Lecture 3 - Angina and ACS

Question 1

Define coronary syndrome

Answer 1

Obstruction of or reduction in coronary blood supply and subsequent cardiac ischaemia (reduced supply to the heart)

Question 2

Define stitch analogy

Answer 2

Reduced blood to muscles when exercising, blood diverted elsewhere, so pain is felt

Question 3

Define a STEMI

Answer 3

Complete occlusion of the artery
No blood supply getting to that area
Severe pain on LHS of chest radiating to the arm to the upper jaw
Nausea, dizziness and sickness
Uncomfortable for the patient
Rise in cardiac markers - troponin

Question 4

Define NSTEMi

Answer 4

Partial occlusion of the artery
Still some blood supply to the area
Severe pain
Rise in cardiac markers - troponin

Question 5

Define unstable angina

Answer 5

Some occlusion of the parties
Chest pain at rest
Can be uncomfortable

Question 6

Define stable angina

Answer 6

Chest pain occurs through the exertion and should not occur at rest

Question 7

What ECG changes and cardiac markers occur in an STEMI?

Answer 7

ST-segment elevation
Raised cardiac markers

Question 8

What ECG changes and cardiac markers occur in NSTEMI?

Answer 8

ST/T-abnormalities or none
Raised cardiac markers

Question 9

Define arteriosclerosis

Answer 9

Hardening of the arteries
Formation of atheroma - an inflammatory cascade of endothelial damage, infiltration of immune cells and fatty tissue infiltration of immune cells and fatty tissue infiltration

Question 10

Name a cardiac marker of ACS

Answer 10

Troponin - detected 3-12 hours after the onset of pain

Question 11

Name factors which suspect ACS

Answer 11

Cardiovascular risk factors (e.g. smoking, age, BP, diabetes and obesity or family history of a cardiac event)
Presenting symptoms - chest pain, radiation in left arm to the jaw
Signs and Investigations
Differential diagnosis - indigestion or chest pain?

Question 12

Are there other causes of ECG changes?

Answer 12

Can also be associated with Inflammation or conditions such as pericarditis or trauma to the cardiac failure

Question 13

How is a pharmacist involved in ACS and angina?

Answer 13

NMS - purpose, side effects and their management, doses
Discuss medicines management at home
Post-discharge medication review
Smoking cessation
Healthy lifestyle advice
Cardiac rehabilitation - reduce chances of events reoccurring

Question 14

Describe the immediate management of angina/ ACS?

Answer 14

analgesics and antiemetics
GTN, isosorbide dinitrate, and beta-blockers - Lower GR and reduce chest pain
Oxygen - optimise oxygen around the body
STAT dose of Antiplatelets
=> Aspirin 300mg
=> Prasugrel 60mg, Clopidogrel 300mg or ticagrelor 180mg prevent further platelet aggregation
=> Bivalirudin or tirofiban - considered as GPllb/lla
VTE prophylaxis - fondaparinux
Blood tests

Question 15

Define percutaneous coronary intervention

Answer 15

Metal/ polymer lattice - allows blood to flow through the artery
Balloon used to inflate the stent and open it up so it pushes the fatty deposits away and enables blood to flow through the vessels
Occurs straight away

Question 16

What is percutaneous coronary intervention used for?

Answer 16

STEMI AND STEMI

Question 17

What are the complications with PCI?

Answer 17

Contrast-induced nephrotoxicity
Restenosis - overtime the atherosclerotic disease starts to worsen around the stent as well - occurs quickly in some patients
Bleeding - from Antiplatelets and anticoagulants - need to monitor
In-stent thrombosis - introduction of foreign material can cause platelet aggregation

Question 18

Define a drug-eluting stent

Answer 18

Metal framework is inserted and coated with a drug that will stop platelet aggregation - stop build up of cells and fatty tissue within that area where the stent is inserted
Often contain anti-proliferative drugs - drugs which are traditionally used as chemotherapies to stop cell division and cell build up

Question 19

Define angioplasty

Answer 19

Balloon is used to inflate and widen the artery - used in patients that are unable to take antiplatelets and anti-coagulants due to bleeding risk

Question 20

Define thrombolysis

Answer 20

Clot-busting medicine

Question 21

Define emergency CABG

Answer 21

Coronary Artery Bypass Surgery
Restore blood flow around a blocked heart artery
Involves opening up the chest wall and carrying out cardiac surgeries

Question 22

Define GRACE scoring

Answer 22

Likelihood of death within 6 months from another cardiac event
Helps determine urgency of some treatment options
Takes into account symptoms at presentation

Question 23

If grace score is more than 3%…

Answer 23

Angiogram - type of x-ray used to examine blood vessels
PCI within 72 hours

Question 24

If GRACE score is less than 3%…

Answer 24

Medically managed

Question 25

What are the complications of CABG?

Answer 25

AF, Infection fluid overload and increased secretions

Question 26

When is fondaparinuz used?

Answer 26

It is a Factor Xa inhibitor
People waiting for their interventions

Question 27

Name some secondary prevention medicines

Answer 27

Dual Antiplatelets medicines, ACE inhibitors, Beta Blockers, Lipid-Lowering Therapy

Question 28

When is dual anti-platelet required?

Answer 28

Post intervention:
1-12 months depending on stent type
Include Aspirin in combination with either prasugrel, ticagrelor or clopidogrel
1 month bare metal stent
6-12 months for drug eluting stent

Continue single Antiplatelets for there after

Question 29

When is a PPI considered?

Answer 29

one of - History of UGIB, ulcer on anticoagulant, NSAIDS/Steriods
two of - age >65, dyspepsia, GORD, H.pylori, chronic alto use

Question 30

When are anticoagulants used?

Answer 30

AF
Previous VTE
Prosthetic heart valves

Question 31

Examples of secondary prevention medication

Answer 31

Smoking cessation, diet and exercise
GTN spray - anti-anginals
Cardiac rehabilitation
Eplerenone - blood pressure medication used to treat heart failure
Screening for diabetes

Question 32

Define echocardiogram

Answer 32

• Ultrasound scan of heart - determines the weakness of the heart

Question 33

What is key to observe at when looking at an ECG?

Answer 33

• The left ventricular function - function of the cardiac muscle which is responsible for pumping blood around the body

Question 34

When does NICE recommend a ECHO should be taken after STEMI/NTEMI?

Answer 34

Before discharge home

Question 35

Key monitoring points with ACE inhibitors

Answer 35

Potassium levels
Patients with liver failure
caution in liver and renal failure and hyperkalaemia, aortic stenosis

Question 36

What do beta-blockers do?

Answer 36

Reduce HR, contractility and renin secretion

Question 37

When should beta-blockers not be used?

Answer 37

in heart block