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Acute coronary syndrome summary

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Summary of 5 pages for the course Pharmacy at UOM (summary of ACS)

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  • May 21, 2023
  • 5
  • 2022/2023
  • Summary
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rosiemalley
Acute Coronary syndrome

Unstable Angina NSTEMI STEMI




ECG Normal ST depression ST segment elevation
T wave inversion T wave inversion
ST inversion




troponin none Positive positive
Myocardia none Myocardial injury Myocardial necrosis (death)
l damage
occlusion partial partial total
pain Chest Chest Suffocating and squeezing pain
occurs at res, minimal occurs at res, minimal ✅
exertion. Can radiate to exertion. Can radiate to
arms or jaw arms or jaw

Initial diagnosis (risk stratification) ✅
 Angina symptoms
 Clinical history
 ECG
 Renal function (coronary angiography can cause kidney damage, also to see medication
considerations as the medication will be given quickly).
 Cardiac troponin (used in the body during muscle contraction, myocardium death or damage will
cause the release of troponin).
 Other symptoms: nausea, vomiting, crushing, heaviness, and tightness.
What do we do after we diagnose?
NSTEMI
TIMI risk score
 30-day and 1-year mortality.
 For NSTEMI.
 A score above 3=benefit from LMW heparin, GP 2b,3a inhibitors and invasive strategies.
GRACE risk score✅
 Predicts in hospital vs post-discharge mortality.
 High score=above 140.
 If a high score, early invasive strategies are looked at.
 TIMI is faster, but GRACE is more thorough so done if more time is available.
CRUSADE risk score✅
 Bleeding risk score
 In NSTEMI patients.
 Initial medications depend on these risk scores.
Initial Anti-ischemic therapies
ALL ACS PATIENTS
Morphine=opioid used for chest pain and vasodilation.

, Oxygen=used if pO2<94%
Nitro-glycerine=nitrates used for vasodilation and pain
Aspirin =inhibits platelet aggregation, and pain, reduces mortality, and clopidogrel if intolerant or allergy.
Beta blocker=beta 1 selective, decreases ischemia and stops arrhythmias
 Beta-blockers should be given within 24 hours if not contraindicated (heart block, heart failure,
asthma, reactive airway disease).
 Oral beta blockers are safer as IV increases the risk of shock.

NSTEMI/unstable angina

 Offer 300mg single-loading aspirin and fondaparinux (Heparin IV) unless there is a high bleeding
risk or immediate angiography.


Low TIMI score<3
 Consider management via medication rather than angiography.
 No bleeding risk: offer ticagrelor with aspirin.
 High-risk bleeding: clopidogrel with aspirin
 Ischemia testing before discharge
 If ischemia comes up on this testing, then consider doing an angiography.
 Assess left ventricular function and record in their record.

Moderate/High TIMI score>3
 Offer angiography within 72 hours with follow on PCI.
 Or immediately if the condition is unstable.
 Offer prasugrel or ticagrelor with aspirin unless already taking an anticoagulant.
 Prasugrel should only be offered if PCI is intended.
 If already taking one: offer clopidogrel with aspirin.
 Offer unfractionated heparin unless contraindicated even if they’ve already been given
fondaparinux.
 PCI: Offer a drug-eluting stent=slow-release medication to prevent blood clots from forming in
the stent.
Both: finish with cardiac rehabilitation and secondary prevention.


STEMI
 Offer aspirin 300mg maintenance dose then 75mg indefinitely unless contraindicated.
 Diagnose within 10 minutes.
 Assess eligibility for reperfusion therapy (PCI or fibrinolysis).
 Deliver the reperfusion therapy as soon as possible.
 Don’t offer G protein inhibitors or fibrinolysis if PCI is planned.
 Decide to start between primary PCI or fibrinolysis.
 If the wait time is less than 2 hours for a PCI start it within 90 minutes
 If not start fibrinolysis within 10 minutes.
 If not at a PCI centre transfer to one.
 PCI preferred to fibrinolysis.
PCI therapy
Angiography with follow on primary PCI
 Offer PCI within 2 hours if symptoms started 12 hours or less previously.
 Consider radial vs femoral access (hand vs pelvis/groin, radial=lower risk and fewer
complications).
Drugs taken with PCI
 not previously taken anticoagulant: offer prasugrel with aspirin.
 previously taking anti-coagulant: clopidogrel with aspirin.

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