IC6 Flashcards
what are the symptoms of ACS
main: chest pain that radiates to the neck, jaw, back, abdomen
others: SOB, cool/clammy skin, nausea, light-headedness.
Differential Diagnosis for ACS
PUD = pain at the epigastric region.
- reflux? burping?
Hypoglycaemia = sweating (characteristic), unwell, pale
- skip meals?
pneumonia? may present with fever and cough. check FBC (CRP, WBCs, procalcitonin, urinary antigen tests, gram stain and culture from sputum or LRT, blood cultures) and imaging (CT scan = consolidates).
pneumothorax? check SPO2? imaging
ACS MI should be widespread and not at a single point.
algorithm for confirmation of ACS MI
1) clinical setting symptoms and vital signs
- is it widespread or at a single area?
2) ECG
- any ST elevation or depression?
3) troponin at 0h and any changes (in 1,2,3h)
- presence of troponin could be a sign of myocardial injury (sensitive but not specific; could be associated with other stress states)
if troponin increase is not high (and st depression) = observe = possible unstable angina, other cardiac problems…
what is the treatment algorithm for suspected ACS?
treat with aspirin 100 or 300mg (300mg if newly initiated)
ECG on ambulance
confirmed STEMI = initiate 180mg ticagrelor or 600mg clopidogrel prior to PCI
- (nSTEMI more stable = can choose to monitor first before initiating p2y12i and sending to PCI)
- goal of DAPT = prevent stent thrombosis.
coronary angiography (imaging) to identify the vessel affect for insert of stent.
PCI (angioplasty) = initiate
- iv bolus UFH/LMWH
- iv bolus gp2b3a f/b infusion
- iv cangrelor (p2y12i)
- iv fibrinolytic
monitoring parameters AND counselling for a patient on followup after stent thrombosis and DAPT therapy?
MONITORING
- FBC including Hb to check for any bleeding
- bleeding in general (ask PMH)
- any side effects from the drugs = dyspnoea from P2Y12i?
COUNSELLING
- risk of stent thrombogenicity = to counsel adherence to the medication and need for DAPT.
- counsel duration of DAPT, and lifelong use of asprini.
- counsel management of bleeding: if serious bleeding go a&e = tarry stools, bloody stools
- non serious: gum bleeding (use soft bristle), small cuts (10-15min, apply pressure), heavy menstrual bleeding.
- dental procedures = to inform.
what are the treatment options for STEMI
1st line: ticagrelor
2nd line: prasugrel
3rd line: clopidogrel
DAPT for at least 12 months (depends on bleeding risk = vv high = 1 month, high = 3 month… weigh risk vs benefit)
what are the treatment options for NSTEMI
if pci not indicated,
use tica or clopidogrel
not recommended to use prasugrel due to lack of coronary anatomy
if pci indicated,
follow stemi pathway.
what are the dosing (loading, maintenance) for the 3 p2y12i?
ticagrelor: 180mg loading, 90mg BD maintenance
clopidogrel: 600mg loading, 75mg OD
prasugrel: 60mg loading, 10mg OD
what are the treatment options for SIHD/CCS
STABLE CAD
clopidogrel 600mg (loading) for 6 months and indefinite aspirin therapy.
indications for clopidogrel as first line over prasugrel and ticagrelor
1) stable CAD
2) patient receiving thrombolysis.
what other treatment considerations for patients with a high risk of bleeding?
consider PPI in high-risk bleeding patients
how does PRECISE-DAPT scoring
short DAPT (≥25pts) = 3-6months
long DAPT (<25pts) = 12-24months
major and minor criteria for HBR
MAJOR
Blood
1) hb <11g/dl
2) spontaneous bleeding req hosp/transfusion past 6 months, OR recurrent
3) mod-severe thrmobocytopenia (platelet < 100 x 10^9)
4) chronic bleeding conditions
5) previous intracranial haemorrhage
Renal
6) severe, end stage CKD egfr <30
Hepatic
7) liver cirrhosis with portal htn
Cancer
8) active malignancy past 12 months
Surgery/trauma
9) non-deferable major surgery
10) recent major surgery or trauma last 30 days
MINOR
1) >75y.o
2) mod ckd egfr 30-60
3) hb 11-12.9 (m) or 11.9 (f)
4) long termNSAIDs or steorids
5) spontaneous bleeding req hosp/transfusion past 12 months
CONSIDER STOPPING AFTER 3 MONTHS
ischemic risk factors /thrombotic risk
high risk:
Dm req meds
history of recurrent MI
multivessel CAD
polyvascular disease
premature or accelerated CAD
concomitant systemic inflammatory disease (HIV, SLE, chronic arthritis)
CKD with eGFR (15-59)
at least 3 stents implanted
at least 3 lesions treated
total stent length >60mm
history complex revascularization
history of stent thrombosis on antiplatelet treatment
what are the CV risk factors
used for secondary prevention of ASCVD
1) Blood sugar
- manage diabetes through diet and exercise,
- drugs: metformin (primary) with SGLT2 or GLP1
2) Hypertension
- ensure below 130/80
3) Hyperlipidemia
4) Physical activity
- >150min/week of moderate intensity
- >75min.week of vigorous
5) smoking = quit
6) diet = fruits and vegetables
7) aspirin use = maintain
