Ischemic heart disease II

Question 1

ACS acute supportive care (MONA)

Answer 1

Morphine
* Oxygen
* Nitroglycerin
* Aspirin

Question 2

ACS acute supportive care (THROMINS acronym)

Answer 2

Thienopyridine (clopidogrel)
* Heparin
* RAAS
* Oxygen
* Morphine
* B-blocker
* Intervention
* Nitroglycerin
* Statin/salicylate

Question 3

Initial management of unstable ANGINA PECTORIS &
NSTEMI

Answer 3

Oxygen 40% via facemask, if saturation < 94% or if in distress.
* Aspirin, oral, 150 mg as a single dose (chewed or dissolved) as soon as
possible.
* ADD
* Nitrates, short acting, e.g.: isosorbide dinitrate, sublingual, 5 mg
immediately as a single dose.
* May be repeated at 5-minute intervals for 3 or 4 doses.
* ADD
* Morphine 10 mg diluted with 10 mL of water for injection or sodium
chloride 0.9%, slow IV (Doctor prescribed).
* Start with 5 mg; thereafter slowly increase by 1 mg/minute up to 10 mg.
* Can be repeated after 4–6 hours if necessary, for pain relief.
* Beware of hypotension.

Question 4

Initial management of unstable acute MI & STEMI

Answer 4

Before transfer: cardiopulmonary resuscitation if necessary
* Oxygen 40% via facemask, if saturation < 94% or if in distress.
* Aspirin, oral, 150 mg as a single dose (chewed or dissolved) as soon as possible.
* AND
* Nitrates, short acting, e.g.: isosorbide dinitrate, sublingual, 5 mg immediately as a
single dose.
* May be repeated at 5-minute intervals for 3 or 4 doses.
* AND
* Morphine 10 mg diluted with 10 mL of water for injection or sodium chloride 0.9%,
slow IV (Doctor prescribed).
* Start with 5 mg; thereafter slowly increase by 1 mg/minute up to 10 mg.
* Can be repeated after 4–6 hours if necessary, for pain relief.
* Beware of hypotension.
* AND (if patient qualify)
* Thrombolytic: streptokinase OR if unavailable alteplase

Question 5

Indications of thrombolytic therapy (5)

Answer 5

For acute myocardial infarction with ST
elevation or left bundle branch block:
* maximal chest pain is ≤6 hours
* beyond 6 hours and chest pain, consult a
specialist
* >6 hours and no chest pain, manage with
anticoagulants
* if on-going ischaemic pain

Question 6

Contra-indications of thrombolytic therapy

Answer 6

Absolute:
* streptokinase used within the last year, (not for alteplase)
* previous allergy,
* CVA within the last 3 months,
* history of recent major trauma,
* bleeding within the last month,
* aneurysms,
* brain or spinal surgery or head injury within the preceding
month, or recent (<3 weeks) major surgery,
* active bleeding or known bleeding disorder,

Question 7

What to monitor after administration of thrombolytic therapy? 4

Answer 7

Pulse
* BP
* Respiration depth and rate (count for a full minute)
* ECG

Question 8

Antiplatelet tx (2)

Answer 8

Clopidogrel
* Aspirin, oral, 150 mg stat, then as daily single dose, continued
indefinitely in the absence of contraindications

Question 9

MOA of aspirin

Answer 9

Provides its antiplatelet effect by acetylating a hydroxyl group of
serine 530 on the cyclooxygenase (COX) 1 enzyme on platelets and
thereby preventing the conversion of arachidonic acid into
prostaglandins, and eventually thromboxane A2.

Question 10

Function of thromboxane A2

Answer 10

Thromboxane A2 produces platelet activation as well as
vasoconstriction.

Question 11

Discuss half life of aspirin

Answer 11

• While unbound aspirin has a half-life of only about 15 to 20 minutes,
  the irreversible binding of aspirin to the platelet COX1 enzyme
  inhibits thromboxane A2–induced platelet activation for the life of
  the platelet (7 - 10 days).

Question 12

Explain why low dose daily aspirin therapy is preferred than high dose

Answer 12

After the initial dose of aspirin, daily doses of aspirin should be
continued indefinitely.
* Higher daily maintenance doses of aspirin (300- 325 mg) do not
reduce CV death, MI, or stroke compared to lower daily maintenance
doses (75 – 100 mg), but significantly increase the incidence of
gastrointestinal (GI) bleeding.

Question 13

Contraindications of aspirin 2

Answer 13

Hypersensitivity
GI intolerance

Question 14

Aspirin is often used in combination with what in ACS?

Answer 14

s typically combined with an oral P2Y12 inhibitor (clopidogrel) as part of
dual antiplatelet therapy (DAPT).

Question 15

How does P2Y12 inhibitor work?

Answer 15

P2Y12 receptor irreversible bond and prevents the receptor’s ability
to be activated by adenosine diphosphate and subsequent platelet
activation and aggregation.

Question 16

What do anticoagulants inhibit?

Answer 16

Currently available anticoagulants inhibit the production of
thrombin by inhibiting factor Xa, inhibiting thrombin itself, or a
combination of these.

Question 17

Anticoagulant therapy for STEMI

Answer 17

Adjunctive treatment with thrombolytic therapy : alteplase,
streptokinase (do not use heparins after streptokinase)
* Enoxaparin

Question 18

NSTEMI/unstable angina anticoagulation treatment

Answer 18

• Enoxaparin, sc, 1mg/kg, 12 hourly for minimum 2 days
  OR
• Unfractionated heparin for minimum 2 day

Question 19

Chronic management of STEMI/NSTEMI/UNSTABLE ANGINA

Answer 19

Clopidogrel, oral 75mg daily for (12) months
* Aspirin, oral, 150 mg daily (continued indefinitely in absence of
contraindications)

Question 20

When clinically stable without signs of heart failure, hypotension,
bradydysrhythmias or asthma(caution), which chronic tx for stemi/nstemi/unstable angina can you use?

Answer 20

Cardio-selective beta-blocker: Atenolol
* HMGCoAreductase inhibitors: Simvastatin 40mg

If there is cardiac failure or LV dysfunction
* ACEI: enalapril / ARB: losartan