Myocardial Ischaemia Flashcards
What condition is characterised by predicatable chest pain/pressure often on exertion?
Stable angia
What is the pathophysiology behind stable angina?
Atherosclerotic plaques in the coronay arteries restricting blood flow to the heart
What type of angia is caused by narrowing or occlusion of the proximal coronary arteries due to spasm - normally at rest?
Prinzmetals / vasospastic angina
How should acute attacks of stable angina be managed?
GTN spray
How should long term prevention of stable angina be mananged?
- Beta blocker (atenolol, bisoprolol, metoprolol etc)
- RL CCB if beta blocker is inappropriate (e.g. in Prinzmetals angina - amlodipine may also be useful in this type of angina)
- BB + CCB
- addition of Long acting nitrate, Ivabradine, Nicorandil or Ranolazine
If a patient has stable angia but cannot tolerate a beta blocker or CCB what else can be offered?
Long acting nitrate, Ranolazine, Ivabradine, Nicorandil
All patients with stable angina due to atherosclerotic disease should be offered what secondary prevention medications?
Aspirin + Statin
consider adding an ACEI (particularly if diabetic)
At what heart rate would you consider discontinuing Ivabradine?
50bpm
What is a serious side effect of Nicorandil?
serious skin, mucosal and eye infections including GI ulcers whihc may progress to perforation /haemorrhage / fistula
How would you counsel a patient to use GTN spray?
Sit down. Spray 1-2 doses under the tongue on the onset of pain. Dose may be repeated 5 minutes after if pain not subsided. Max of 3 doses in one time. If not resolved after 5 mins of 2nd dose call ambulance. If pain resolves when stand up do so slowly and carefully.
What conditions are encompassed under ACS
NSTEMI, STEMI, unstable angina
What should be given in the initial management of an NSTEMI / UA?
- Oxygen
- Nitrates - Sublingual/IV/buccal GTN or ISDN
- Pain relief - morphine by slow IV
- Antiemetics - metoclopramide
- Aspirin 300mg ( or clopidogrel is intolerant)
- Fondaparinux 2.5mg SC unless coronary angiography is planned within24 hoursof admission then give LMWH
- Ticagrelor 180mg STAT then 90mg BD (12 months)
If a patient presents with a low risk NSTEMI what antiplatelet therapy is used?
Clopidogrel
If a patient presents with a medium-high risk NSTEMI what antiplatelet therapy is used?
Abciximab or eptifabatide ( in combination with LMWH + aspirin) or Tirofiban (+LMWH+Aspirin+clopidogrel)
What 2 medications are given STAT if suspected ACS?
300mg Aspirin + 300mg Clopidogrel
What are the secondary prevention medications following ACS?
- ACEI
- Beta blocker
- Statin
- GTN
Initial management of a STEMI
- Oxygen
- Analgesia
- Antiemetics
- Aspirin 300mg + clopidogrel 300mg Stat ( or prasugrel if patient is undergoing PCI)
- PCI - (use a glycoprotein IIb/IIa inhibitor may be necessary in high risk patients)
- Nitrates
- Beta blocker
- ACEI
Long term management on STEMI
- Aspirin + clopidogrel
2.Beta blocker - ACEI
4.Nitrates - Statins
NB: epelernone is licensed following an MI with LV dysfunction
Non-pharmacological advice to reduce risk of future MI
diet, exercise, smoking cessation,
At what weight is prasugrel cautioned?
60kg
What class of antiplatelet is ticagrelor?
P2Y12 inhibitor
Within how many hours of symptom onset should Streptokinase or reteplase be given?
12 hours
Examples of nitrate side effects?
Flushing, headache, postural hypotension
How long does the effect of GTN last for?
20-30 minutes
What is the issue with using a GTN transdermal patch over the spray/tablet?
Tolerance is more likely to occur
What preparation of nitrate is more stable for those who use GTN spray less frequently?
Isosorbide dinitrate spray
What is the duration of action of MR preparations of nitrates?
12 hours
How can nitrate tolerance be prevented?
Nitrate break for 4 - 12 hours each day
If a patient uses a nitrate patch and tolerance is suspected, how long should they leave the patch off for?
8 - 12 hours (usually overnight) in each 24 hours
What is dobutamines mechanism of action?
Works on beta 1 receptors in the heart as a cardiac stimulant to increase contractility
What drug should be given every 3 to 5 minutes in cardiac resus?
Adrenaline 100mcg/mL solution, 1mg every 3 to 5 minutes
How many adrenaline autoinjectors should be prescribed at once?
Two
What brand of autoinjector had a product recall in may 2020?
Emerade
How long after the first administration of adrenaline autoinjector can another dose be given?
5 to 15 mins
When prescribing an adrenaline autoinjector what do prescribers need to specify?
the brand ( non bioavailble)
