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Flashcards in Cardio Deck (220)
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ACS includes what?

Unstable angina, myocardial infarction with or without ST-segment elevation.


Unstable angina and ST-segment elevation myocardial infarction (STEMI) are related acute coronary syndromes. Why do they usually occur?

As a result of atheromatous plaque rupture, and are often characterised by stable angina that suddenly worses, recurring or prolonged angina at rest, or new onset of severe angina.


Patients with unstable angina differ from those with NSTEMI how?

Unstable angina = no evidence of myocardial necrosis, whereas in NSTEMI, myocardial necrosis (less significant than with STEMI) will be evident.


What five drugs/drug classess are used in the initial management of ACS?

Oxygen if evidence of hypoxia, pulmonary oedema.Nitrates to relieve ischaemic pain, if sublingual is not effective, intravenous or buccal glycerl trinitrate or IV isosorbide dinitrate is given. Diamorphine hydrochloride or morphine can be given by slow IV injection; an antiemetic such as metoclopramide should also be given. Aspirin (chewed or dispersed in water) is given for its antiplatelet effect. Clopidogrel as well should be given. Also heparin, LMWH or fondaparinux sodium. Patients without contra-indications should receive beta-blockers which should be continued indefinitely.


When is oxygen administered in the treatment of ACS?

If there is evidence of hypoxia, pulmonary oedema, or continuing myocardial ischaemia. Caution with COPD.


Why are nitrates used in ACS management? What different ones should be used?

Used for ischaemic pain. If sublingual glyceryl trinitrate is not effective then IV or buccal routes or IV isosorbide dinitrate.


What form of isosorbide is used in the management of ACS?



When are opioids used in ACS?

If pain continues despite nitrates, diamorphine or morphine can be given by slow intravenous injection; an antiemetic such as metoclopramide should also be given.


What drugs should be given for their antiplatelet effects in ACS?

Aspirin (Chewed or dispersed in water) should be given and so should clopidogrel.


What is an alternative to clopidogrel in certain patients undergoing PCI?



When would eptifibatide or tirofiban be used for unstable agina or for NSTEMI?

When patients at a high risk of either MI or death.Glycoprotein IIb/IIIa inhibitors. Eptfibatide must be used with heparin (unfractionated) and aspirin. Tirofiban must be used with heparin (unfrac), aspirin and clopidogrel.


What must the glycoprotein IIb/IIIa inhibitor Eptfibatide be used in combination with?

Heparin (unfrac) and aspirin.


What must the glycoprotein IIb/IIIa inhibitor Tirofiban be used in combination with?

Heparin (unfrac), aspirin and clopidogrel.


In ACS, patients without contra-indications should receive beta-blockers which should be continued indefinitely. In patients without left ventricular dysfunction and in whom beta blockers are inappropriate, what can be given?

Rate-limiting CCBs diltiazem and verapamil.


What is the main difference between the treatment of STEMI of UA/NSTEMI?

Because a STEMI is sudden complete blockage of a heart artery, the patency of the occluded artery can be restored by PCI or by giving a thrombolytic drug. PCI is preferred and patients undergoing PCI chould be given either heparin (unfrac) or a LMWH; bivalirudin is an alternative to the combination of a glycoprotein IIb/IIIa inhibitor plus a heparin.


What is the difference between NSTEMI and STEMI?

STEMI is caused by a sudden complete (100%) blockage of a heart artery. An NSTEMI is caused by a severely narrowed artery but the artery is not normally completely blocked.


In patients recieving treatment for STEMI who cannot be offered percutaneous coronary within 90 minutes, what should be offered?

A thrombolytic drug should be administered along with either heparin (unfrac) (for a maximum of 2 days), a low molecular weight heparin or fondaparinux sodium.


Patients with STEMI who do not reveive reperfusion therapy (with percutaneous coronary intervention or a thrombolytic) should be treated with what?

Either fondaparinux sodium, enoxaparin sodium, or heparin (unfrac).


ACEi and ARB (if ACEi not tolerated) should be started within how many hours of STEMI and continued for how long?

Within 24 hours, continued for at least 5-6 weeks.


Following an STEMI, what drugs should ideally be started in a patient with no previous regular medicines or contra-indications/intolerances to medicines?

Aspirin + the addition of clopidogrel. Beta-blockets such as acebutolol, metoprolol, propranolol and timolol. For patients with left ventricular dysfunction: carvedilol, bisoprolol or a long-acting metoprolol may be appropriate. ACE inihbitor or ARB if ACEi intolerant at high doses. Nitrates if angina. A statin ideally.


Prevention of cardiovascular events in patients with unstable angina or NSTEMI is comprised of what?

Clopidogrel is given, in combination with aspirin, for up to 12 months (most benefit during first 3 months) alongside an ACEi. Prasugrel or ticagrelor are alternatives to clopidogrel in certain patients.


Which NOAC in low-doses, in combination with aspirin alone or aspirin and clopidogrel, is licensed for the prevention of atherothrombotic events following an acute coronary syndrome with elevated cardiac biomarkers.



What are the two types of peripheral vascular disease?

Occlusive (Intermittent Claudication) in which occlusion of the peripheral arteries is caused by atherosclerosis, or vasoplastic (e.g. Raynaud's syndrome).


Naftifrofuryl oxalate can alleviate the symptoms of what type of peripheral vascular disease? intermittent claudication or Raynaud's?

BOTH:Intermittent claudication. IT can improve pain-free walking distance in moederate disease.Patients taking naftidrofuryl oxalate should be assessed for improvement after 3-6 months.


Cilostazol is licensed for use in what? intermittent claudication or Raynaud's?

Cilostazol is licensed for use in intermittent claudication to improve walking distance in patients without peripheral tissue necrosis who do not have pain at rest; use is restricted to second-line treatment where lifestyle modifications and other appropriate interventions have failed to improve symptoms.


Patients receiving cilostazol for intermittent claudication should be assessed for improvement after how long?

3 months; consider discontinuation of treatment if there is no clinically relevant improvement in walking distance.


What is a treatment option for critical limb ischaemia in patients unsuitable for surgery? (Off-label use)

Intravenous iloprost.


What does the management of Raynaud's syndrome comprise of? (2)

1. Avoidance of exposure to cold.2. Stopping smoking.


Which CCB is useful for reducing the frequency and severity of vasospastic attacks in Raynaud's?



What are alternatives to nifedipine for the treatment of Raynaud's?

Naftidofuryl oxalate may produce symptomatic improvement;Inositol nicotinate (a nicotinic acid derivative) may also be considered. Pentoxifylline, prazosin and moxisylyte are not established as being effective for the treatment of Raynaud's syndrome.