Acute Coronary Syndromes 2

Question 1

Initial drug therapy for unstable angina & NSTEMI (anti platelet & antithrombin)

Answer 1

• Aspirin ASAP (single loading dose 300mg) to all people and continue indefinitely unless contraindicated by bleeding risk/aspirin hypersensitivity
• Offer fondaparinux to people who do not have high bleeding risk unless they are undergoing immediate coronary angiography
• Consider unfractionated heparin with dose adjustmentt guided by monitoring of clotting function as an alternative to fondaparinus for people with significant renal impairment (creatinine >265 micro moles/litre)]
• Do not offer dual anti platelet therapy to people with chest pain before diagnosis of unstable angina/NSTEMI is made
• Carefully consider choice & dose of antithrombin for people who have higher risk of bleeding associated with advanced age, known bleeding complications, renal impairment, low body weight

Question 2

Risk assessment for unstable angina & NSTEMI once diagnosis has been made and aspirin and antithrombin therapy has been offered

Answer 2

• Formally assess individual risk of future adverse CV events using an established risk scoring system that predicts 6 month mortality (e.g. GRACE)
• Use risk assessment to guide clinical management and balance benefit of a treatment against any risk of related adverse events
• Use predicted 6 month mortality to categorise the risk of future adverse CV events

Question 3

What factors should you include in the formal risk assessment for risk of adverse events in unstable angina and NSTEMI

Answer 3

• full clinical history (age, PHx MI, PCI, CABG)
• physical exam (BP, HR)
• resting 12-lead ECG, looking for dynamic or unstable patterns that indicate MI
• blood tests e.g. troponin I or T, creatinine, glucose, Hb

Question 4

Predicted 6 month mortality and risk of further adverse CV events categories

Answer 4

Question 5

What do you need to offer to pt with unstable angina or NSTEMI if their clinical condition is unstable

Answer 5

• immediate coronary angiography

Question 6

When would you consider offering coronary angiography to pt with unstable anigna or NSTEMi

Answer 6

• immediate coronary angiography to pt whose clinical condition is unstable
• consider (with follow on PCI if indicated) within 72h of first admission in pt with intemriediate-oigher risk of adverse CV events (predicted 6 month mortality >3%) and no contraindications to angiography (e.g. active bleeding, comorbid)
• Consider (with follow on PCI indicated) in pt initially assessed to be at low risk of adverse events (3% or less) if ischaemia is subsequently experienced or demonstrated by ischaemia testing

Question 7

benefits and risks of early invasive treatment (coronary angiography with follow on PCI if needed) compared to conservative management for pt with unstable angina/NSTEMI

Answer 7

Question 8

anticoagulation to offer to people with unstable anigna or STEMI who are undergoing PCI

Answer 8

Offer systematic unfractionated heparin in the cardiac catheter laboratory to people whether or not they have received fondaparinux

Question 9

anticoagulation to offer to pt who are having coronary angiography

Answer 9

• prasugrel or ticagrelor (dual anti platelet therapy with aspirin)) if no separate indication for ongoing oral AC
• if using prasugrel, only give it once coronary anatomy has been defined and PCI intended
• use maintenance dose in prasgurel SoPC
• pt 75 and over think about risk of bleeding with prasugrel vs effectiveness
• give clopidogrel + aspirin dual therapy is separate indication for ongoing oral AC

Question 10

what to give is stenting is indicated to people undergoing vevascularisation by PCI

Answer 10

drug-eluding stent

Question 11

management of NSTEMI/unstable angina when PCI not indicated, including AC

Answer 11

• consider conservative management w/o early coronary angiography for pt with low risk of adverse CV events (3% or less)
• offer ticagrelor with aspirin to people when PCI not indicated unless higher bleeding risk
• consider clopidogrel + aspirin or aspirin alone for people whom PCI is not indicated for, if they have high bleeding risk

Question 12

tests before discharge

Answer 12

• consider ischaemia testing before discharge in pt who have been managed convervatively and have not had coronary angiography, to detect and quantify inductible ischaemia
• assess LV function in all pt who has NSYEMI
• consider assessing LV function in pt with unstable angina
• record measured LVF in pt care record, and in correspondence with primary HCT and the pt

Question 13

managing hyperglycaemia in patients within 48h of ACS

Answer 13

• keep BG levels below 11mmol/L, while avoiding hypoglycaemia
• in the first instance consider dose-adjusted insulin infusion with regular monitoring of BG levels
• do not routinely offer intensive insulin therapy (IV infusion of insulin + glucose w or w/o potassium) to manage hyperglycaemia in people admitted to hospital or an ACS unless clinically indicated

Question 14

Process for identifying people with hyperglycaemia after Acs who are at high risk of developing diabetes

Answer 14

offer all pt with hyperglycaemia after ACS and w/o known diabetes tests for:
- HbA1c levels before discharge
- FBGT no earlier than 4 days after onset of ACS
- these tests should not delay discharge

Do not routinely offer OGTT to people with hyperglycaemia after ACS and w/o known diabetes if HbA1c and FBG levels normal

Question 15

Advise people without known diabetes that if they have had hyperglycaemia after an ACS, they

Answer 15

• increased risk developing T2D
• see GP if experience symptoms e.g. frequent urination, excessive thirst, weight loss, fatigue
• they should be offered tests for diabetes (HbA1c or FBG) at least annually by their GP

Question 16

secondary prevention for pt who have had MI

Answer 16

• ACEi
• dual anti platelet therapy (unless separate indication for platelet therapy
• statin
• BB

Question 17

ACEI for secondary prevention - when to give & titration in hosp/out of hospital

Answer 17

• Offer to pt who present with acute MI as soon as haemodynamically stable and continue indefinitely
• titrate dose upwards at short intervals e.g. every 12-24h before pt leaves hospital until max tolerated/target dose achieved
• if it is not possible to complete titration during this time, ensure it is completed within 4-6 weeks of hosp discharge

Question 18

ACEI (or ARB) for secondary prevention: monitoring

Answer 18

• renal, serum electrolytes and BP before starting ACEi (or ARB)
• measure again within 1-2 weeks of initiation
• more freq monitoring may be required in pt at risk of deterioration in renal function
• chronic HF: once stable, monitor each month for 3 months, then at least every 6 months & when acutely unwell

Question 19

Offer an ACEi to people who have had an MI >12 months ago…

Answer 19

…and titrate dose to max tolerated/target dose over 4-6 week period and continue indefinitely
- if intolerant to ACEI, give ARB instead

Question 20

anti platelet therapy secondary prevention after MI

Answer 20

• offer to all pt after MI to continue indefinitely unless intolerant or if they have an indication for anticoagulation
• offer to all people who have had an MI >12 months ago and continue indefinitely
• consider dual anti platelet therapy for up to 12 months after MI unless contraindicated
• aspirin hypersensitive and MI: consider clopidogrel monotherapy

Question 21

When to offer clopidogrel and MR dipyridamole instead of aspirin

Answer 21

• clopidogrel monotherapy instead of aspirin if allergy
• clopidogrel instead of aspirin to pt who also have other clinical vascular disease
• MR dipyridamole for prevention of occlusive vascular events and who have had MI and stopped anti platelet therapy / or have had MI >12 months ago

Question 22

Beta blockers as secondary prevention after MI

Answer 22

• offer ASAP after MI when pt is haemodynamically stable
• titrate BB up to max tolerated or target dose

Question 23

BB as secondary prevention after MI - pt with reduced LVEF vs people without reduced LVEF

Answer 23

• consider continuing for up to 12 months after MI for people without reduced LVEF
• discuss potential benefits and risks of stopping or continuing BB beyond 12 months after an MI for people without reduced LVEF
• there is lack of evidence on relative benefits and harms of continuing beyond 12 months, and some pt experience adverse effects
• do not offer in pt without reduced LVEF of HF who have had an MI >12 months ago unless there is additional clinical indication for a BB
• continue indefinitely in people with reduced LVEF
• offer all pt who have had MI >12 months ago who have reduced LVEF whether or not they have symptoms

Question 24

Use of CCBs after MI

Answer 24

• do not routinely offer CCBs to reduce CV risk after MI
• if BBs contraindicated or need to be discontinued, consider RL-CCBs instead in people without pulmonary congestion or reduced LVEF
• for people whose condition is stable after an MI, CCBs can be used to treat hypertension and/or angina
• for people with HF and REF, amlodipine is the only CCB that can be used!! avoid all others

Question 25

Aldosterone antagonists in pt with HF and reduced LVEF and monitoring

Answer 25

• start an AA that is licensed for post-MI treatment (eplerenone) within 3-14 days of the MI, pref after ACEi therapy
• Start it in pt who have had acute MI and how have symptoms/signs of HF and reduced LVEF
• pt who have recently had acute MI and have clinical HF with reduced LVEF and are already being treated with AA for a concomitant condition (e.g. chronic HF), should continue with the AA or an alternative licensed for early post-MI treatment
• monitor renal function and serum potassium before and during treatment
• if hyperkalaemia is a problem, half dose of AA or stop drug