MYOCARDIAL ISCHAEMIA + ACS Flashcards
Myocardial ischameia
build up of atherosclerotic plaques
restricts arteries
reducing blood supply and o2 to heart
Stable angina
Predictable chest pain or pressure due physical exertion or emotional
Stable angina - Initial treatment
- Can be taken prophylactically or when symptoms arise
- Glyceryl Trinitrate dose to be taken at 5 minutes intervals
- If symptoms haven’t resolved after the second dose: medical emergency
When should emergency services be called
Emergency services should be called 5 minutes after second dose of GTN not working
Long-term Prevention
1st Line: Beta-blocker (RL-CCB if B-blocker contraindicated)
2nd Line: Beta-blocker + CCB (Amlodipine, Lacidipine, etc)
3rd Line: Long-acting nitrate, Nicorandil, Ivabradine or Ranolazine
Nicorandil - side effects
can cause Gl and mucosal ulceration
When should response to treatment be assessed?
Response to treatment should be assessed every 2–4 weeks following initiation or change of drug therapy; drug doses should be titrated to the maximum tolerated effective dose.
RL CCB and BB
never give together
Secondary prevention of cardiovascular events
Need to implement healthy life-style measures
Introduce 75mg aspirin and low dose stätin
Nitrates - MoA
Potent coronary vasodilators.
Reduce venous return and cardiac output.
Short-acting nitrates
Management of acute angina attacks
- Glyceryl trinitrate
- Isosorbide dinitrate (S/L)
long- acting Nitrates - examples
Long-term prophylaxis of angina
- MR isosorbide dinitrate
- Isosorbide mononitrate
ivabradine, nicorandil, or ranolazine.
Nicorandil
K channel activator
Risk of ulcer complications: mouth, skin, eye, GI
Do not drive until it is established and performance is not impaired.
GTN Sublingual tablets - counselling
should be discarded 8 weeks after opening bottle
MR Isosorbide dinitrate and Isosorbide mononitrate
Both taken BD.
Second dose should be taken after 8 hours.
Tolerance
Patients should have nitrate free period to prevent tolerance
Second dose of nitrate should be given 8 hours after first dose instead of 12
In transdermal use: patches should be left off for 8-12 hours a day
Nitrates - side effects
Dizziness, Flushing and headaches
Nitrates - elderly
Should be prescribed in caution in elderly due to risk of falls
ACS
Acute coronary syndrome (ACS) encompasses a spectrum of conditions which include myocardial infarction with or without ST-segment-elevation (STEMI or NSTEMI respectively), and unstable angina.
Acute coronary syndromes (ACS) - risk factors
Major Risk Factors:
Family History
Hypertension
Hypercholesterolaemia
Diabetes
Smoking
ECG and biomarkers evaluated
Tests determine if symptoms are unstable angina/NSTEMI or STEMI
If it is a STEMI
PCI is needed within 2 hours
all 3 syndromes started on secondary prevention
ACS - Initial management
Confirmed ACS:
* Loading dose of Aspirin 300mg
Pain relief: GTN +/ - IV morphine
* Oxygen if needed
NSTEMI and Unstable Angina
Partial blockage of artery
From test results, determine if NSTEMI, Unstable Angina or STEMI.
Partial blockage of artery - myocardial necrosis in only NSTEMI
Complete blockage of artery causing myocardial necrosis in STEMI
STEMI
Complete blockage of artery
ST zone of ECG is elevated
NSTEMI
ST zone of ECG is not elevated
STEMI requires Percutaneous Coronary Intervention (PCI) within 2 hours:
Patients should be given heparin if PCI is done through radial access
* Preferred secondary anti-platelet would be prasugrel in long-term management
Secondary prevention
DAPT - lifelong aspirin 75mg. 12 months: clopidogrel, prasugrel, ticagrelor
ACEi - ARB if ACEi CI
BB - may be discontinued after 12m in pt w/o LVEF
Statin - high strength (atorvastatin 80mg)
pt with NSTEMI might consider PCI to prevent future MI
Assess risk of HF
