ACS management

Question 1

Initial management of ACS?

Answer 1

MONA

Morphine or diamorphine 5-10mg slow IV with anti-emetic

Oxygen, but only to avoid hypoxia

Nitrates. Sublingual GTN, IV GTN if ineffective.

Anti-platelets. 300mg aspirin STAT. Clopi 300 second line.

Question 2

Secondary prevention following ACS in ALL patients, regardless of outcome?

Answer 2

The MI-5

Aspirin
Clopidogrel
ACEi
Beta-blocker
Statin

Question 3

MOA of aspirin?

Answer 3

Irreversible COX1 and COX2 inhibitor = decreased formation of thromboxane A therefore inhibiting platelet aggregation

Question 4

Dose of aspirin following ACS?

Answer 4

75mg OD in ALL patients while considering GI risk and comorbidities

Question 5

AEs of aspirin?

Answer 5

GI irritation (+ haemorrhage)
Bronchospasm

Question 6

Contraindications for aspirin?

Answer 6

Hypersensitivity
Active peptic ulcer
Haemophilia and other bleeding disorders

Question 7

Interactions of aspirin?

Answer 7

Drugs which increase GI bleed risk

AntiPLTs, AntiCOAGs, SSRIs, NSAIDs, prednisolone, nicorandil

Question 8

Clopidogrel MOA

Answer 8

Pro-drug, converted to active metabolite by CYP enzymes

Irreversible blockade of P2Y12 components of adenosine receptors ON PLATELET SURFACE

Question 9

Indications for clopidogrel?

Answer 9

1. NSTEMI: dual therapy with aspirin for 12 months, then LDA after
2. STEMI: dual therapy for 1 month then LDA after
3. BARE METAL STENT: dual therapy with aspirin for 1 month then LDA
4. DRUG ELUTING STENT: dual therapy with aspirin for 12 months then LDA
5. UNABLE TO TOLERATE ASPIRIN - monotherapy

Question 10

AEs of clopi?

Answer 10

GI irritation

Question 11

COntraindications of clopi?

Answer 11

Active bleeding

Question 12

Interactions of clopi?

Answer 12

Other drugs which increase risk (NSAIDs, prednisolone, antiPLTs, antiCOAGs, nicorandil, SSRIs)

FLUOXETINE - reduces antiPLT effect

Enzyme inducers - reduce antiPLT effect

Question 13

Which drugs should clopi not be prescribed with?

Answer 13

Fluoxetine

Enzyme inducers:

• Carbamazepine
• Fluconazole
• PPIs (omerazole)

All reduce anti PLT effect

Question 14

Which anti PLT shouldnt be prescribed w/ fluoxetine?

Answer 14

Clopi

Question 15

Prasugrel MOA?

Answer 15

Similar to clopi…. P2Y12 component of adenosine receptor on platelet blockade = reduced aggregation

Question 16

Indications of prasu?

Answer 16

Combination with aspirin post-PCI for 12 months in STEMI patients

Stent rethrombosis after clopidogrel

Question 17

AEs of prasu

Answer 17

Haemorrhage (GI and intracranial)

Question 18

Contraindications for prasu

Answer 18

Active bleeding
Stroke / TIA hx
Reduce dose in elderly

Question 19

Interactions of prasu

Answer 19

Drugs which increase bleeding

Question 20

Ticagrelor MOA

Answer 20

Reversibly and non compeittive inhibition of P2Y12 component of adenosine receptor on platelets - reduces aggregation

Question 21

Indications of ticagrelor

Answer 21

Combo with aspirin in ACS for 12 months

Question 22

AEs of ticagreol

Answer 22

Haemorrhage

SOB

Question 23

Contraindicationsof ticagreol

Answer 23

Active bleeding

Hx of ICH

Question 24

Interactions of ticagrelor

Answer 24

Other drugs which increase bleeding

Clarithromycin, simvastatin, digoxin - increases plasma concentration

Question 25

ACEi MOA

Answer 25

Inhibits ACE = less ATII 1. inhibition of arteriolar vasoconstriction 2. Inhibiton of aldosterone = less Na+/H2O retention

Question 26

AEs of ACEi

Answer 26

``` Drug cough Hyperkalaemia Renal impairment Hypotension Angioedema Hepatic impairment ```

Question 27

ACEi indications

Answer 27

ALL patients post MI | Low dose then titrate

Question 28

Contraindications to ACEi

Answer 28

Hypersensitivity Caution w/ renal impairment - monitor function during initiation and titration Severe aortic stenosis Bilateral renal artery stenosis

Question 29

Interactionsof ACEi

Answer 29

Diuretics - cause v rapid fall in BP in volume depleted patients Nephrotoxic drugs

Question 30

ATII receptor blockers (ARBS) MOA

Answer 30

Antagonist of ATII receptors - reduces vasoconstriction and aldosterone release Doesnt cause accumulation of bradykinin so no dry cough as in ACEi

Question 31

Indicationsof ARBs

Answer 31

ACEi intolerance e.g. dry cough

Question 32

AEs of ARBs

Answer 32

Hypotension Hyperkalaemia Renal impairment Angioedema

Question 33

Cautions of ARBs

Answer 33

Renal artery stenosis | Renal impariment

Question 34

Interactions of ARBs

Answer 34

Diuretics ACEi

Question 35

Which is the shorter acting BB?

Answer 35

Metoprolol