management of ACS
- morphine 5-10 mg iv
- consider antiemetic metoclopramide 10 mg iv or cyclizine 50 mg iv
- oxygen - only if patients have a SpO2 < 95%
- Nitrates - only use for HTN or LVF
- Dual anti-platelet: Aspirin - 300 mg po/iv
- prasugrel 60mg po/ticagrelor 180mg po/clopidogrel 300 mg po
- Restore perfusion - PCI or thrmobolysis..
- anticoagulation for PCI - injectable (pref bivalirudin, otherwise enoxaparin and Gp IIb/IIIa blocker
- beta-blockers (bisoprolol 2.5 mg od) - CIs: heart failure, asthma, bradycardia, cardiogenic shock
what is the evidence for restricting oxygen to patients with SpO2 < 95%?
DETO2X-AMI, a SWEDEHEART study
NEJM 2017
no statistical significance between 6 L/min supplimental O2 or ambient air inhalation in composite clinical end points, biochemically and at 1-year follow up
what is the evidence for ticagrelor versus clopidogrel?
PLATO study, sponsored by AstraZenica.
Pub: Sept 2009, NEJM
also NICE guidance from 2011
ticagrelor has a shorter onset of action and more robust anti-platelet effect than clopidogrel
follow up was at 1 year
vascular composite end-points (stroke and MI) were greater with clopidogrel than ticagrelor
ticagrelor > clopidogrel for all-cause mortality
ticagrelor has a greater bleeding risk than clopidogrel
management algorithm for restoring perfusion in STEMI?
confirm STEMI on ECG
- PCI available within 120 mins, presenting within 12 hours of symptom onset
- primary PCI, needs anticoagulation - bivalirudin IM
- PCI not available within 120 mins
- thrombolysis (tenecteplase iv bolus)
- transfer to specialist care centre for residual PCI or angiography +/- stenting
- presenting to medical services >12 hours from symptom onset?
- fondaparinux
what are the ECG diagnostic criteria for STEMI?
- ST segment elevation:
- >1 mm in 2 consecutive limb leads
- >2mm in 2 consecutive chest leads
- new onset LBBB
- posterior changes: deep ST segment depression and tall R waves in V1-V3
what clinical calculator would be suitable to assess 6-month mortality risk in patients with ACS?
GRACE
what are the indications for admission in NSTEMI ACS?
rise in troponin
dynamic ST or T-wave changes
secondary criteria: LVEF <40%, prev CABG, prev PCI, early angina post-MI, diabetes, CKD
intermediate- or high-risk GRACE score
which ACS patients are you happy to discharge?
- no recurrence of chest pain
- no changes on ECG
- normal range cardiac enzymes (1st test)
- check with biochem when the patient should have their second Troponin taken, can they come back for it? do they just have to wait until the result?
- no signs of heart failure
what is the anticoagulation method for NSTEMI?
fondaparinux (direct factor Xa inhibitor) 2.5 mg OD
if not, then LMWH (enoxaparin 1 mg/kg/12hrs)
beta-blocker SHOULD NOT be used with another cardiac drug… ?
verapamil - precipitates asystole
beta-blockers CI?
asthma/COPD
heart failure
heart block/brady
cardiogenic shock
what is the role of nitrates in management of ACS?
only for pain relief - recurrent following MI
or chronic pain management with stable angina
on discharge following ACS, what other medicines should be offered?
ACE-I to prevent cardiac remodelling and control BP
statins
dual anti-platelet
beta-blockers (if CI, use cardioselective CCB diltiazem or verapamil)
what are the causes of ARDS?
trauma
burns
sepsis/malaria
pancreatitis
post-op
aspirin overdose
glue sniffing / drug abuse
what are the causes of pulmonary oedema?
LVF, valvular disease, malignant hypertension, arrythmia
ARDS
fluid overload
neurogenic (head injury)
investigations for pulmonary oedema
CXR ECG ABG
bloods - U&E, toponin, BNP
further tests - echocardiogram
managing pulmonary oedema
1st line
- diamorphine 1.25-5 mg iv slowly
- care in liver failure
- furosemide 40-80 mg iv slowly
- dose adjustment in renal failur
- GTN 2 sprays SL, or 2 x 0.3 mg SL tablets
- avoid if SBP <90 mmHg
- convert to ISDN 2-10 mg/hr infusion if SBP >100 mmHg
added therapies for pulmonary oedema not getting better with 1st line?
CPAP
further furosemide
further nitrate infusion
first steps for cardiogenic shock…
call for help! - difficult to treat and has a high mortality
oxygen, sats aiming 94-98%
diamorphine 1.25-5 mg
investigate U&E, arrythmias and acid-base disturbance
(bloods, ABG, ECG)
what is the difference between a ventricular ectopic and a run of VT?
>3 together at a rate of >100 bpm is a VT
how many small squares for a QRS complex to be called ‘broad’?
3 small squares (120 ms)
ventricular fibrilation
ventricular tachycardia
torsade de pointes
