Intervention Flashcards
What is the medical management of SCAD?
Beta blockers - reduces recurrent scad
Aspirin lifelong
Clopidogrel 12 months
Statin if dyslipidaemi
What are the indications for urgent revascularisation in SCAD?
Haemodynamic instability
Left main dissection
Ongoing ischaemia
What is the preferred method of revascularisation for SCAD if required?
Cabg
What is the mortality of SCAD?
4%
What is the rate of recurrent SCAD in 2 years?
13%-17%
What is the long term success rate of PCI for SCAD without complications?
30%
What are the ESC guidelines for Diagnosis of STEMI on ecg
Two contiguous leads >1mm (apart from V2-3)
V2-3
Men >40 years - >2mm
Men <40 years - >2.5mm
Women - >1.5mm
What are the ECG findings of NSTEACs as per ESC?
New horizontal/downsloping ST depression >0.5 in 2 contiguous leads
New t wave inversion >1mm in two contiguous leads with dominant R wave
How do you define post PCI MI based on the ESC?
20% increase in troponin with absolute value greater than 5 times the ULN
How do you define myocardial injury?
Rise in troponin without objective evidence of ischaemia.
Objective evidence: Chest pain Ecg changes Echo findings Angiographic evidence
What are the contraindications for ticagrelor?
Weight <60
COAD
Bradycardia
Liver dysfunction
What are the contraindications for prasugrel?
Stroke or TIA
Weight <60
Age >75
Asian
In conservatively managed NSTEAC what is the preferred method of anticoagulation?
Enoxaparin
Essence trial - lower rate of death MI and recurrent angina compared to heparin
What is the absolute reduction in MI and death in NSTEACS with anticoagulation?
3%
Definition of myocardial infarction.
Rise and fall in troponin with one value above the 99th percentile with one of the following
- Symptoms of myocardial ischaemia
- new ischaemic changes on ECG
- Development of pathological q waves
- Imaging evidence of loss of viable myocardium or new regional wall motion change
- Coronary thrombus on angio or autopsy
What are the features that may distinguish Takotsubo Cardiomyopathy from Myocardial Infarction?
Regional wall motion abnormalities
QTC >500
Improvement in EF within 2 weeks
What is the specificity of sgarbossa criteria for MI?
99%
What is the ARR for mortality of ticagrelor over clopidogrel in patients ACS?
2% reduction in vascular and all cause mortality
In the setting of ACS with invasive strategy and prasugrel/ticagrelor DAPT, when are GP2b3a inhibitors recommended by ESC guidelines?
Bailout situations with thrombotic complications of PCI
What do meta analyses show regarding thrombectomy in the management of STEMI?
Overall no difference in mortality with and without thrombectomy with Increased stroke risk.
Trend towards improved mortality with manual aspiration thrombectomy (P = 0.05)
What is the ARR for MACE with ticagrelor over clopidogrel in medically managed ACS?
2.3%
How does heparin compare to enoxaparin in acute coronary syndromes?
Less death, MI and major bleeding with enoxaparin (Meta-analysis Silvain 2012)
What is the absolute risk reduction with anticoagulation for acute coronary syndromes?
2.9% (Meta-analysis Eikelboom 2000)
What did Oasis-5 show?
Fondaparinux (2.5mg sc OD) was superior to enoxaparin in bleeding risk and mortality at 1 and 6 months with non-inferiority in recurrent MI
What is the ARR for MI/Death of a routine invasive strategy over selective invasive strategy in low, moderate and high risk NSTEAC?
2, 4, 11%
What is the ARR for Death of a routine invasive strategy over selective invasive strategy in NSTEAC?
1.6%
In what setting is non-invasive stress testing indicated in ACS before deciding on an invasive strategy?
Low risk patients (No high/intermediate risk factors)
No recurrent symptoms
What are the high risk criteria in ACS?
Rise and fall in troponin - dynamic troponin
Dynamic ECG changes
Grace score >140
What are the intermediate risk criteria in ACS?
Diabetes GFR <60 LVEF <40% Post Infarct Angina Prior revascularisation Grace between 110 and 140
What syntax score is associated with worse mortality with PCI in ACS?
> 8
What proportion of NSTEAC patients with cardiogenic shock have TVD?
70%
What is the mortality of untreated left main stenosis after 3 years?
50%
