ACS

Question 1

What are the modifiable and non-modifiable risk factors?

Answer 1

modifiable
- smoking, dyslipidaemia, hypertension, physical inactivity, obesity, diabetes, stress

non-modifiable
- ethnicity, age, male sex, family history

Question 2

What is the difference between diagnosis of STEMI, UA and NSTEMI?

Answer 2

STEMI
- history of chest pain, nausea, vomiting and sweating
- ST elevation
- highly elevated troponin levels

UA
- angina at rest >20 minutes
- normal ECG
- normal troponin levels

NSTEMI
- angina at rest >20 minutes
- normal ECG or ST depression, T wave inversion
- slightly elevated troponin

Question 3

When is troponin released?

Answer 3

troponin is released due to myocardial necrosis
- during myocardial infarction

rises 3-8 hours after injury
peaks 12 hours after onset symptoms
may remain elevated for up to two weeks

Question 4

What is the acute treatment for ACS?

Answer 4

resuscitation as required

MONA
- morphine, oxygen, nitrate and aspirin

anti-emetic can be considered
- cyclizine, metoclopramide

Question 5

What is the immediate management for STEMI?

Answer 5

primary percutaneous coronary intervention (PCI)
- emergency repercussion to restore coronary flow and minimise myocardial injury
- must occur within 12 hours of symptoms onset and first 90 minutes of first medical contact
= stenting is preferred

• must give dual anti-platelet therapy (A/P or A/C), anticoagulants (unfractionated heparin or bivalirudin) and glycoprotein iib/iiia inhibitor (abciximab if needed)

Question 6

What is second line immediate treatment for STEMI?

Answer 6

fibrinolysis
- offer if presenting in 12 hours of symptoms and PCI is not possible in 120 mins
- give a thrombolytic/fibrinolytic (alteplase/streptokinase)
- offer dual anti-platelet therapy (A/T)

PCI can still be considered following thrombolysis

Question 7

How should NSTEMI be treated?

Answer 7

single loading dose of aspirin (300mg)
antithrombin therapy - unfractionated heparin, fondaparinux

assess individual risk of future adverse CV effects using an established risk scoring system
- GRACE or HEART score
consider PCI if needed and follow up cardiac rehabilitation and secondary prevention

Question 8

What is GRACE?

Answer 8

Global Registry of Acute Coronary Events
- scoring system which estimates 6-month mortality risk in patients with NSTEMI / UA.

Question 9

What are the types of antithrombin drugs used in ACS treatment?

Answer 9

unfractionated heparin
low molecular weight heparins (LMWH)
fondaparinux
bivalirudin

Question 10

What is the long term management for ACS?

Answer 10

dual antiplatelet therapy
- aspirin plus a second antiplatelet agent for up to one year

ACE inhibitor (or ARB)
- prevent cardiac remodelling and are nephroprotective

Beta-blocker
- decreases infarction size

Statins (or lipid reduction via other drugs)
- for plaque stabilisation (lower LDL blood level)
= also fibrates, ezetimibe, PCSK9 inhibitors (inclisiran)

gastroprotection
- PPI (lansoprazole)
- H2RA (famotidine)