Case 1 - MI

Question 1

Common CVS risk factors

Answer 1

• Smoking
• High blood pressure
• High cholesterol
• Diabetes mellitus

Question 2

Immediate management of STEMI

Answer 2

• Oxygen if needed
• Pain relief - 5-10mg IV morphine
• 300mg Aspirin
• Another antiplatelet agent - Prasugrel if PCI
• Maybe antiemetic - metoclopramide 10mg IV

Question 3

What is involved in cardiac rehab?

Answer 3

• Education about healthy living
• How to eat healthy
• Medication as prescribed advice
• Smoking cessation
• Physical activity
• Counselling to improve mental health and coping with stress

Question 4

Complications of MI

Answer 4

• Stroke
• Heart failure
• Cardiogenic shock
• Failure to re-perfuse
• Death

Question 5

Long term medications post MI

Answer 5

• ACEi - Ramipril
• Beta blocker
• Cardiac rehab
• Dual antiplatelet - aspirin and ticagrelor
• Statin - Atorvastatin

ABCDS

Question 6

Dual antiplatelet therapy options explained STEMi

Answer 6

• If having PCI - prasugrel + aspirin
• If having PCI + already taking oral anticoagulant - Clopidogrel + aspirin

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• If not having PCI and are managing medically - offer Ticagrelor and aspirin
• If not having PCI and high bleed risk - clopidogrel + aspirin or aspirin alone

Question 7

When to offer PCI or fibrinolysis?

Answer 7

• PCI if presenting within 12hrs of symptoms and can be delivered within 120 minutes
• Fibrinolysis if not possible to do PCI within 120 mins

With fibrinolysis then give aspirin + ticagrelor unless high bleed risk give clopidogrel + aspirin or aspirin alone

Question 8

NSTEMI management - initial management

Answer 8

• 300mg loading dose aspirin
• Fondaparinux unless high bleed risk or immediate angiograph
• Consider UFH instead if crt 265 micromols or more

Question 9

How to decide management of NSTEMI

Answer 9

• Use established scoring system such as GRACE to predict 6 month mortality rate and risk of CV events
• Balance benefits against treatment risk

Question 10

Management for low risk NSTEMI (mortality 3% or lower in 6 months)

Answer 10

• Consider conservative without angiography - but younger people may benefit
• Offer ticagrelor with aspirin (unless high bleed risk then clopidogrel + aspirin or aspirin alone)
• Consider ischaemia testing before discharge
• Consider angiography + PCI if ischaemia develops or shown on testing

Question 11

Management for high risk NSTEMI (predicting 6 month mortality rate is more than 3%)

Answer 11

• Immediate angiography if unstable
• If stable consider angiography + f/u PCI within 72hrs
• Offer prasugrel/ticagrelor with aspirin - if no seperate indication for anticoag
• If already indicated, give clopidogrel + aspirin
• ONLY give prasugrel once PCI intended
• UFH in cath lab