Acute Coronary Syndromes

Question 1

Define Acute Coronary Syndrome

Answer 1

Covers a spectrum of acute cardiac conditions from unstable angins to varying degrees of MI

Question 2

What indicates a Q-wave infarction

Answer 2

ST elevation

Question 3

What indicates a Non-Q infarction

Answer 3

ST depression/ T wave inversion

Question 4

What indicates an unstable angina on an ECG

Answer 4

Normal (can’t detect)

Question 5

Clinical classification of unstable angina

Answer 5

1. Cardiac chest pains at rest and increasing

2. No rise in troponin levels

Question 6

When can MI be diagnosed on ECG alone

Answer 6

If ST is elevated

Question 7

When is diagnosis made if there is no ST elevation but MI has happened

Answer 7

After troponin results come in

Question 8

What are characteristics of a non Q-wave MI

Answer 8

1. Poor R wave progression
2. Biphasic (inverted) T wave
3. ST elevation

Question 9

Signs of an MI

Answer 9

1. Unremitting
2. Severe
3. Occurs at night
4. Sweating
5. Breathlessness
6. Nausea

Question 10

Risks that increase MI chances

Answer 10

1. Higher age
2. Diabetes
3. Renal Failure
4. Left ventricular systolic dysfunction

Question 11

How is MI initially managed

Answer 11

1. 999!
2. if ST elevation is seen by paramedic, transfer to PCI centre
3. 300mg aspirin immediately
4. Pain relief

Question 12

How is MI managed in hospitals

Answer 12

1. Diagnosis
2. Bed rest
3. Oxygen therapy
4. Narcotics/nitrates
5. Aspirin and P2Y12 inhibitor
6. Beta-blockers

Question 13

How is ACS commonly caused

Answer 13

Plaque rupture - arterial thrombosis

or CORONARY VASOSPASM (not common)

Question 14

What is troponin

Answer 14

Regulates actin:myosin contraction

Question 15

Why is looking at troponin levels not accurate for MI

Answer 15

1. Positive in pulmonary embolism
2. Myocarditis
3. Arrythmias
4. Heart failures

Question 16

How does aspirin function

Answer 16

1. Inhibits COX-1 and COX-2 which produce PROSTAGLANDINS

irreversibly

Question 17

Role of prostaglandins

Answer 17

Pro-inflammatory - induce clotting

Question 18

Role of P2Y12

Answer 18

Promotes platelet proliferation

Question 19

Name three P2y12 inhibitors

Answer 19

Clopidogrel
Prasugrel
Ticagrelor

Question 20

Problem with P2Y12 inhibtors

Answer 20

Can cause severe bleeding

Question 21

What are GP11b/IIIa antagonists

Answer 21

Intravenous drugs

Question 22

What are sued in conjunction with GPIIb/IIIa antagonists

Answer 22

Aspirin and oral P2Y12 inhibitors

Question 23

Why has the use of GPIIb/IIIa decreased

Answer 23

Oral anti platelet therapy more convenient

Question 24

When is GPIIb/IIIa still given

Answer 24

In patients taken opiates which are delaying gastric emptying

Question 25

What are anticoagulants used for

Answer 25

Target formation of thrombin Inhibit fibrin formation and platelet activation

Question 26

Why is Fondaparinux better than heparin

Answer 26

Fonaparinux is safer because of low-level of anticoagulation used

Question 27

What anticoagulant is usually used during PCI

Answer 27

Heparin

Question 28

When else is heparin used

Answer 28

CABG surgery

Question 29

What are given to patients with heart failure

Answer 29

Diuretic ACEI Beta Blocker Aldosterone antagonist

Question 30

When is coronary angiography performed

Answer 30

Patients with troponin elevation or unstable angina

Question 31

What is the most common revascularisation procedure

Answer 31

CABG

Question 32

Name drugs that inhibit thrombin

Answer 32

Heparin Apixaban Bivalirudin Rivaroxaban

Question 33

How is clopidogrel activated/ inactivated

Answer 33

In the liver

Question 34

What factors effect response to clopidogrel

Answer 34

1. Dose 2. Age 3. Weight 4. Disease states (diabetes) 5. Drug-drug interactions 6. CYP loss of function

Question 35

Describe the activation of Clopidogrel

Answer 35

Clopidogrel -> 2-oxo-clopidogrel -> R-130964

Question 36

Describe the activation of prasugrel

Answer 36

Prasugrel -> R-95913 -> R-138727

Question 37

Describe the mechanism of action of ticagrelor

Answer 37

Inhibits adenosine uptake by cells via the ENT-1 channels in the membrane

Question 38

Role of adenosine in the blood

Answer 38

Cause vasodilation Caridoprotection Anti platelet

Question 39

Adverse effects of ticagrelor

Answer 39

Bleeding Rash Gi disturbances

Question 40

How is dyspnoea caused by using ticagrelor resolved

Answer 40

Switching to prasugrel and clopidogrel

Question 41

What is the idiosyncratic effect of ticagrelor

Answer 41

Ventricular pauses

Question 42

How is an acute STEMI treated

Answer 42

1. ECG 2. Tropinin/ Glucose count in FBC 3. 300mg ASPIRIN 4. 180mg Ticagrelor 5. Morphine (5-10mg) + metoclopramide (anti-emetic) 6. PCI or Fibrinolysis

Question 43

Non-STEMI treatment

Answer 43

1. Low flow O2 2. Morphone + Metoclopramide 3. GTN spray 4. 300mg Aspirin 5. 2.5mg Fondaparinux 6. Ticagrelor 7. IV GTN 8. ORAL BISOPROLOL