MYOCARDIAL ISCHAEMIA + ACS

Question 1

Myocardial ischameia

Answer 1

build up of atherosclerotic plaques
restricts arteries
reducing blood supply and o2 to heart

Question 2

Stable angina

Answer 2

Predictable chest pain or pressure due physical exertion or emotional

Question 3

Stable angina - Initial treatment

Answer 3

• Can be taken prophylactically or when symptoms arise
• Glyceryl Trinitrate dose to be taken at 5 minutes intervals
• If symptoms haven’t resolved after the second dose: medical emergency

Question 4

When should emergency services be called

Answer 4

Emergency services should be called 5 minutes after second dose of GTN not working

Question 5

Long-term Prevention

Answer 5

1st Line: Beta-blocker (RL-CCB if B-blocker contraindicated)
2nd Line: Beta-blocker + CCB (Amlodipine, Lacidipine, etc)
3rd Line: Long-acting nitrate, Nicorandil, Ivabradine or Ranolazine

Question 6

Nicorandil - side effects

Answer 6

can cause Gl and mucosal ulceration

Question 7

When should response to treatment be assessed?

Answer 7

Response to treatment should be assessed every 2–4 weeks following initiation or change of drug therapy; drug doses should be titrated to the maximum tolerated effective dose.

Question 8

RL CCB and BB

Answer 8

never give together

Question 9

Secondary prevention of cardiovascular events

Answer 9

Need to implement healthy life-style measures
Introduce 75mg aspirin and low dose stätin

Question 10

Nitrates - MoA

Answer 10

Potent coronary vasodilators.
Reduce venous return and cardiac output.

Question 11

Short-acting nitrates

Answer 11

Management of acute angina attacks
- Glyceryl trinitrate
- Isosorbide dinitrate (S/L)

Question 12

long- acting Nitrates - examples

Answer 12

Long-term prophylaxis of angina
- MR isosorbide dinitrate
- Isosorbide mononitrate

ivabradine, nicorandil, or ranolazine.

Question 13

Nicorandil

Answer 13

K channel activator
Risk of ulcer complications: mouth, skin, eye, GI
Do not drive until it is established and performance is not impaired.

Question 14

GTN Sublingual tablets - counselling

Answer 14

should be discarded 8 weeks after opening bottle

Question 15

MR Isosorbide dinitrate and Isosorbide mononitrate

Answer 15

Both taken BD.
Second dose should be taken after 8 hours.

Question 16

Tolerance

Answer 16

Patients should have nitrate free period to prevent tolerance
Second dose of nitrate should be given 8 hours after first dose instead of 12
In transdermal use: patches should be left off for 8-12 hours a day

Question 17

Nitrates - side effects

Answer 17

Dizziness, Flushing and headaches

Question 18

Nitrates - elderly

Answer 18

Should be prescribed in caution in elderly due to risk of falls

Question 19

ACS

Answer 19

Acute coronary syndrome (ACS) encompasses a spectrum of conditions which include myocardial infarction with or without ST-segment-elevation (STEMI or NSTEMI respectively), and unstable angina.

Question 20

Acute coronary syndromes (ACS) - risk factors

Answer 20

Major Risk Factors:
Family History
Hypertension
Hypercholesterolaemia
Diabetes
Smoking

Question 21

ECG and biomarkers evaluated

Answer 21

Tests determine if symptoms are unstable angina/NSTEMI or STEMI

Question 22

If it is a STEMI

Answer 22

PCI is needed within 2 hours

all 3 syndromes started on secondary prevention

Question 23

ACS - Initial management

Answer 23

Confirmed ACS:
* Loading dose of Aspirin 300mg
Pain relief: GTN +/ - IV morphine
* Oxygen if needed

Question 24

NSTEMI and Unstable Angina

Answer 24

Partial blockage of artery

Question 24

From test results, determine if NSTEMI, Unstable Angina or STEMI.

Answer 24

Partial blockage of artery - myocardial necrosis in only NSTEMI Complete blockage of artery causing myocardial necrosis in STEMI

Question 25

STEMI

Answer 25

Complete blockage of artery ST zone of ECG is elevated

Question 26

NSTEMI

Answer 26

ST zone of ECG is not elevated

Question 27

STEMI requires Percutaneous Coronary Intervention (PCI) within 2 hours:

Answer 27

Patients should be given heparin if PCI is done through radial access * Preferred secondary anti-platelet would be prasugrel in long-term management

Question 28

Secondary prevention

Answer 28

DAPT - lifelong aspirin 75mg. 12 months: clopidogrel, prasugrel, ticagrelor ACEi - ARB if ACEi CI BB - may be discontinued after 12m in pt w/o LVEF Statin - high strength (atorvastatin 80mg) pt with NSTEMI might consider PCI to prevent future MI Assess risk of HF