L15 - Pharmaceutical Care For Patietns Suffering From Coronary Syndrome

Question 1

What is stable angina?

Answer 1

A symptom caused by myocardial ischaemia due to an imbalance between oxygen supply and demand, typically triggered by exertion and relieved by rest or GTN.

Question 2

What is unstable angina?

Answer 2

An unprovoked or prolonged episode of chest pain raising suspicion of acute myocardial infarction (AMI) with no ECG changes and no troponin release.

Question 3

What is NSTEMI?

Answer 3

A non-ST elevation myocardial infarction characterised by chest pain, non-specific ECG changes (ST depression, T wave inversion, or normal ECG), and elevated troponin levels.

Question 4

What is STEMI?

Answer 4

A ST-elevation myocardial infarction involving chest pain, ST elevation in at least two ECG leads, troponin release, and full-thickness myocardial damage.

Question 5

How does myocardial infarction (MI) occur?

Answer 5

• Plaque rupture leads to thrombus formation.
• Thrombus occludes a coronary artery, leading to myocardial ischaemia.
• If blood flow is not restored, irreversible myocardial cell death occurs.

Question 6

How does tissue necrosis progress in MI?

Answer 6

• Necrosis starts within 20-40 minutes.
• Damage spreads in a “wavefront” from the subendocardial layer outward.
• Substantial tissue salvage is possible if reperfusion occurs within 6 hours.

Question 7

What are the differences between NSTEMI and STEMI?

Answer 7

• NSTEMI: Partial thickness damage (subendocardial infarct).
• STEMI: Full thickness damage (transmural infarct).

Question 8

What are the symptoms of MI?

Answer 8

• Chest pain (crushing, squeezing, or pressure-like).
• Pain radiating to jaw, arm, back, or neck.
• Shortness of breath, sweating, nausea, vomiting.
• Not relieved by GTN (unlike stable angina).

Question 9

What are key biochemical markers for MI?

Answer 9

• Troponin I/T: Rise in 3-5 hours, peak at 14-18 hours, remain elevated for days.
• CK-MB: Peaks in 12-28 hours, normalises in 72-96 hours.
• Myoglobin: Rises within 1-2 hours, peaks at 3-15 hours (not specific for MI).
• LDH-1: Elevated in later stages of MI.

Question 10

What ECG changes indicate MI?

Answer 10

• Hyperacute T waves: Early ischaemia sign.
• T wave inversion: Ongoing ischaemia.
• ST depression: Subendocardial ischaemia (NSTEMI).
• ST elevation: Transmural ischaemia (STEMI).
• Pathological Q waves: Permanent marker of myocardial necrosis.

Question 11

What is the immediate management of STEMI?

Answer 11

1. Reperfusion therapy:
   • Primary PCI (Percutaneous Coronary Intervention) within 120 minutes (preferred).
   • Thrombolysis (Tenecteplase) if PCI unavailable.
2. Antiplatelets:
   • Ticagrelor 180mg + Aspirin 300mg stat.
3. Reduce cardiac workload:
   • Beta-blockers (e.g., bisoprolol).
   • GTN IV for vasodilation.

Question 12

What is the immediate management of NSTEMI/Unstable Angina?

Answer 12

1. MONA protocol:
   • Morphine (5-10mg IV).
   • Oxygen (maintain SpO₂ 94-98%).
   • Nitrates (IV GTN).
   • Aspirin 300mg stat.
2. Anticoagulation:
   • Fondaparinux 2.5mg SC.
3. Risk stratification (GRACE score):
   • Consider coronary angiography within 72 hours.

Question 13

What is the long-term management after MI?

Answer 13

1. Aspirin 75mg OD (lifelong).
2. Ticagrelor 90mg BD (up to 1 year, standard NHS duration = 6 months).
3. Beta-blockers (e.g., bisoprolol 2.5mg daily, for 1 year-lifelong).
4. ACE inhibitors (e.g., ramipril 2.5mg BD).
5. Statins (e.g., atorvastatin 80mg daily, high-intensity).
6. Lifestyle modifications (smoking cessation, diet, exercise, alcohol moderation).

Question 14

What are the first-line medications for stable angina?

Answer 14

• Beta-blockers: Reduce cardiac workload, proven mortality benefit.
• Calcium channel blockers (e.g., amlodipine, diltiazem, verapamil): Vasodilation and rate control.
• GTN spray (400mcg/dose): Acute relief before exertion or at onset of pain.

Question 15

What are alternative/add-on treatments for stable angina?

Answer 15

• Long-acting nitrates (ISMN, ISDN): Used if angina is not controlled.
• Nicorandil: A potassium channel activator, third/fourth-line option.
• Ivabradine: If beta-blockers are not tolerated or contraindicated.
• Ranolazine: Adjunctive therapy for refractory angina.

Question 16

What secondary prevention measures are used in stable angina?

Answer 16

• Aspirin (lifelong, 75mg OD).
• High-intensity statin (atorvastatin 40-80mg OD).
• Lifestyle modifications.

Question 17

What are early complications (<72 hours) after MI?

Answer 17

• Cardiogenic shock.
• Acute heart failure.
• Ventricular arrhythmias (VT, VF).
• Myocardial rupture.
• Thromboembolism.
• Pericarditis.

Question 18

What are late complications of MI?

Answer 18

• Ventricular aneurysm.
• Cardiac tamponade.
• Dressler’s syndrome (post-MI pericarditis).
• Heart failure.