Acute Coronary Syndrome

• What does Acute Coronary Syndrome (ACS) describe?

  A group of conditions that reduce or stop blood flow to the heart muscle

  
• What type of disease is Acute Coronary Syndrome (ACS)?

  It is a type of coronary heart disease (CHD)

  
• What conditions are included in Acute Coronary Syndrome (ACS)?

  • Unstable Angina
  • ST-segment-elevation myocardial infarction (STEMI)
• What causes the conditions included in Acute Coronary Syndrome?

  Formation of thrombus on an atheromatous plaque

  
• What contributes to the formation of thrombus in ACS?

  A plaque with a large amount of lipids, thinner fibrous tissue, and many inflammatory cells

  
• What is the difference between Stable Angina and Unstable Angina?

  Stable Angina is predictable, while Unstable Angina is unpredictable
• What are the characteristics of Stable Angina?

  • Pathophysiology: Fixed stenosis (narrowing of blood vessels)
  • Clinical features: Predictable, related to effort, demand-led ischaemia symptoms over long-term
• What are the characteristics of Unstable Angina?

  • Pathophysiology: Dynamic stenosis, ruptured or inflamed plaque
  • Clinical features: Unpredictable, symptoms at rest, supply-led ischaemia symptoms over short term, frequent or nocturnal symptoms
• When can Acute Coronary Syndrome (ACS) occur in patients?

  It can occur at rest due to the rupture of atheromatous plaques or due to unexpected factors in patients with stable angina
• Does Acute Coronary Syndrome (ACS) need to be treated urgently?

  Yes, there is a risk of death
• What diagnostic tools can be used to help diagnose someone with ACS?

  • ECG, BP, HR, SpO2
  • Cardiac Enzymes
  • Troponins (released into the bloodstream when there is heart muscle damage)

  
• What are some symptoms to suspect in people with ACS?

  Chest pain lasting longer than 15 minutes
• What additional symptoms may accompany chest pain in ACS?

  Nausea/vomiting, sweating, and breathlessness
• What does chest pain with haemodynamic instability indicate in ACS?

  It indicates abnormal or unstable blood pressure, causing inadequate blood flow to organs
• What does new onset of chest pain or abrupt deterioration in previous stable angina indicate?

  It indicates recurrent chest pain with little or no exertion lasting longer than 15 minutes
• Should people's response to GTN be used to make a diagnosis of ACS?

  No, do not use people's response to GTN to make a diagnosis
• What is the initial/primary management for Acute Coronary Syndrome (ACS)?

  • Percutaneous Coronary Intervention (PCI)
  • Key Antiplatelets: aspirin, clopidogrel, prasugrel, ticagrelor
  • Other Antiplatelets: glycoprotein IIb/IIIa inhibitors
  • Anticoagulants: unfractionated heparin, low molecular weight heparin, fondaparinux, rivaroxaban
  • Thrombolytic drugs: alteplase

  
• What is Percutaneous Coronary Intervention (PCI)?

  A catheter into coronary arteries injecting contrast medium to identify thrombosed arteries
• How can a thrombosed artery be opened during PCI?

  Using balloons (angioplasty) or metal mesh (stenting)
• What are the key initial pharmaceutical management options for ACS?

  • Key Antiplatelets: aspirin, clopidogrel, prasugrel, ticagrelor
  • Other Antiplatelets: glycoprotein IIb/IIIa inhibitors (abciximab, eptifibatide)
  • Anticoagulants: unfractionated heparin, low molecular weight heparin, fondaparinux, rivaroxaban
  • Thrombolytic drugs: alteplase

  
• What is the difference between anticoagulants and antiplatelets?

  Antiplatelets prevent platelets from clumping together, while anticoagulants slow down the body's ability to clot

  
• What are the key antiplatelets used in ACS management?

  • Aspirin
  • Clopidogrel
  • Prasugrel
  • Ticagrelor

  
• What is the mechanism of action (MOA) for Aspirin?

  Aspirin inhibits cyclo-oxygenase (COX) enzyme irreversibly by acetylation
• What are the side effects of Aspirin?

  • Dyspepsia (common)
  • Nausea
  • Peptic ulcer (incidence not known)
  • Hypersensitivity (rare)
• What are the side effects of Clopidogrel?

  • Nausea
  • Abdominal pain
  • Diarrhoea (common)
  • Leucopenia
  • Eosinophilia
  • Rash (uncommon)
  • Thrombotic thrombocytopenia purpura (very rare)
• What are the side effects of Prasugrel?

  • Anaemia
  • Rash (common)
  • Hypersensitivity (uncommon)
• What are the side effects of Ticagrelor?

  • Hyperuricaemia
  • Dyspnoea (very common)
  • Dizziness
  • Syncope
  • Headache
  • Hypotension
  • Vertigo
  • Diarrhoea
  • Nausea
  • Dyspepsia
  • Rash (common)
• What interactions can affect Clopidogrel?

  Clopidogrel is affected by variation in CYP2C19 function

  
• What is the difference between STEMI and NSTEMI?

  NSTEMI is due to a major coronary artery being narrowed, while STEMI is due to prolonged interruption of blood supply
• What is the mechanism of action (MOA) for thrombolytics (fibrinolytics)?

  Thrombolytics dissolve blood clots that obstruct blood flow

  
• What is the secondary pharmaceutical management and cardiovascular disease (CVD) prevention in ACS?

  • Give a PPI for DAPT cover if the patient is at high risk of GI bleeding
  • GTN for ischaemic chest pain
  • Atorvastatin 20-80 mg is preferred for high intensity; Simvastatin 80 mg is not recommended
  • Beta blockers for up to 12 months, continue if there is heart failure

  
• When can beta-blockers be initiated in ACS patients?

  Beta-blockers can be initiated as soon as the patient is stable unless contraindicated or has suspected heart failure
• When can calcium channel blockers be given in ACS management?

  They are not usually given after MI but can be used if beta-blockers are contraindicated
• What is the RAAS system?

  • A system of hormones, proteins, enzymes, and reactions
  • Regulates blood pressure and blood volume on a long-term basis
  • ACE inhibitors and Aldosterone Antagonists affect this system
• When should ACE inhibitors be offered to MI patients?

  As soon as they are haemodynamically stable
• When can Aldosterone Antagonists be used in ACS management?

  In patients with signs and symptoms of heart failure and left ventricular systolic dysfunction
• What is a common side effect of Aldosterone Antagonists?

  Gynaecomastia (producing breast tissue)