ABCDE: STEMI & NSTEMI

Question 1

Classification of STEMI vs NSTEMI?

Answer 1

STEMI –> ST-segment elevation + elevated biomarkers of myocardial damage

NSTEMI –> ECG changes but no ST-segment elevation + elevated biomarkers of myocardial damage

Question 2

Initial drug therapy in all patients with ACS?

Answer 2

1) Morphine –> if in extreme pain

2) Nitrates (useful if ongoing chest pain or HTN) –> if not hypotensive

3) Aspirin 300mg

Question 3

What is the ECG criteria for a STEMI?

Answer 3

Clinical symptoms consistent with ACS (≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of:

1) 2.5 mm ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm in men over 40 years

2) 1.5 mm ST elevation in V2-3 in women

3) 1mm ST elevation in other leads

4) new LBBB

Question 4

What is next question once STEMI has been diagnosed?

Answer 4

Is PCI possible within 120 minutes of the time when fibrinolysis could have been given AND is the presentation within 12 hours of the onset of symptoms?

Question 5

If patients with STEMI are eligible for PCI, what is the next step?

Answer 5

Give additional antiplatelet (i.e. aspirin + another drug).

Question 6

What 2nd antiplatelet is given prior to PCI:

a) if the patient is not taking an oral anticoagulant

b) if taking an oral anticoagulant

Answer 6

a) prasugrel

b) clopidogrel

Question 7

What additional drug therapy is required DURING PCI?

a) patients undergoing PCI with radial access

b) patients undergoing PCI with femoral access

Answer 7

a) unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)

b) bivalirudin with bailout GPI

Question 8

What 2 other procedures should be considered during PCI?

Answer 8

1) thrombus aspiration, but not mechanical thrombus extraction, should be considered

2) complete revascularisation should be considered for patients with multivessel coronary artery disease without cardiogenic shock

Question 9

What stents are used in PCI?

Answer 9

Drug-eluting stents

Question 10

Is radial or femoral access in PCI preferred?

Answer 10

Radial

Question 11

If PCI cannot be delivered within 120 minutes in a STEMI, what is the management?

Answer 11

Fibrinolysis

Question 12

What should patients undergoing fibrinolysis be given?

Answer 12

An antithrombin drug eg. UH, LMWH, fondaparinux

Question 13

What investigation should be done following fibrinolysis in a STEMI?

Answer 13

An ECG should be repeated after 60-90 minutes to see if the ECG changes have resolved.

If patients have persistent myocardial ischaemia following fibrinolysis then PCI should be considered.

Question 14

What are 2 examples of GP IIb/IIIa inhibitors?

Answer 14

1) tirofiban

2) eptifibatide

Question 15

What is given after fibrinolysis?

Answer 15

Ticagrelor

Question 16

If an NSTEMI/unstable angina is identified, what is the next step? (aspirin 300mg has already been given)?

Answer 16

Fondaparinux

This should be given to all patients who are NOT high bleeding risk and do NOT have immediate PCI planned.

Question 17

If immediate PCI is planned in NSTEMI, what should be given?

Answer 17

UH

Question 18

In what 3 situations would fondaparinux not be given in NSTEMI treatment?

What should be given instead?

Answer 18

1) High risk of bleeding

2) Having immediate PCI

3) Creatinine >265 µmol/L

Give UH instead.

Question 19

What is the tool used for risk assessment in NSTEMI?

Answer 19

GRACE score

Question 20

What is next step after giving aspirin & fondaparinux in NSTEMI?

Answer 20

Calculate the GRACE score

Question 21

What are the 2 key GRACE scores?

Answer 21

> 3% –> high risk

≤3% –> low risk

Question 22

How does the GRACE score determine management in NSTEMI?

Answer 22

GRACE ≤3% –> conservative managemnet

GRACE >3% –> PCI

Question 23

What does the GRACE score take into account? (6)

Answer 23

1) age

2) HR, BP

3) cardiac (Killip class) and renal function (serum creatinine)

4) cardiac arrest on presentation

5) ECG findings

6) troponin levels

Question 24

Mx of patients with NSTEMI with GRACE ≤3%?

Answer 24

Conservative management –> ticagrelor or clopidogrel

Question 25

What antiplatelet is given in conservative management of NSTEMi?

Answer 25

If high risk of bleeding –> clopidogrel

If not high risk of bleeding –> ticagrelor

Question 26

Mx of patients with NSTEMI with GRACE >3%?

Answer 26

Refer for PCI.

If unstable e.g. hypotensive –> immediately

If stable –> within 72 hours

Question 27

What further drug therapy in indicated in patients with NSTEMI having PCI?

Answer 27

1) UH –> given regardless of whether the patient has had fondaparinux or not

2) Further antiplatelet (i.e. dual antiplatelet) prior to PCI:
- if taking oral anticoag –> clopidogrel
- if not taking oral anticoag –> prasugrel or ticagrelor