Treatment

Question 1

ACS Drug Treatment

Answer 1

1. Anti-ischaemic agents:
   - Beta blockers
   - Nitrates
   - Calcium channel blockers
   - Ivabridine
   - Ranolazine
   - Nicorandil
2. Antiplatelet agents
   - Aspirin
   - P2Y12 receptor inhibitors - clopidogrel, ticagrelor
   - Glycoprotein IIb/IIIa inhibitors
3. Anticoagulation
   - Indirect inhibitors of coagulation (unfractionated heparin, LMWH, factor Xa inhibitors e.g. fondaparinux)
   - Direct inhibitors (dabigatran, factor Xa inhibitors apixaban, rivoroxaban)

Question 2

Coronary Revascularisation in ACS

Answer 2

• Percutaneous Coronary Intervention (PCI)

- Coronary Artery Bypass Grafting (CABG)

Question 3

Long term management of ACS

Answer 3

• Manage chest pain with PRN GTN and opiates. If this proves insufficient, consider GTN infusion (monitor BP).
• Aspirin for life, dual antiplatelet therapy for 12 months, + 2nd antiplatelet agent (e.g. clopidogrel). Consider adding PPI (e.g. lansoprazole) for gastric protection.
• Anticoagulate until discharge
• Statins for life, aiming for LDL <1.8mmol/l
• Beta blockade to all with left ventricular impairment (LVEF <40%)
• ACEi (especially with LVEF <40%)
• ARBs to those intolerant of ACEi
• Aldosterone antagonists to patients already taking beta blockers and ACEi with LVEF <35%
• Enrolment in secondary prevention programme (diet, exercise, lifestyle)

Question 4

Immediate management of ACS

Answer 4

• 12 lead ECG
• Pain relief, GTN, 300mg aspirin
• Clopidogrel in hospital
• Oxygen/monitor
• Examination
• Bloods including troponin
• MONA - morphine + metocloperamide, O2 (if sats <94%), nitrates, aspirin

Question 5

What is the treatment for AF?

Answer 5

1. Anticoagulation: heparin at first, chronic with warfarin or DOAC
2. Rate control: beta blocker or rate-limiting Ca blocker. If this fails add digoxin, then consider amiodarone
3. Rhythm control: cardio version