Non ST segment elevation ACS, T

Question 1

Non-ST elevation ACS: Therapy

Answer 1

MONA:
- Morphine, O2, Nitroglycerine, Aspirin

BASH:
- Beta blocker, ACEi, Statins, Heparin

Question 2

Risk stratification: GRACE score, what is it, what is it based on,

Answer 2

GRACE score is a scoring system designed to
- risk stratify patients with diagnosed ACS,
- estimate their in-hospital and 6 months to 3 year mortality
- Based on:
Age, HR, SBP, creatinine, CHF, cardiac arrest, ST segment abnormalities, cardiac biomarkers

Question 3

Which NSTE-ACS require an urgent invasive strategy, which ones require an early invasive strategy (invasive cardiology -> angioplasty + stent)

Answer 3

.Urgent invasive strategy (ASAP):
- Refractory angina, recurrent angina despite intense anti-anginal treatment, Deep ST depression in V1-V4, heart failure or shock, life threatening arrhythmias

.Early invasive strategy (<24h):
- Grace score >140, elevated troponin, dynamic ST-T changes, DM, Renal failure, depressed LV function (EF<40%), early post-MI angina, PCI within 6 month, Previous CABG, Intermediate or high risk according to a risk score

Question 4

Non-ST elevation ACS: drugs

Answer 4

• ASA/clopidogrel (antiplatelet), take both if STEMI
  Increased clopidogrel dose in PCI treatment
  Stent implant -> ASA for life, clopidogrel for 1 month
• LMWH: an anticoagulant
• Beta-blockers, Nitroglycerin
• Fibrinolytics: only in STEMI
• Statins and ACEi

Question 5

What to give in case of High risk Patients based on GRACE score

Answer 5

• Infusion of GPIIb/IIIa antagonists (antiplatelet agents) and ideally urgent angiography
• clopidogrel + ASA for 12 months

Question 6

What to give in case of low risk patients based on GRACE score

Answer 6

• if no ECG change, no pain, no troponin -> discharged

Question 7

Subsequent treament

Answer 7

• rest for 48h
• exercise, daily ECG and cardiac enzymes for 3 days
• thromboembolism prophylaxis (Heparin, warfarin, aspirin)
• BB, ACEi, Statins
• Modifiable factors
• Exercise ECG

Question 8

Treatment of ACS can be divided in 2 phases

Answer 8

• Acute (<24h):
  ASA, Clopidogrel, Heparin/LMWH, GPIIb/IIIa inhibitors, BB, nitrates, ACEi, Statins
• Long term (discharge):
  ASA, Clopidogrel, BB, ACEi, Statins, RF + lifestyle’s (no smoking, optimal weight, BP control, AHA diet, control of glucose in DM)