Acute Coronary Syndrome (ACS)

What conditions are part of ACS?

• Unstable Angina

• NSTEMI

• STEMI

How is ACS diagnosed?

• 12 lead ECG

• Cardiac Enzymes - Troponins

Can you make an individuals ACS diagnosis if they dont respond to GTN?

• No

What test should be done if ACS suspected?

• 12-lead ECG, BP, HR, SpO2 monitoring

• Order troponins (baseline) and 3 hours later

• Coronary angiography

• The Global Registry of Acute Coronary Events (GRACE) Risk Calculator

What key thing might help you identify suspected ACS?

• Chest pains occurring with little or no exertion

What is the initial management of ACS?

• SL or Buccal GTN

• Slow IV morphine

• Metoclopramide 10mg IV

• Aspirin 300mg STAT + Antiplatelet

• Oxygen - If needed

• PCI or Fibrinolytics

When should PIC or thrombolysis be offered for people with a STEMI?

• PCI - within 12 hours of symptom onset and within 120 minutes since first medical contact

• Thrombolysis - If within 12 hours of symptom onset and PCI cant be delivered within 120 minutes

What are they 4 key antiplatelets ?

• Aspirin

• Clopidogrel

• Prasugrel

• Ticagrelor

What are the common side effects other than haemorrhage for antiplatelets?

• Aspirin - Dyspepsia

• Clopidogrel - Diarrhoea

• Prasugrel - Rash

• Ticagrelor - Dyspnoea and Rash

What are the key interactions of aspirin?

• Methotrexate - Toxicity

• Thiazide - Renal Failure

• Nicorandil - GI perforation

What are the key interactions of clopidogrel?

CYP2C19 inhibitors

• (Es)omeprazole

• Fluoxetine

• Fluconazole

• Carbamazepine

What are the key interactions of Ticagrelor?

CYP3A4 Inhibitors

• Clarithromycin

• Ritonavir (Avoid)

CYP3A4 Inducers

• Rifampicin (Caution)

What are the key medications that increase bleed risk for all antiplatelets?

• NSAIDs

• Anticoagulants

• SSRIs

If an individual has a STEMI when should prasugrel or ticagrelor?

• Prasugrel - If PCI has been done

• Ticagrelor - If no PCI

When may ticagrelor or prasugel be given if an individual who has NSTEMI or unstable angina?

• If undergoing coronary angiography

• If PCI is not indicated then ticagrelor is appropriate

When are other antiplatelets like glycoprotein IIb/IIIa inhibitors given?

• Only given during procedures

Give examples of glycoproteins IIb/IIIa inhibitors?

• Abciximab

• Tirofiban

• Eptifibatide

List me 4 types of anticoagulants

• Unfractionated Heparin

• Low Molecular Weight Heparin (Enoxaparin)

• Bivalirudin

• Fondaparniux

List me 3 examples of thrombolytics

• Alteplase

• Reteplase

• Tenecteplase

List the long term pharmaceutical management and CVD prevention

• Dual antiplatelet therapy (DAPT)

• Beta Blockers

• ACE inhibitors

• Lipid Lowering Agents

How long is the DAPT for?

• Aspirin 75mg OD - lifelong

• Antiplatelets - up to 12 months

Why should prasugrel or ticagrelor not be offered with an anticoagulant?

• Bleed risk

How long is a beta blocker continued for?

• At least 12 months

• Indefinitely if they have heart failure

What’s an alternative medication for BB ?

CCB - Verapamil or Diltiazem

How long should the ACE inhibitors should be continued for?

• As long as the patient is haeomdynamically stable - continued indefitnely

What are the common side effects of ACE inhibitors?

• Cough (ACE inhibitors)

• Angioedema

• Electrolyte imbalances – high potassium

• Renal impairment

What are the contraindications for ACE inhibitors?

• History of angioedema

• Patients with renal artery stenosis

• Significant bilateral renal artery stenosis or renal artery stenosis in a single functioning kidney.

• Caution in aortic stenosis

What are the monitoring for ACE inhibitors?

• BP

• CrCl

• K+ (electrolytes)

• Measure at baseline and within 1-2 weeks, before dose changes, then

annually

When may an aldosterone antagonists be used?

For patients with signs & symptoms of heart failure and left ventricular systolic dysfunction (LVEF ≤40%)

Give 2 examples of aldosterone antagonist

• Spironolactone

• Eplerenone

Name a third line lipid lowering agent

• PCSK9 Inhibitor - alirocumab