1
Q
What does ACS include?
A
Unstable angina
NSTEMI
STEMI
2
Q
Modifiable risk factors of ACS
A
Hypertension Smoking High Cholesterol Obesity Diabetes*
3
Q
Non modifiable risk factors of ACS
A
Age
Male (gender)
Ethnicity
4
Q
What is a STEMI?
A
- ST-segment elevation myocardial infarction
- Complete occlusion of the artery by clot (rupture of atherosclerotic plaque)
- 40% of cases
5
Q
What should be immediately be assessed in people with STEMI?
A
Eligibility (irrespective of age, ethnicity or sex) for coronary
reperfusion therapy (either primary percutaneous coronary intervention [PCI]
or fibrinolysis)
6
Q
What is the first initial therapy given for STEMI?
A
300mg loading dose of aspirin as soon as possible and continue aspirin indefinitely unless contraindicated
*do not offer routine GPIs (glycoprotein inhibitors) or fibrinolytic drugs before arrival at the catheter lab if primary PCI planned
7
Q
What are the 2 types of reperfusion therapy for STEMI?
A
- Primary PCI
2. Fibrinolysis
8
Q
What are the presenting symptoms of ACS?
A
- central chest pain (radiating to shoulder, down the left arm, to the back or jaw)
- SOB
- N/V
- diaphoresis (sweating)
9
Q
What are the major signs of ACS?
A
- syncope (fainting)
- bradycardia (inferior infarction)
- tachycardia increased sympathetic activity, decreased cardiac output), other arrhythmias
- elevated or low BP
- wheezing, respiratory distress usually indicating pulmonary oedema and CHF
- jugular venous distention indicates right atrial hypertension, usually from RV infarction or elevated LV filling pressure
10
Q
What diagnosis/initial management is carried out in ACS?
A
- ECG
- troponin levels (increased in NSTEMI)
- IV opioids to relieve chest pain
- Aspirin 300mg STAT
- O2 dependent on stats
11
Q
What are the 2 enzymes that are released into the circulation when cardiac cells are damaged?
A
- creatinine kinase
- troponin
12
Q
What can be expected from troponin levels after an ACS?
A
- troponin T appears in serum within 4-12 hours after MI onset peaks 12-48 hours, and stays elevated for 7-10 days
13
Q
When should biomarker essays be done after an MI?
A
- Should be done stat on presentation, then should be redone every 4-6 hours for the first 12-24 hours, then, periodically
14
Q
What signs on an ECG can be indicative of a STEMI?
A
ST elevation
15
Q
What signs on an ECG can be indicative of an NSTEMI?
A
ST depression
T wave inversion
16
Q
What is the main priority in STEMI?
A
- to quickly re-establish blood flow to the occluded artery asap
17
Q
What is given alongside loading dose of aspirin in STEMI?
A
- p2y12 receptor antagonist e.g. ticagrelor 180mg
18
Q
When should a primary PCI be initiated?
A
- ASAP within 120 minutes if presenting in 12 hours of symptoms
19
Q
Describe the primary process of PCI
A
- Diagnostic catheter is placed and advanced through the femoral artery to the aorta and the coronary arteries
- Contrast dye is injected once the catheter is in place
- X-rays taken to locate the exact location of coronary occlusion
- a balloon catheter (with or without a stent mounted) is advanced to the blockage site, the balloon is inflated for a few seconds to open the blocked coronary
- the stents are left in place to keep coronary vessel open
20
Q
What drug therapy is offered for primary PCI?
A
- Prasugrel offered with aspirin if not already taking oral anticoagulant (offer clopidogrel in this case)
- offer unfractionated heparin with bailout GPI for radial access
- Consider bivalirudin with bailout GPI if femoral access needed
- For people aged 75 and over, think about whether risk of bleeding with
prasugrel outweighs its effectiveness ; if so offer ticagrelor or clopidogrel as
alternatives
21
Q
What should be offered if stenting indicated?
A
- If stenting indicated, offer a drug-eluting stent
- Offer complete revascularisation (consider doing this in the index
admission) if multivessel coronary artery disease and no cardiogenic shock,
but consider culprit only during the index procedure for cardiogenic shock
22
Q
When should fibrinolysis be offered and what else should be offered with it?
A
- only in STEMI
- offer if presenting in 12 hours of symptoms and PCI not possible in 120 mins
- give an antithrombin at the same time
- offer ECG 60-90 mins after fibrinolysis
- offer ticagrelor with aspirin unless high bleeding risk
- consider clopidogrel with aspirin, or aspirin alone for high bleeding risk
- offer immediate coronary angiography with follow on PCI if indicated
- do not repeat fibrinolytic therapy
23
Q
What is done after PCI/fibrinolysis in STEMI?
A
Cardiac rehabilitation and secondary prevention
24
Q
What is NSTEMI?
A
- Non ST elevation myocardial infarction
- partial obstruction
25
What initial therapy is given in NSTEMI/unstable angina?
- initial antiplatelet therapy: 300mg loading dose aspirin and continue indefinitely
- initial antithrombin therapy: offer fondaparinux unless high bleeding risk or immediate angiography. Think about choice and dose of antithrombin if high
bleeding risk (advancing age, bleeding complications, renal impairment, low body weight). Consider unfractionated heparin with dose adjusted to clotting
function if creatinine above 265 micromoles/litre
26
What should be carried out after initial therapy to assess risk in NSTEMI/unstable angina?
- Use established risk scoring system, such as GRACE, to predict 6-month mortality and risk of cardiovascular events. Include in the risk
assessment clinical history, physical examination, resting 12-lead ECG and blood tests (troponin I or T, creatinine, glucose, haemoglobin).
Balance possible benefits of treatment against bleeding risk.
27
What 2 risk categories are established after assessment in NSTEMI/unstable angina?
- low risk (predicted 6-month mortality ≤ 3%)
| - immediate or higher risk (predicted 6-month mortality > 3%)
28
What should be offered in NSTEMI/unstable angina if low risk?
- Consider conservative management without
angiography but be aware that some younger people
may benefit from early angiography
- Offer ticagrelor with aspirin unless high bleeding risk
Consider clopidogrel with aspirin, or aspirin alone, for
high bleeding risk
- Consider ischaemia testing before discharge
- Consider angiography (with follow-on PCI if indicated) if
ischaemia develops or shown on testing
29
What should be offered in NSTEMI/unstable angina if high risk?
- Offer immediate angiography if clinical condition unstable
Otherwise, consider angiography (with follow-on PCI if indicated) within 72 hours if no
contraindications such as comorbidity or active bleeding
- If no separate indication for oral anticoagulation, offer prasugrel* or ticagrelor with aspirin. If a
person has a separate indication for oral anticoagulation, offer clopidogrel with aspirin. Only give
prasugrel once PCI intended
- Offer systemic unfractionated heparin in catheter laboratory if having PCI
Offer a drug-eluting stent if stenting indicated
*For people aged 75 and over, think about whether bleeding risk with prasugrel outweighs its
effectiveness
30
What test should be done before discharge in NSTEMI/unstable angina?
- assess left ventricular function for NSTEMI
| - consider assessing for unstable angina
31
What fibrinolytic should be given due to its high specificity?
- tenectephase when possible should be given as single IV bolus for 5 seconds
32
What are the contraindications to fibrinolytics?
- any prior ICH
- known structural cerebral vascular lesion
- known malignant intracranial neoplasm
- ischaemic stroke within 3 months
- suspected aortic dissection
- active bleeding
- significant closed head or facial trauma within 3 months
- severe uncontrolled hypertension
33
When is the use of heparin appropriate for use in ACS?
-usually initiated on presentation and discontinued after PCI
34
How long should a p2y12 inhibitor be used after ACS
- 1 year minimum (can be longer)
35
What is the appropriate use of heparin in STEMI patients receiving fibrinolytics?
- LMWH or UFH should be initiated at the time of fibrinolysis and continued for a minimum of 48 hours and up to 8 days (or until revascularization)
36
What is enoxaparin?
most commonly used LMWH
37
What heparin needs to be monitored more regularly?
- LMWH needs to be monitored more often
| - UFH should be used in those that we are not sure of their dose and in renal impairment and obese
38
Should enoxaparin always be given as an IV bolus?
- NO
| - should only be given as a bolus dose in STEMI patients under 75yrs
39
When is the use of heparin indicated in patients ?
*think this is a certain type of heparin>**
- should be used in patients >149kg
| - used for those with renal impairment, CrCl <30ml/min
40
Prasugrel should not be used in what patients ?
- in those with a history of stroke of TIA due to higher rates of major bleeding in these populations
41
What therapy may be indicated in STEMI patients with low ejection fraction or if the patient has a concurrent AF?
Triple therapy (dual antiplatelet therapy + warfarin)
42
What needs to be monitored in a patient after repercussion therapy is done?
- signs and sx of ongoing chest pain, ECG changes, serial monitoring of biomarkers
- stent thrombosis
- complications: arrhythmias, HF, pericarditis
- major and minor bleeding complications
- clinical signs of bleeding: bloody stools, hematuria, hematemesis, bruising, oozing from arterial or venous puncture sites
43
What are some of the main complications associated with STEMI?
1. Heart Failure
2. Cardiogenic shock
3. Arrhythmias
4. Pericarditis
44
What is used to assess LV ejection fraction?
- echocardiography
| - intervention is required in those with LVEF <40%
45
What causes cardiogenic shock after MI?
- decreased cardiac output and evidence of tissue hypoxia in presence of adequate intravascular volume
- often due to systolic, diastolic and valvular dysfunction
- incidence 10% of hospitalized STEMI patients
46
What long term therapy should be initiated after an MI?
- aspirin indefinitely (+ dual antiplatelet therapy for 1 year)
- beta blockers (3-4 years)
- ace inhibitors (indefinitely)
- nitrates
- statins
47
What are GP IIb/IIIa inhibitors?
- they are potent anti-platelet agents
- they block the binding of fibrinogen to GP IIb/IIIa receptors on the platelet surface, therefore inhibiting platelet aggregation
- abciximab, epifibatide, tirofiban
48
What anticoagulant is the standard given?
- LMWH - long acting and has renal elimination (however this is a disadvantage)
49
What drugs should be avoided post MI?
- NSAIDS, including selective COX2 inhibitors
