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pre reg afsha > Acute Coronary Syndromes 1 > Flashcards

Acute Coronary Syndromes 1 Flashcards

Define ACS, STEMI, NSTEMI & unstable angina. Initial mangement & management of STEMI

1
Q

What is ACS?

A

Spectrum of conditions which includes STEMI, NSTEMI and unstable angina

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2
Q

What does ACS result from?

A

ACS (e.g. STEMI, NSTEMI, unstable angina) result from formation of a thrombus on atheromatous plaque in a coronary artery

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3
Q

Definitive diagnosis of ACS is based on the following 3 things

A

ECG changes
Clinical presentation
Measurement of biochemical cardiac markers

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4
Q

What is a STEMI usually caused by

A

Complete and persistent blockage of coronary artery resulting in myocardial necrosis with ST-segment elevation seen on ECG

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5
Q

What is NSTEMI caused by

A

Partial or intermittent blockage of artery, which usually results in myocardial necrosis
ECG may show ST-segment depression, T-wave inversion, or may be normal

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6
Q

What is unstable angina caused by

A

Partial or intermittent blockage of artery which does not result in myocardial necrosis
ECG may show ST-segment depression, T-wave inversion, or may be normal

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7
Q

How would you differentiate between NSTEMI and unstable angina?

A

The partial or intermittent blockage of the coronary artery usually results in myocardial necrosis in NSTEMI, not in unstable angina
A high-sensitivity blood test for serum troponin

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8
Q

Troponin as a differentiation test for NSTEMI and unstable angina

A
  • High sensitivity blood test for serum troponin are used to differentiate these
  • Troponin elevated in NSTEMI due to the myocardial necrosis, but is normal in unstable angina
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9
Q

What are the non drug treatment options available following an ACS

A
  • Revascularisation procedures e.g. percutaneous coronary intervention (PCI) or coronary arrest bypass graft (CABG)
  • These help restore blood flow when it is limited or blocked
  • These are often appropriate alongside drug treatment for pt with ACS
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10
Q

Initial management - pain relief in ACS

A

ASAP: GTN (sublingual or buccal)
IV opioids e.g. morphine may be administered, esp if acute MI is suspected

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11
Q

Aims of initial management of ACS

A
  • Provide supportive care & pain relief & prevent progression of cardiac injury
  • Start as soon as ACS suspected, but treatment should not delay transfer to hospital
  • Pain relief: GTN (sl or buccal), IV opioids esp if acute MI
  • Loading dose of aspirin ASAP (if given before arrival at hospital, a note saying it has been given should be sent with pt)
  • Only offer other anti platelets once in hospital according to their diagnosis and RF
  • Do not routinely administer oxygen but monitor pt oxygen saturation (ideally before admission) and offer supplemental oxygen is indicated
  • Monitor all pt admitted in hospital for hyperglycaemia (if BG>11mol/L, give insulin)
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12
Q

Aims of management of STEMI

A

Restore adequate coronary blood flow ASAP and reduce mortality

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13
Q

Management of STEMI - reperfusion therapy

A
  • Immediately assess eligibility (irrespective of age, ethnicity or sex) for coronary reperfusion therapy
  • Deliver coronary reperfusion therapy (primary PCI or fibrinolysis) ASAP in eligible patients
  • Do not use level of consciousness after cardiac arrest caused by suspected acute STEMi to determine whether pt is eligible for coronary angiography (with follow on PCI if indicated)
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14
Q

What is coronary angiography

A
  • Performed to detect obstruction in coronary arteries
  • Uses a special dye (contrast material) and x-rays to see how blood flows through the arteries in your heart
  • If blocked, follow up PCI may be indicated to help restore blood flow
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15
Q

Initial drug therapy in acute STEMI

A
  • Single loading dose of 300mg aspirin ASAP unless evidence of allergy
  • Do NOT offer routine glycoprotein IIb/IIIa inhibitors or fibrinolytic drugs before arrival at catheter lab to pt with acute STEMI who have primary PCI planned
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16
Q

What is the preferred coronary reperfusion strategy for people with acute STEMI and when should it be performed

A
  • Coronary angiography with follow on primary PCI
  • Preferred strategy for people with acute STEMI if:
    • presentation within 12 hours of symptom onset
    • primary PCI can be delivered within 120 mins of the time when fibrinolysis could have been given
17
Q

When would you offer coronary angiography with follow on PCI

A
  • Acute STEMI & cardiogenic shock who present within 12 hours of onset of symptoms of STEMI
  • Acute STEMI presenting more than 12 hours after onset of symptoms if there is evidence of continuing MI
18
Q

Site of arterial access for people undergoing coronary angiography

A

Consider radial in preference to femoral artery

19
Q

Dual anti platelet therapy for people with acute STEMI having primary PCI

A

Aspirin + prasugrel/ticagrelor/clopidogrel
- Choice of second anti platelet depends on planned intervention (primary PCI, fibrinolysis, conservative management) and pt bleeding risk
- Prasugrel is preferred for most pt undergoing primary PCI unless bleeding risk outweighs effectiveness
- If pt already taking oral AC, give aspirin + clopidogthrl
- Aspirin alone may be appropriate for some pt with high bleeding risk not undergoing PCI

20
Q

Prasugrel dose and considerations

A
  • Initially 60mg for one dose, then maintenance is either 5mg or 10mg daily for usually up to 12 months depending on weight and age
  • 75 and over or body weight under 60kg: 5mg daily
  • Body weight over 60kg: 10mg daily
  • In 75 and over, think about whether the bleeding risk outweighs its effectiveness
21
Q

Antithrombin therapy during primary PCI for STEMI

A

For pt undergoing primary PCI with radial access: unfractionated heparin + bailout glycoprotein IIb/IIIa inhibitor in combination with dual anti platelet therapy
Femoral access: bivalirudin (unlicensed) + bailout glycoprotein IIb/IIIa inhibitor in combination with dual anti platelet therapy

22
Q

Thrombus extraction during primary PCI

A

Consider thrombus aspiration during primary PCI for people with acute STEMI
Do not routinely use mechanic thumbs extraction during primary PCI for people with acute STEMI

23
Q

When to offer complete or culprit vessel only revascularisation with PCI in people with acute STEMI treated by primary PCI

A
  • Offer complete revascularisation with PCI for pt with acute STEMI & multi -vessel coronary artery disease w/o cariogenic shock
  • Consider culprit vessel only revascularisation with PCI during index procedure for people with acute STEMI and multi vessel coronary artery disease WITH cardiogenic shock
  • Consider doing these during index hospital admission
24
Q

Drug eluding stents in primary PCI

A

If stunting is indicated, offer a drug-eluding one to people with acute STEMI undergoing revascularisation by primary PCI

25
Q

Fibrinolysis - what is it and when should you offer it

A

-Fibrinolysis is the process by which fibrin in blood clots is removed enzymatically
- Offer this to patients with acute STEMI presenting within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 mins of the time when fibrinolysis could be given
- Also give antithrombin at the same time

26
Q

Fibrinolysis & ECG

A
  • Offer ECG 60-90 mins after administration of fibrinolysis after STEMI
  • If pt has residual ST-segment elevation suggesting failed coronary repercussion, DO NOT repeat fibrinolytic therapy
  • Offer immediate coronary angiography with follow on PCI if indicated
27
Q

What to do if a patient with acute STEMI has recurrent MI after fibrinolysis

A

Seek immediate specialist cardiological advice and, if appropriate, offer coronary angiography, with follow-on PCI if indicated

28
Q

What to consider for pt with acute STEMI who are clinically stable after successful fibrinolysis

A

Consider coronary angiography during the same hospital admission

29
Q

How to manage patients with STEMI who were not treated with PCI

A
  • Ticagrelor + aspirin (dual antiplatlet therapy) unless high bleeding risk
  • Consider clopidogrel as part of dual anti platelet therapy, or aspirin alone, for pt who have high bleeding risk
  • Offer medical management top people with acute STEMI who are ineligible for any repercussion therapy
30
Q

Tests before discharge for all patients who have had STEMI

A

Assess LV function

pre reg afsha (60 decks)

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