STEMI / NSTEMI / ANGINA Flashcards
Acute coronary syndrome can be classified as
ST-elevation myocardial infarction (STEMI): ST-segment elevation + elevated biomarkers of myocardial damage
non ST-elevation myocardial infarction (NSTEMI): ECG changes but no ST-segment elevation + elevated biomarkers of myocardial damage
unstable angina - pain ocurs whulst resting
Criteria for STEMI
clinical symptoms consistent with ACS
(generally of ≥ 20 minutes duration)
with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of:
2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years,
or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years
1.5 mm ST elevation in V2-3 in women
1 mm ST elevation in any two contiguous leads except leads V2 or V3
new LBBB (LBBB should be considered new unless there is evidence otherwise)
Mx of all ACS patients ?
aspirin 300mg
oxygen should only be given if the patient has oxygen saturations < 94% in
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nitrates
can be given either sublingually or intravenously
useful if the patient has ongoing chest pain or hypertension
should be used in caution if patient hypotensive
If STEMI confirmed?
assess eligibility for coronary reperfusion therapy
1) percutaneous coronary intervention
if the presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given (i.e. consider fibrinolysis if there is a significant delay in being able to provide PCI)
if patients present after 12 hours and still have evidence of ongoing ischaemia then PCI should still be considered
drug-eluting stents are now used.
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fibrinolysis
tPA+DAPT + Antithrombin
tPA: Alteplase
Antithrombin: Unfractionated heparin/Bivalirudin
patient’s ECG taken 90 minutes after fibrinolysis failed to show resolution of the ST elevation then they would then require transfer for PCI
streptokinase, alteplase
Mx prior to PCI if PCI possible within 120mins
aspirin + not taking an oral anticoagulant/ no bleeding risk : prasugrel
taking an oral anticoagulant and bleeding risk : clopidogrel
Mx during PCI ?
undergoing PCI with radial access:
unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor
atients undergoing PCI with femoral access:
bivalirudin with bailout GPI
other procedures during PCI ?
thrombus aspiration, over mechanical thrombus extraction, should be considered
complete revascularisation should be considered for patients with multivessel coronary artery disease without cardiogenic shock
Mx of NSTEMI/ unstable angina ?
all have ASPIRIN 300MG and clopidrogel 300mg
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clinically unstable
(presence of any of the following conditions:
Ongoing or recurring pain despite treatment
Haemodynamic instability, such as low blood pressure or shock
Dynamic ECG changes
Left ventricular failure)
then PCI
high risk on grace score of more than 3 percent percent of predicted 6 month mortality risk :
angiography wiithin 72 hours with PCI if indicated
in the interim : aspirin + fondaparinoux +
Not on anticoagulation : + ticagrelor
on previous anticoagulation : clopidrogel
if PCI indicated : unfractionated heparin
Low Risk on GRACE Score
Step 1. Aspirin 300mg PO + Fondaparinux
Step 2.
- Low Bleeding Risk: Ticagrelor + Aspirin
- Higher Bleeding Risk: Clopidogrel
Long term MX ?
Dual Antiplatelet Therapy (DAPT) is typically prescribed for 12 months as per NICE
after 12 months , lifelong single antiplatelet therapy with aspirin or a P2Y12 inhibitor may be continued depending on the clinical scenario.
Statin
beta blocker
Angina pectoris: drug management
sublingual glyceryl trinitrate to abort angina attacks
beta-blocker or a calcium channel blocker
if a calcium channel blocker is used as monotherapy a rate-limiting one / non DHP = such as verapamil or diltiazem should be used
if used in combination with a beta-blocker then use a longer-acting dihydropyridine calcium channel blocker (e.g. amlodipine, modified-release nifedipine)
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if a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa
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patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs:
a long-acting nitrate
or
ivabradine (non-DHP CCB should not be combined with ivabradine )
HR >75
left ventricular fraction < 35%
or
not given with LOW BP:
nicorandil
ranolazine
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if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG
ECG territories ?
Anterior - v3-v4
Left anterior descending artery
Septal - v1-v2
Proximal left anterior descending artery
Lateral - lead 1, Avl ,v5 v6
Left circumflex artery
Inferior -lead 2,3,avf
Right coronary artery
