ic6 (acs, ccs, ais, tia)

Question 1

What should be done during a suspected ACS? (3 points)

Answer 1

1) Load Aspirin 100mg (if pt had aspirin before) or 300mg (if pt aspirin naive) in the ambulance

2) Load Ticagrelor 180mg or Clopidogrel 600mg

3) When confirmed ACS, need to do reperfusion
Send for Primary Angioplasty or PCI (Primary Coronary Intervention) to remove clot
Anticoagulants and Antiplatelets: prevent clots from forming during procedure
IV bolus UFH or LMWH (anticoagulants)
IV bolus GP2b/3a infusion eg. Eptifibatide (antiplatelet)
IV Cangrelor (P2Y12i)
(if PCI not used) Fibrinolytics eg. Alteplase, Tenecteplase

Question 2

When is the TCU for ACS patients?

Answer 2

See patients at 3 months mark
Determine bleeding risk using ARC-HBR risk factors

1 major or 2 minor risk factors = high bleeding risk
If high bleeding risk:
Stop P2Y12i (Ticagrelor) after 3 months

If low bleeding risk:
Continue DAPT for 12 months, Aspirin lifelong

Question 3

What are 3 signs (tests) or symptoms of MI?

Answer 3

Symptoms (eg. chest discomfort, pale, breathlessness, abdominal discomfort)

ECG changes (ST depression or elevation)

Troponin (marker of myocardial death)

Question 4

What are the doses of DAPT in ACS?

Answer 4

P2Y12i should be loaded when initiating

Ticagrelor + ASA (100mg OM)
180mg loading dose, 90mg BD
Used in ACS (MI or Unstable Angina)

Clopidogrel + ASA (rarely, only if)
1) 600mg loading dose, 75mg OD
If patients cannot receive Ticagrelor or Prasugrel

2) 300mg loading dose, 75mg OD
For patients receiving fibrinolytics eg. Tenecteplase, Alteplase

Question 5

When is loading dose of P2Y12 not needed?

Answer 5

During de-escalation, when there is bleeding or when there is bleeding concerns eg. when switching from Tica to Clop

Question 6

What is used to measure bleeding risk in ACS?

What are the risk factors?

Answer 6

ARC-HBR

Major risk factor
Use of long term oral anticoagulant
Severe CKD, end stage
Hb < 11
Spontaneous bleeding in past 6 months
Moderate or severe thrombocytopenia (platelet < 100 x 10^9)
Chronic bleeding
Liver cirrhosis + portal hypertension
Active cancer
Intracranial haemorrhage

Minor risk factor
Age ≥ 75
Moderate CKD (GFR 30-59)
Hb 11-12.9 for men, 11-11.9 for women
Spontaneous bleed in past 12 months
Long term NSAIDs or steroids
Ischemic stroke

Question 7

What to do if patient has loss of function genotype?

Answer 7

Use Ticagrelor, dont use Clopidogrel

Question 8

When are thrombolytics used (across ICs)

Answer 8

1) During acute ischaemic stroke (if meets criteria)

2) high risk PE or DVT with risk of losing lower limb loss

Question 9

What is the duration of ACS and CCS?

Answer 9

Acute Coronary Syndrome (STEMI, NSTEMI, Unstable angina)
12 months, 3 months if high bleeding risk

Chronic Coronary Syndrome (Stable Ischaemic Heart Disease / Angina)
6 months

Question 10

What score is used to assess severity of ischaemic stroke?

Answer 10

NIHSS

Question 11

What is ABCD2 used for?

Answer 11

To estimate risk of stroke after 2 days of Transient Ischaemic Attack (TIA)

Question 12

Treatment algorithm for AIS or TIA?

Answer 12

1) Eligible for rTPA?
If Eligible for rTPA
Start Aspirin after 24hrs of thrombolysis

If Not eligible for rTPA
Minor stroke (NIHSS 0 - 3) OR high risk TIA (ABCD2 score ≥ 4)
Start DAPT (Clopidogrel) for 21 days

IF not minor stroke or not high risk TIA
Start Aspirin ASAP

2) Evaluate stroke mechanism
Cardioembolic stroke (having underlying AF)
Stop antiplatelets, do SPAF instead
Proceed with CHADVA and HASBLED

Non cardioembolic stroke
Ig Severe major ICAS (Intracranial Arterial Stenosis)
All 3 main arteries in brain blocked, ie. Anterior, Middle, Posterior Cerebral Arteries
Add clopidogrel to Aspirin DAPT for 90 days
After 90 days, lifelong Aspirin

If NOT Severe major ICAS
Lifelong Aspirin

3) Start high intensity statins if there are no contraindications
Atorvastatin 40-80mg OD
Rosuvastatin 20-40mg OD

Question 13

What are the criteria for rTPA in AIS? (4 points)

Answer 13

1) Presenting within 3-4.5hrs of onset of symptoms
2) Disabling stroke symptoms, NIHSS > 5
3) BP < 185/110mmHg (not too high), blood glucose > 2.8
4) CT brain changes (to ensure that it is an Ischaemic stroke, not a haemorrhagic stroke)

Question 14

What are cardiovascular risk factors to manage in stroke patients? (7 points)

Answer 14

1) Hypertension
Maintain BP below 130/80

2) Diabetes
Control diet and exercise
Target Hba1c 7%
Use Metformin, SGLT2i or GLP2 agonist

3) Cholesterol
High intensity statins

4) Smoking cessation
Pharmacotherapy, behavior interventions

5) Diet
Emphasise intake of vegetables, fruits, nuts, whole grains

6) Physical activity
≥ 150 mins moderate or ≥ 75 mins vigorous physical activity a week

7) Low dose Aspirin use

Question 15

Counselling points for DAPT (role of DAPT, red flags)

Answer 15

Role of DAPT
To prevent clots from happening
Stent can also cause clots to form, and the mortality rate is 50%
So while the skin heals over the stent in 1 year, hence DAPT is used during this period (6 months for CCS, 12 months for ACS)
Aspirin is lifelong medication to prevent strokes and clots, only Clopidogrel / Ticagrelor can be stopped
Important to adhere as the risk for clots is higher right after a MI
If you need to go for a biopsy, dental extraction or any invasive procedures, MUST inform the doctor that you are taking antiplatelets, so that we can minimise the bleeding

Red flags
black, sticky, tarry stools
Dont rub bruises as it might expand
Gum bleeding, use a soft bristle toothbrush or may indicate gum infection