ticagrelor or 600mg clopidogrel prior to PCI
- (nSTEMI more stable = can choose to monitor first before initiating p2y12i and sending to PCI)
- goal of DAPT = prevent stent thrombosis.
coronary angiography (imaging) to identify the vessel affect for insert of stent.
PCI (angioplasty) = initiate
- iv bolus UFH/LMWH
- iv bolus gp2b3a f/b infusion
- iv cangrelor (p2y12i)
- iv fibrinolytic
monitoring parameters AND counselling for a patient on followup after stent thrombosis and DAPT therapy?
MONITORING
- FBC including Hb to check for any bleeding
- bleeding in general (ask PMH)
- any side effects from the drugs = dyspnoea from P2Y12i?
COUNSELLING
- risk of stent thrombogenicity = to counsel adherence to the medication and need for DAPT.
- counsel duration of DAPT, and lifelong use of asprini.
- counsel management of bleeding: if serious bleeding go a&e = tarry stools, bloody stools
- non serious: gum bleeding (use soft bristle), small cuts (10-15min, apply pressure), heavy menstrual bleeding.
- dental procedures = to inform.
what are the treatment options for STEMI
1st line: ticagrelor
2nd line: prasugrel
3rd line: clopidogrel
DAPT for at least 12 months (depends on bleeding risk = vv high = 1 month, high = 3 month… weigh risk vs benefit)
what are the treatment options for NSTEMI
if pci not indicated,
use tica or clopidogrel
not recommended to use prasugrel due to lack of coronary anatomy
if pci indicated,
follow stemi pathway.
what are the dosing (loading, maintenance) for the 3 p2y12i?
ticagrelor: 180mg loading, 90mg BD maintenance
clopidogrel: 600mg loading, 75mg OD
prasugrel: 60mg loading, 10mg OD
what are the treatment options for SIHD/CCS
STABLE CAD
clopidogrel 600mg (loading) for 6 months and indefinite aspirin therapy.
indications for clopidogrel as first line over prasugrel and ticagrelor
1) stable CAD
2) patient receiving thrombolysis.
what other treatment considerations for patients with a high risk of bleeding?
consider PPI in high-risk bleeding patients
how does PRECISE-DAPT scoring
short DAPT (≥25pts) = 3-6months
long DAPT (<25pts) = 12-24months
major and minor criteria for HBR
MAJOR
Blood
1) hb <11g/dl
2) spontaneous bleeding req hosp/transfusion past 6 months, OR recurrent
3) mod-severe thrmobocytopenia (platelet < 100 x 10^9)
4) chronic bleeding conditions
5) previous intracranial haemorrhage
Renal
6) severe, end stage CKD egfr <30
Hepatic
7) liver cirrhosis with portal htn
Cancer
8) active malignancy past 12 months
Surgery/trauma
9) non-deferable major surgery
10) recent major surgery or trauma last 30 days
MINOR
1) >75y.o
2) mod ckd egfr 30-60
3) hb 11-12.9 (m) or 11.9 (f)
4) long termNSAIDs or steorids
5) spontaneous bleeding req hosp/transfusion past 12 months
CONSIDER STOPPING AFTER 3 MONTHS
ischemic risk factors /thrombotic risk
high risk:
Dm req meds
history of recurrent MI
multivessel CAD
polyvascular disease
premature or accelerated CAD
concomitant systemic inflammatory disease (HIV, SLE, chronic arthritis)
CKD with eGFR (15-59)
at least 3 stents implanted
at least 3 lesions treated
total stent length >60mm
history complex revascularization
history of stent thrombosis on antiplatelet treatment
what are the CV risk factors
used for secondary prevention of ASCVD
1) Blood sugar
- manage diabetes through diet and exercise,
- drugs: metformin (primary) with SGLT2 or GLP1
2) Hypertension
- ensure below 130/80
3) Hyperlipidemia
4) Physical activity
- >150min/week of moderate intensity
- >75min.week of vigorous
5) smoking = quit
6) diet = fruits and vegetables
7) aspirin use = maintain
difference between myocardial infarction (acs vs ccs) and stroke?
MI: usually due to atherosclerotic plque causing narrowing of the vessels walls = rupture = blood clot = occlude blood flow to the heart muscle
CCS = occurs on exertion, related to demand and supply.
ASC = occurs spontaneously.
stroke
(i) ischemic stroke = blood clot blocks blood flow of artery within the brain
(ii) haemorrhagic stroke = rupture of blood vessel in the brain
what are the symptoms of stroke
FAS of FAST
face drooping
arms weakness = unable to raise both arms and keep up
slurring of speech/unclear
what is the NIHSS scoring and scale
0-42 points
determines the severity of the stroke (and impacted brain density)
what is the ABCD2 scoring
A = age
- ≥60y/o (1)
B = blood pressure
- S ≥140, D≥90mmHg (1)
C = clinical features
- unilateral weakness (2)
- isolated speech disturbance (1)
D = duration
- ≥60min (2)
- 10-59min (1)
- <10min (0)
DM = present (1) or absent
predicts likelihood of TIA (within first 2 days) transitioning to ischemic stroke.
max 7 points
what is the eligibility for r-tpa
1) within 3-4.5h of onset of symptoms
2) BP <185/110 and BG >2.8mmol/L
(risk of hemorrhagic conversion if BP too high)
3) disabling stroke symptoms
4) CT brain changes (to check for haemorrhagic stroke)
what is the algorithm for new onset AIS not on antithrombotic therapy
if eligible = start SAPT after 24h and within 48h of thrombolysis
if ineligible
1) minor stroke, high risk TIA
= DAPT ASAP x21 days
2) not minor stroke OR high risk TIA
= SAPT ASAP
minor stroke = 0-3
high risk TIA = ≥4
afterwards evaluate stroke mechanism for underlying reasons:
- MRI brain
- TTE = transthoracic echocardiogram = LV thrombus
- 24h holter = ECG = AF
- US carotids = atherosclerosis in carotid arteries
- lipid, TFT (thyroid), HbA1c
how does the treatment plan vary according to the stroke mechanism?
if ischemic stroke
1) cardioembolic
- stop SAPT, start DOAC.
2) non-cardioembolic
- severe major ICAS = add clopidogrel to aspirin x90days
- not severe iCAS = lifelong SAPT
INTRACRANIAL ARTERIAL STENOSIS (ICAS)
BOTH:
start high-intensity statins
- atorvastatin 40-80mg OD
- rosuvastatin 20-40mg OD
initiation of vtep while hospitalised
in general ward
VTEP with LMWH within 48h but after 24h if rTPA used.
IPC (intermittent pneumatic calf) for high bleeding risk within 72h.
what is the dosing for dipyridamole po?
25-150mg TDS
used for IV imaging agent in cardiology (SG)
eptifibatide (IV) dosing
double bolus of 180ug/kg given at a 10min interval followed by infusion of 2ug/kg/min for up to 18h.
dose adj if crcl<50ml/min, do not use in ESRD.
time to platelet aggregation steady state for the 3 antiplatelets p2y12i
clop 5-6 days
prasu 2-4 days
ticagrelor appx 2 days (faster recovery after stoppingthe drug)
when to stop p2y12i for surgery
clo: min 5 days
prasu: 7 days
tica: 2-3 days
cyp2c19 polymorphism for clopidogrel
loss of fnction = poor metabolism of clopidogrel prodrug into active metabolite
intermediate metabolism:
1/2
1/3
poor metabolism:
2/2
2/3
3/3
more prevalent in Asian population
clopidogrel dosing and time to platelet inhibition
if load 600mg = 2h to platelet inhibition
if load 300mg = 6h to platelet inhibition
load because of slow onset due to metabolism into parent drug by cyp2c19
drug interactions for ticagrelor
3a5 strong and pop inhibitor = increase serum levels of simvastatin and digoxin
substrate of 3a4/5, 2c19, 1a2, pgp
2c9 inducer (both parent and metabolites)
Prasugrel C/I and cautions
C/I in patients with: PMH stroke or TIA. due to bleeding risk
Caution: >75y/o
INcreased bleeding risk compared to clopidogrel.
what is the dosing plan for UFH in pCI?
2000-5000 IU (nomore than 50-70iu/kg) to achieve activated clotting time ACT of 250-300
repeat bolus as needed (max 10000IU) to maintain ACT throughout PCI
if gp2b3a used, repeat bolus (max 7000IU) as needed to maintain PCI
what is the dosing plan for ENOXAPARIN in pCI?
if
last sq lmwh 8-12h before pCI = 0.3mg/kg bolus
last sq lmwh <8h before pCI = no need further
last sq lmwh >12h before pCI = use UFH instead
