ACS

Question 1

What are Acute
Coronary Syndromes (ACS)?

Answer 1

• Unstable Angina
• NSTEMI (“Heart attack)
• STEMI (“Serious Heart attack”)

Question 2

What is the difference between stable angina and UNSTABLE angina?

Answer 2

• Both occur as a result of restricted blood flow to the heart
• Stable angina occurs due to physical activity/exertion
• Whilst in UNSTABLE angina, symptoms occur at rest or during very little activity

Question 3

NSTEMI

Answer 3

• Non ST segment elevation MI
• ST segment is not elevated on ECG
• Partial blockage

Question 4

Difference between NSTEMI and unstable angina

Answer 4

• Unstable = partial block which can = NSTEMI/STEMI. But heart muscles are preserved
• NSTEMI = some cardiac necrosis (heart damaged)
• STEMI = more cardiac necrosis

Question 5

A partial block of the coronary artery is…

Answer 5

NSTEMI OR Unstable angina

Question 6

STEMI

Answer 6

• Complete blockage of artery
• ST zone of ECG is elevated

Question 7

Complications

Answer 7

1. Arrythmias
2. HF

Question 8

Diagnosis

Answer 8

• Full clinical history
• Physical examination e.g. BP and HR
• ECG (12-lead)
• Blood tests (including Troponin I and T)
  MAIN ONE!
• Creatinine

Question 9

Troponin

Answer 9

• Protein found in heart muscles
• When damage occurs, it is released into the blood treat
• High levels of troponin = NSTEMI/STEMI

Question 10

What are the steps involved in the initial
management of
NSTEMI and UA?

Answer 10

1. Pain relief: GTN +/- IV morphine
2. Aspirin 300mg loading dose
3. fondaparinux sodium
   - if bleeding risk is NOT high
   and
   - NOT undergoing immediate coronary angiography
4. Monitor for
   Hyperglycaemia
   - Give insulin if necessary
5. Oxygen
   - Only if hypoxia is suspected

Question 11

Which drugs are given to manage pain in the initial management of
NSTEMI and Unstable angina?

Answer 11

1. GTN
2. IV Morphine

Question 12

What if the patient has already administered an aspirin 300mg
loading dose before admission to the hospital?

Answer 12

Inform medical team

Question 13

Why is fondaparinux sodium administered to patients with
NSTEMI or UA in the initial management?

Answer 13

• anti-thrombin
• NSTEMI and UA occur as a result of thrombus restricting blood flow to the heart
• prevents thrombus formation

Question 14

What is an alternative to fondaparinux
sodium if patients have renal impairment?

Answer 14

Heparin (unfractionated)

Question 15

What are the revascularisation procedures used in
NSTEMI and UA?

Answer 15

1. PCI
2. CABG

Question 16

PCI

Answer 16

Percutaneous coronary intervention
- coronary angioplasty (baloon that inflates to expand blood vessels and stents)
- minimally invasive procedure

Question 17

CABG

Answer 17

Coronary artery bypass graft (CABG)
- Taking blood vessels from other parts of the body
- These new blood vessels (graft) are used to deliver blood to the heart and bypasses the blocked or narrowed arteries

Question 18

If patient is undergoing a PCI, which anticoagulant should be administered to them?
Does it matter if they have already received anti-thrombin treatment
e.g. fondaparinux?

Answer 18

• Patients undergoing PCI should be administered
  Heparin (unfractionated)
• Regardless of whether or not they have received fondaparinux

Question 19

Dual-antiplatelet therapy

Answer 19

Following diagnosis, initial management and whether or not revascularisation procedures are given, patients will need a second antiplatelet in addition to aspirin
- Prasugrel
- Ticagrelor
- Clopidogrel

Question 20

In summary, when is Prasugrel offered as a second anti-platelet?

Answer 20

ONLY when PCI is indicated!!
P for PCI and Prasugrel

Question 21

What if patient has a high bleeding risk, can they take dual-antiplatelet therapy?

Answer 21

Patients can take Aspirin as monotherapy (no dual anti-platelet therapy)

Question 22

What if patients cannot take Aspirin due to hypersensitivity,
which anti-platelet can you offer?

Answer 22

• Clopidogrel monotherapy

Question 23

How long is dual-antiplatelet therapy given for?

Answer 23

• Dual antiplatelet given for 12 months
• Aspirin should be taken for life

Question 24

What is the dose of Aspirin in ACS?

Answer 24

• On symptom onset (during
  initial management) = 300mg
  loading dose
• Secondary prevention of CVD
  = 75mg OD

Question 25

Which oral anticoagulant may be considered in combination with anti-platelets for the prevention atherothro mbotic events following ACS?

Answer 25

- Rivaroxaban 2.5mg BD - Taken in combination with Aspirin AND Clopidogrel (or in combination with Aspirin alone)

Question 26

In summary, if patient is already taking an anti-coagulant for another condition, which anti-platelet do you offer in combination with Aspirin?

Answer 26

Clopidogrel DO NOT OFFER TICAGRELOR OR PRASUGREL IF PATIENT IS TAKING ORAL ANTICOAGULANT

Question 27

What should be performed IMMEDIATELY following a STEMI?

Answer 27

1. PCI (PREFERRED) or 2. Fibrinolysis - Via fibrinolytic drugs e.g. Streptokinase

Question 28

How do you determine whether to give PCI or fibrinolysis for reperfusion treatment following STEMI?

Answer 28

- PCl is most preferred method and should be offered within 120 minutes if presented to hospital within 12 hours of symptom onset - Offer Fibrinolysis if PCI cannot be offered within 120 minutes if presented to hospital within 12 hours of symptom onset

Question 29

Patients should also recieve dual-antiplatelet therapy following STEMI, which antiplatelet do you offer in addition to aspirin?

Answer 29

PCI - P + A or T + A Fibrinolysis - T + A or C+A

Question 30

What are the long-term treatments for secondary prevention of CVD following ACS?

Answer 30

1. Dual anti-platelet therapy - for 12 months 2. ACE-Inhibitors - ARB if ACE intolerated 3. Beta-Blocker - May be discontinued after 12m in pt w/o LVEF 4. Statins - ato 80mg