What is the initial treatment for acute coronary syndrome with ST elevation?
ROMANCE
Reassure
Oxygen - if sats <95% or breathless or acute LVF
Morphine - 5-10mg IV repeat after 5 mins if necessary
Aspirin 300mg PO
Nitrates - if patient Is hypertensive or in acute LVF
Clopidogrel 300mg (not used anymore)
Enoxaparin - 2.5mg (not preferred)
Aim is to PCI within 120 mins
What should be given with the first dose of morphine in acute coronary syndrome?
Anti-emetic
1st line - 10mg metoclopramide
2nd line 50mg cyclizine
What is now recommended ahead of the use of clopidogrel?
Ticagrelor 180mg
Prasugrel 60mg - if no history of stroke/TIA and <75yo
What is the preferred anticoagulation to use in acute coronary syndrome?
Bivalirudin
How is right ventricular infarction confirmed?
ST elevation in rV3/V4 and or shown on Echo
rV3/V4 is where pad is placed on right 5th intercostal space, mid clavicular line
How is a right ventricular infarct managed?
Treat hypotension and oliguria with fluids
Avoid nitrates and diuretics
Assess for early signs of pulmonary oedema
May req. inotropes and intensive monitoring
What is the ECG criteria for diagnosing a STEMI?
ST elevation >1mm in 2+ adjacent limb leads or >2mm in 2+ adjacent chest leads
New found LBBB
Posterior changes - deep ST depression and tall R waves in v1-3
When is primary PCI (primary percutaneous intervention) offered?
Within 12 hours of symptom onset
What should be done if a patient can’t be offered primary percutaneous intervention (PCI) within 120 mins?
Thrombolysis and transfer to primary PCI centre ideally before 12 hours
When should you aim to thrombolyse a patient with a ?STEMI by?
Within 30 mins of admission
Use >12 hrs post symptom onset req. specialist advice
When should you not thrombolyse a patient with ?ACS?
ST Depression alone
T wave inversion alone
Normal ECG
How do you thrombolyse patients with ?ACS?
Tissue plasminogen activators - tenecteplase
Give some contraindications for thrombolysis in ?ACS?
Previous intracranial haemorrhage
Ischaemic stroke <6 months
Cerebral malignancy or AV malformation
Recent major trauma/surgery/head injury (<3 wk)
GI bleed <1month
Known bleeding disorder
Aortic dissection
Non-compressible punctures <24hr - liver biopsy/lumbar puncture
What are the relative contraindications for thrombolysis in ?ACS?
TIA <6months Anticoag therapy Pregnancy or <1wk post partum Refractory hypertension (>180/110) Advanced liver disease Infective endocarditis Active peptic ulcer Prolonged/traumatic resuscitation
How should patients with STEMI who do not receive repercussion managed?
Fondaparinux
Enoxaparin/unfractionated heparin if not available
What things in the history may indicate a diagnosis of acute coronary syndrome (NSTEMI)?
Previous angina
Relief with rest or nitrates
History of CVS disease
Risk factors for IHD
What is the aim of management of an NSTEMI?
Control pain
Initiate anti-ischaemic and antiplatelet therapy
What oral anti-platelet therapy is initiated for an NSTEMI?
Aspirin 300mg PO followed by 75mg OD
If confirmed ACS - give second antiplatelet:
- clopidogrel 300mg PO then 75mg OD
- ticagrelor 180mg PO then 90mg BD (preferred)
- Prasugrel 60mg PO then 10mg OD - if undergoing PCI
What anticoagulation is indicated in a patient with a ?NSTEMI?
Fondaparinux 2.5mg OD
If unavailable then LMWH (enoxaparin 1mg/kg/12h) or unfractionated heparin (aim for APTT 50-70s) until discharge
What other medications are offered for a patient with an NSTEMI?
Beta blockers (if no CI)
Nitrates - recurrent chest pain
ACE inhibitors - unless CI
Statins - atorvastatin 80mg OD
When should you not use beta blockers in NSTEMI management?
With verapamil as it can precipitate asystole
What is the prognosis for an NSTEMI?
~1-2% risk of death
~15% risk of refractory angina
How is risk stratified in patients post NSTEMI?
GRACE score
Which factors are associated with a high risk post NSTEMI?
History of unstable angina
ST depression or widespread t wave inversion
Raised troponin (except patients with STEMI)
Age >70yo
General co-morbidities - previous MI, poor LV function, diabetes
