ACS & Stroke

Question 1

What are the two main types of revascularisation procedures used in ACS management?

Answer 1

Percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG).

Question 2

What factors influence the choice between PCI and CABG in ACS management?

Answer 2

Type of ACS, time since symptom onset, clinical condition, comorbidities, and formally assessed cardiovascular risk.

Question 3

What analgesic should be administered first in suspected ACS?

Answer 3

Glyceryl trinitrate (sublingual or buccal).

Question 4

When are intravenous opioids such as morphine indicated in ACS?

Answer 4

When an acute myocardial infarction (MI) is suspected and pain persists.

Question 5

What antiplatelet should be administered as early as possible in suspected ACS?

Answer 5

A loading dose of aspirin.

Question 6

When should antiplatelet agents other than aspirin be administered in ACS?

Answer 6

After hospital admission, based on diagnosis and risk factors.

Question 7

When should supplemental oxygen be administered to a patient with suspected ACS?

Answer 7

Only if oxygen saturation is low; it is not recommended routinely.

Question 8

What is the glucose threshold for initiating insulin in ACS patients?

Answer 8

Blood glucose >11.0 mmol/L.

Question 9

What is the preferred method of reperfusion for most STEMI patients?

Answer 9

Primary PCI if performed within 12 hours of symptom onset and within 120 minutes of possible fibrinolysis.

Question 10

What reperfusion option is used if PCI is not available within the recommended timeframe in STEMI?

Answer 10

Fibrinolysis.

Question 11

What antiplatelets are used in combination with aspirin in STEMI?

Answer 11

Prasugrel, ticagrelor, or clopidogrel depending on the strategy and bleeding risk.

Question 12

When is prasugrel preferred in STEMI management ?

Answer 12

For most patients undergoing primary PCI, unless bleeding risk outweighs benefits.

Question 13

What antithrombin is recommended with radial-access PCI in STEMI?

Answer 13

Unfractionated heparin.

Question 14

What antithrombin is considered with femoral-access PCI in STEMI?

Answer 14

Bivalirudin [unlicensed].

Question 15

What antithrombin should be given with fibrinolysis in STEMI?

Answer 15

An antithrombin agent such as enoxaparin or unfractionated heparin.

Question 16

When might a glycoprotein IIb/IIIa inhibitor be used during PCI in STEMI?

Answer 16

As a bailout option if needed during the procedure.

Question 17

Which second antiplatelet agents may be used in NSTEMI/UA?

Answer 17

Prasugrel, ticagrelor, or clopidogrel.

Question 18

When might aspirin monotherapy be used in NSTEMI/UA?

Answer 18

In patients with a high bleeding risk.

Question 19

What antithrombin is preferred unless urgent angiography is required in NSTEMI?

Answer 19

Fondaparinux sodium

Question 20

What four classes of medications are routinely used for secondary prevention post-ACS?

Answer 20

ACE inhibitors, beta-blockers, dual antiplatelet therapy, and statins.

Question 21

When should ACE inhibitors be initiated post-ACS?

Answer 21

Once the patient is haemodynamically stable.

Question 22

What should be used if a patient cannot tolerate ACE inhibitors?

Answer 22

Angiotensin II receptor blockers (ARBs).

Question 23

How long should beta-blockers be continued in patients with reduced LVEF?

Answer 23

Indefinitely.

Question 24

How long should dual antiplatelet therapy be continued after ACS?

Answer 24

Up to 12 months unless contraindicated.

Question 25

What can be offered to aspirin-allergic patients post-ACS?

Answer 25

Clopidogrel monotherapy.

Question 26

What role does rivaroxaban play in secondary prevention after ACS?

Answer 26

Used with aspirin or aspirin + clopidogrel in selected patients with elevated cardiac biomarkers.

Question 27

What is the recommended loading and maintenance dose of aspirin in NSTEMI, and when should an additional loading dose be given?

Answer 27

Aspirin 300 mg loading dose (if not already given) followed by 75 mg daily indefinitely. An additional loading dose of 600 mg is given before transfer for PCI if advised by LHCH.

Question 28

Describe the indications and contraindications for ticagrelor in NSTEMI patients.

Answer 28

Indicated for moderate-to-high risk patients (e.g. elevated troponins). Contraindicated in those intolerant to aspirin (should not be used as monotherapy), those already on clopidogrel (clopidogrel should be stopped), or where ticagrelor is not tolerated.

Question 29

Under what circumstances should clopidogrel be used instead of ticagrelor in NSTEMI patients?

Answer 29

In patients who cannot take ticagrelor or prasugrel, or who are on oral anticoagulation. A 300 mg loading dose is used on admission, followed by 75 mg daily.

Question 30

What are the recommended loading and maintenance doses of prasugrel, and in which patient population is its use contraindicated?

Answer 30

Loading dose 60 mg, maintenance 10 mg daily (5 mg if <60 kg or >75 years). Contraindicated if coronary anatomy is unknown.

Question 31

What are the key considerations when switching between P2Y12 inhibitors or planning for surgery in patients on P2Y12 inhibitors?

Answer 31

Discontinue ticagrelor or clopidogrel 7 days prior to non-emergency surgery. For urgent surgery or bleeding complications, stop P2Y12 inhibitor after 1 month (BMS) or 3 months (DES) if needed.

Question 32

When is fondaparinux recommended in the management of NSTEMI, and what is the dose?

Answer 32

Fondaparinux 2.5 mg subcutaneously daily is recommended for all patients with cardiac-sounding chest pain.

Question 33

When are GPIIb/IIIa inhibitors indicated during PCI in NSTEMI patients, and what is the main contraindication?

Answer 33

Used in bailout or thrombotic complications during PCI. Not recommended if coronary anatomy is unknown.

Question 34

Which beta-blockers are preferred in patients with LV systolic dysfunction (EF <40%) post-MI, and what are their starting doses?

Answer 34

Bisoprolol 1.25 mg daily, nebivolol, or carvedilol 3.125 mg BD. Titrate slowly based on tolerance.

Question 35

What is the recommended starting dose of atorvastatin in NSTEMI patients, and when might a lower dose be considered?

Answer 35

Atorvastatin 80 mg daily. Consider 40 mg in elderly, frail patients with comorbidities.

Question 36

What monitoring is required after initiating statin therapy, and what symptoms should patients report?

Answer 36

Check LFTs before, at 1-3 months, 6 months, and then yearly. Report unexplained muscle pain, tenderness, or weakness.

Question 37

What is the recommended course of action if LDL cholesterol remains ≥1.8 mmol/L despite maximal statin therapy?

Answer 37

Consider adding a non-statin agent to further reduce LDL.

Question 38

When should ACE inhibitors be started in NSTEMI, and how should ramipril be titrated?

Answer 38

Start once haemodynamically stable. Ramipril: 2.5 mg once or twice daily, increasing to 10 mg daily. If EF <40%, start at 1.25 mg and titrate every 1-2 days.

Question 39

When should ARBs be used instead of ACE inhibitors, and what is the initial dose of candesartan in post-MI patients with EF <40%?

Answer 39

Use if intolerant to ACEi due to persistent cough. Start candesartan 4 mg daily, increase to 32 mg as tolerated.

Question 40

What are the initiation criteria and monitoring requirements for starting eplerenone post-MI?

Answer 40

Start 3-14 days post-MI in patients with HF symptoms. Start at 25 mg daily, increase to 50 mg. Monitor potassium before starting, at 1 week, 1 month, after dose changes, and periodically.

Question 41

Which NSTEMI patients should be co-prescribed a PPI with DAPT, and what PPIs should be avoided with clopidogrel?

Answer 41

Prescribe PPI if history of GI bleed, ulcer, NSAIDs, steroids, or age ≥65 with other risks. Avoid omeprazole and esomeprazole with clopidogrel

Question 42

What is the standard duration for DAPT after NSTEMI or PCI, and when might a shorter or longer duration be considered?

Answer 42

Standard duration is 12 months. Consider 3–6 months if high bleeding risk, or longer if high ischaemic risk (must be discussed with pharmacy and primary care).

Question 43

In patients undergoing non-cardiac surgery after PCI, when is it acceptable to stop P2Y12 inhibitors like ticagrelor or clopidogrel?

Answer 43

At least 7 days before surgery if clinically feasible. For urgent surgery, stop after 1 month (BMS) or 3 months (DES).

Question 44

What antithrombotic strategy could be considered in high ischaemic risk NSTEMI patients receiving aspirin or aspirin + clopidogrel, and what is the dose and indication of rivaroxaban?

Answer 44

Rivaroxaban 2.5 mg BD for ~1 year can be considered post-parenteral anticoagulation in patients with no stroke/TIA history, high ischaemic risk, and low bleeding risk.

Question 45

What is the first-line antiplatelet treatment for secondary prevention after an ischaemic stroke or TIA (in the absence of atrial fibrillation)? NICE CKS

Answer 45

Clopidogrel 75 mg once daily.

Question 46

Which combination of drugs can be used if clopidogrel is not tolerated in secondary prevention of stroke/TIA? NICE CKS

Answer 46

Aspirin 75 mg once daily plus modified-release dipyridamole 200 mg twice daily.

Question 47

For how long is dual antiplatelet therapy (e.g., aspirin and clopidogrel) typically prescribed in high-risk TIA or intracranial stenosis?

Answer 47

For up to 90 days.

Question 48

When should anticoagulation be started after a non-disabling ischaemic stroke in a patient with atrial fibrillation?

Answer 48

Within 14 days of onset (once imaging has excluded haemorrhage and there are no contraindications).

Question 49

Which antiplatelet drug may be used alone if both clopidogrel and dipyridamole are contraindicated?

Answer 49

Aspirin 75 mg once daily.

Question 50

In people with atrial fibrillation who had a disabling ischaemic stroke, how long should anticoagulation be delayed?

Answer 50

Until at least 14 days from onset.

Question 51

What is the initial management of Ischaemic Stroke? (national stroke guidelines)

Answer 51

🔹 Immediate Treatment Thrombolysis: Indication: Onset within 4.5 hours. Drugs: IV alteplase or tenecteplase. Extended window (4.5–9 hours): May be used with CT/MRI showing core-perfusion mismatch or DWI-FLAIR mismatch . BP must be <185/110 mmHg before administration . Mechanical Thrombectomy: Indication: Large artery occlusion + disabling stroke (NIHSS ≥6). Time window: Within 6–24 hours (depending on imaging and patient eligibility). Given with or without thrombolysis depending on eligibility . Antiplatelet: Aspirin 300 mg orally/rectally within 24 hours if thrombolysis not given. After thrombolysis, delay aspirin until 24 hours later, after imaging rules out haemorrhage . Other supportive treatments: Maintain glucose 5–15 mmol/L. Start statin (atorvastatin 20–80 mg) once safe to swallow . Restart usual antihypertensives when stable.

Question 52

What is the initial management for Haemorrhagic Stroke? (national stroke guidelines)

Answer 52

Immediate Treatment Blood Pressure Management: If SBP 150–220 mmHg: Lower to 130–139 mmHg within 1 hour, maintain for at least 7 days . Use IV antihypertensives (e.g., labetalol, nicardipine). Stop Antithrombotics: Immediately stop any antiplatelets or anticoagulants. Consider reversal agents (e.g., prothrombin complex concentrate for warfarin, idarucizumab for dabigatran). Cautious Restarting: Antiplatelets: May restart after 24 hours, if risks of recurrent haemorrhage are low Assess risk of recurrent ICH (e.g., lobar vs deep haemorrhage, cerebral amyloid angiopathy).

Question 53

WHat is the treatment for secondary prevention in Ischaemic Stroke or TIA (Without Atrial Fibrillation)? National stroke guidelines

Answer 53

🟦 Ischaemic Stroke or TIA (Without Atrial Fibrillation) 🔹 1. Antiplatelet Therapy First-line: Clopidogrel 75 mg daily. Alternatives: Aspirin 75 mg ± Dipyridamole MR 200 mg BD if clopidogrel not tolerated. Dual Therapy (Short-Term): Aspirin + Clopidogrel (21 days) or Aspirin + Ticagrelor (30 days) if presenting within 24 hours with minor stroke or TIA. Do NOT use dual therapy long-term unless another indication exists (e.g. coronary stents) . 🔹 2. Statins Atorvastatin 20–80 mg daily, initiated as soon as safe to swallow. Target: ≥40% reduction in non-HDL cholesterol or LDL <1.8 mmol/L. If insufficient response: Add ezetimibe or PCSK9 inhibitors (e.g., inclisiran) . 🔹 3. Blood Pressure Control Antihypertensives: Thiazide-like diuretic, ACE inhibitor, ARB, or long-acting calcium channel blocker. General BP target same as other CVD patients. Exception: For bilateral carotid stenosis, maintain SBP 140–150 mmHg.

Question 54

What is the guidance for secondary prevention in Ischaemic Stroke or TIA with Atrial Fibrillation? National stroke guidelines

Answer 54

Ischaemic Stroke or TIA with Atrial Fibrillation 🔹 Anticoagulation Start once bleeding ruled out by imaging. Start DOAC (e.g. apixaban, rivaroxaban) or Warfarin (INR 2.0–3.0) depending on valvular status. Timing: TIA: Start immediately. Mild stroke: Start ≤5 days. Moderate–severe stroke: Start 5–14 days, with aspirin 300 mg daily in interim . 🔹 Bleeding Risk Reduction Use risk tools: HAS-BLED, ORBIT, MICON-ICH. Modify risk factors (BP, renal function, fall risk). Consider left atrial appendage occlusion if anticoagulation is contraindicated.

Question 55

When is Aspirin 300 mg for 2 Weeks Given?

Answer 55

👉 In patients with atrial fibrillation (AF) who have had an ischaemic stroke and anticoagulation is delayed, you give: 🔹 Aspirin 300 mg once daily until oral anticoagulation can be safely started. 🧠 Why is it used? Anticoagulants (e.g. DOACs or warfarin) are usually withheld temporarily after a stroke due to: Risk of haemorrhagic transformation Severity of stroke (especially moderate to severe or disabling strokes) In the meantime, aspirin 300 mg daily is used to offer some thromboembolic protection. 📆 For How Long? The exact duration depends on the severity of the stroke: Mild stroke: Start anticoagulation within 5 days → aspirin used for a few days. Moderate to severe stroke: Start anticoagulation 5–14 days post-stroke → aspirin may be used for up to 2 weeks during this delay. Once anticoagulation is initiated, aspirin should be stopped (unless there's another indication for dual therapy, which is rare and specialist-guided).