NPC: Acute Coronary Syndromes

Question 1

How is a STEMI/new LBBB managed?

Answer 1

< 12 hours since onset –> REPERFUSION (PCI or fibrinolytic treatment [alteplase, streptokinase])

Aspirin

GTN

Morphine

Supplemental O2

Question 2

How are NSTEMIs risk stratified?

Answer 2

Classified into 3 risk criteria - low, intermediate and high

Question 3

What is the criteria for high risk?

Answer 3

On-going pain
ST depression or T wave inversion 
Elevated troponin
Recent hx infarction
HF, shock, syncope

Question 4

What is the criteria for intermediate risk?

Answer 4

Prolonged, repetitive chest pain, rest pain
Recent onset of angina
Remote hx infarction
Age > 65
Diabetes

Question 5

What is the management for low risk?

Answer 5

Outpatient management

Question 6

What is the intermediate risk management?

Answer 6

Aspirin
Beta-blocker
Monitoring & investigation

Question 7

What is the management for high risk?

Answer 7

Anti-platelet - aspirin + clopidogrel
Beta-blocker - atenolol or metoprolol
LMWH or Tirofiban + heparin
Morphine

Question 8

Why are aspirin + clopidogrel given together (when no C/I)?

What are the doses?

What are the major C/I?

Answer 8

Both are anti-platelets but combination use more effective in reducing progression to MI and reducing mortality

Aspirin - 300mg daily
Clopidogrel - 300mg LD, 75mg daily

Severe bleeding risk + hypersensitivity

Question 9

When/why would you choose LMW heparin compared to Tirofiban + UF heparin?

Answer 9

UF heparin given when very severe bleeding risk as it can be reversed with protamine

Tirofiban + UF have additional benefit for improving outcome when pt also undergoing PCI

LMW heparin (enaxoparin) is associated with a greater risk reduction of progression to MI. Doesn’t require APTT monitoring

Question 10

What are the doses for LMW & UF heparin?

Answer 10

Both S/C injection

LMW - 1mg/kg BD (or 0.5mg if renal impairment)

UF - 5000 units IV bolus followed by 1000 units/hr infusion