treatment algorithms

Question 1

Stable angina

Answer 1

immediate symptomatic relief: sublingual GTN

long-term symptomatic relief: beta blocker OR calcium channel blocker
(if beta blocker AND CCB used together, dihydropyridine CCB to be used e.g. amlodipine or nifedipine). If CCB monotherapy, verapamil

secondary prevention:
- aspirin 75mg
- statin 80mg
- ACE inhibitor (if CKD, DM, or HTN)
- already on beta blocker

surgical intervention:
- PCI
- CABG

Question 2

STEMI management

Answer 2

conservative:
- sit patient up

immediate medical:

• morphine (diamorphine IV or oramorph + antiemetic + laxative)
• O2 if hypoxic
• sublingual GTN
• aspirin 300mg
• beta blocker if not bradycardic and in HF

assess eligibility for reperfusion therapy (presenting within 12 hours of symptoms & PCI available within 120 minutes?)

presenting within 12 hours AND PCI available in 120 minutes (do consider if presenting mroe than 12 hours and continuing MI or cardiogenic shock) -> angiography & PCI

if NOT already on an anticoagulant: prasugrel + aspirin
if ALREADY on an anticoagulant: clopidogrel + aspirin

radial access: unfractionated heparin + bailout GPI
femoral access: bivalirudin + bailout GPI

if NOT eligble for reperfusion therapy:

low bleeding risk: ticagrelor + aspirin
high bleeding risk: clopidogrel + aspirin

Question 3

NSTEMI management

Answer 3

conservative:
- sit patient up

immediate medical:

• morphine (diamorphine IV or oramorph + antiemetic + laxative)
• O2 if hypoxic
• sublingual GTN
• aspirin 300mg
• beta blocker if not bradycardic and in HF
• fondaparinux (unless high bleeding risk of immediate angiography)
  -> if creatinine > 265, consider unfractionated heparin

calculate GRACE score

if <3%:
consider conservative management without angiography but aware younger people may benefit from early angiography

if > 3%:
- unstable => immediate angiography
- stable => angiography + follow on PCI in 72 hours (if having PCI, offer systemic unfractionated heparin)

if no separate indication for oral anticoagulation, prasugrel + aspirin

if separate indication for oral anticoagulation, clopidogrel + aspirin