mr bigstuff

Question 1

STEMI treatment

Answer 1

• everyone gets aspirin 300mg
• if present within 12 hrs and PCI available within 120 minutes of when fibrinolysis would have been given
  
  • PCI with stent eluting drugs
  • prior to procedure they also need dual antiplatelet therapy with aspirin and:
    
    • if they’re not taking an oral anto-coagulent: prasugrel
    • if they are taking an oral anticoagulant: clopidogrel
  • during procedure they need
    
    • radial access: unfractionated heparin with bailout GPI
    • femoral access: bivalirudin with bailout GPI
• fibrinolysis should be offered if they present within 12 hours of onset of symptoms and PCI cannot be given within 120 mins they should have fibrinolysis
  
  • they need an antithrombin such as:
    
    • fondaparinux
    • unfractionated heparin
    • lmw heparin
  • ECG changes repeated after 60-90 minutes to see if changes have resolved
    
    • if not they may need PCI

Question 2

nstemi management

Answer 2

• everyone gets 300mg aspirin
• grace score calculated
  
  • low risk → conservative management
  • intermediate - high risk → PCI
• if no immediate PCI then give fondaparinux
• conservative management:
  
  • further DAPT: aspirin +
    
    • ticagrelor if not on oral anticoagulants
    • clopidogrel if on oral anticoagulants
• PCI:
  
  • immediately if unstable
  • otherwise within 72hrs
  • give unfracitonated heparin prior to PCI
  • further DAPT prior to PCI
    
    • if not taking an oral anticoagulant: ticagrelor
    • if taking an oral anticoagulant: clopidogrel

Question 3

what is the grace score and what does it calculate

Answer 3

• uses the following to estimate 6 month mortality
  
  • age
  • heart rate, blood pressure
  • cardiac (Killip class) and renal function (serum creatinine)
  • cardiac arrest on presentation
  • ECG findings
  • troponin levels

Question 4

absolute contraindications to thrombolysis in stroke

Answer 4

• Previous intracranial haemorrhage
• Seizure at onset of stroke
• Intracranial neoplasm
• Suspected subarachnoid haemorrhage
• Stroke or traumatic brain injury in preceding 3 months
• Lumbar puncture in preceding 7 days
• Gastrointestinal haemorrhage in preceding 3 weeks
• Active bleeding
• Pregnancy
• Oesophageal varices
• Uncontrolled hypertension >200/120mmHg