NSTE-ACS Management Quiz
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Questions and Answers

What is the recommended action for individuals suspected of having an ACS who are not on regular aspirin with no history of allergy?

  • Administer 300mg of aspirin only if the patient is transferred to a PCI-capable hospital.
  • Administer 300mg of aspirin only if the patient is experiencing ongoing chest pain.
  • Administer 300mg of soluble or chewable aspirin. (correct)
  • Administer 300mg of solid aspirin, either chewed or swallowed.

    • According to the guidelines, what should be the first step in managing a patient suspected of having an ACS who arrives at the emergency department?

  • Stabilize the patient’s hemodynamics.
  • Perform a 12-lead ECG within 10 minutes of arrival. (correct)
  • Immediately transfer the patient to a PCI-capable hospital.
  • Administer 300mg of aspirin.

    • Under which circumstances should a patient with NSTE-ACS be considered for immediate transfer to a PCI-capable hospital?

  • When the patient has a history of previous myocardial infarction.
  • When the patient’s ECG shows NSTE-ACS.
  • When the patient is experiencing ongoing or recurrent chest pain. (correct)
  • When the patient’s vital signs are stable.

    • What is the primary reason for emphasizing public awareness about heart disease?

    <p>To reduce the time from symptom onset to seeking medical care. (A)</p> Signup and view all the answers

    Which of the following is NOT a key recommendation for the management of NSTE-ACS?

    <p>Administering beta-blockers upon arrival at the emergency department. (C)</p> Signup and view all the answers

    What is the purpose of comparing the initial 12-lead ECG taken in the emergency department with previous ECGs?

    <p>To confirm the diagnosis of STEMI or NSTE-ACS. (D)</p> Signup and view all the answers

    According to the guidelines, who is responsible for identifying patients with STEMI and NSTE-ACS based on their initial ECG?

    <p>Emergency department physician/ medical officer. (B)</p> Signup and view all the answers

    For a patient with NSTE-ACS experiencing ongoing chest pain, what is the recommended course of action?

    <p>Immediate transfer to a PCI-capable hospital. (A)</p> Signup and view all the answers

    Which of the following is NOT a contraindication for prasugrel usage?

    <p>History of coronary artery bypass grafting (D)</p> Signup and view all the answers

    What is a key advantage of using prasugrel over clopidogrel in patients undergoing percutaneous coronary intervention (PCI)?

    <p>It is more effective in reducing major adverse cardiac events (MACE). (D)</p> Signup and view all the answers

    Which of the following statements regarding ticagrelor and prasugrel is TRUE?

    <p>Both drugs have similar efficacy and bleeding rates at 7 days, 1 month, and 1 year. (C)</p> Signup and view all the answers

    What is the recommended loading dose for prasugrel?

    <p>60mg (A)</p> Signup and view all the answers

    When is clopidogrel considered a cost-effective option for dual antiplatelet therapy?

    <p>When used as part of a strategy for up to a year. (D)</p> Signup and view all the answers

    Which P2Y12 inhibitor is recommended for use in patients who have already undergone a coronary angiogram?

    <p>Prasugrel (C)</p> Signup and view all the answers

    What is the main difference between prasugrel and clopidogrel in terms of their use in patients with acute coronary syndrome (ACS)?

    <p>Prasugrel is more effective in patients undergoing PCI. (C)</p> Signup and view all the answers

    Which of the following statements is TRUE regarding the efficacy of different P2Y12 inhibitors?

    <p>The best choice of P2Y12 inhibitor depends on individual patient characteristics. (A)</p> Signup and view all the answers

    Which of the following is NOT a recommended medication for patients with NSTE-ACS?

    <p>Beta-blockers (C)</p> Signup and view all the answers

    A patient presents with ongoing chest pain and hemodynamic instability. What is the recommended course of action according to the guidelines?

    <p>Urgent coronary angiography with view to revascularization (C)</p> Signup and view all the answers

    Which of the following conditions is NOT typically included in the differential diagnosis for NSTE-ACS?

    <p>Acute appendicitis (C)</p> Signup and view all the answers

    What is the primary pathophysiology of Type 1 MI, the most common type of NSTE-ACS?

    <p>A ruptured or fissured plaque with superadded thrombosis (D)</p> Signup and view all the answers

    Based on the risk stratification provided, a patient with moderate risk of NSTE-ACS should be admitted to which unit?

    <p>High dependency unit (D)</p> Signup and view all the answers

    Why does anti-thrombotic therapy play a more crucial role than anti-ischemic agents in NSTE-ACS management?

    <p>NSTE-ACS is primarily caused by plaque rupture and thrombosis. (A)</p> Signup and view all the answers

    What type of NSTE-ACS requires addressing the underlying etiology?

    <p>Type 2 MI (D)</p> Signup and view all the answers

    Which of the following statements is TRUE about the management of stable, low-risk NSTE-ACS?

    <p>They can be managed on telemetry wards, leading to reduced hospital costs. (A)</p> Signup and view all the answers

    What is the loading dose of ticagrelor?

    <p>180mg (B)</p> Signup and view all the answers

    Which of the following is a potential drawback of ticagrelor?

    <p>Dyspnoea and transient ventricular pauses (A)</p> Signup and view all the answers

    What is the maintenance dose of ticagrelor after the loading dose?

    <p>90mg twice daily (A)</p> Signup and view all the answers

    What does the evidence suggest about ticagrelor compared to clopidogrel?

    <p>Significant reduction in cardiac endpoints (D)</p> Signup and view all the answers

    What is the main uncertainty regarding the timing of initiation of dual antiplatelet therapy (DAPT)?

    <p>The exact timing for initiation of the second agent (A)</p> Signup and view all the answers

    What is the recommendation regarding pre-treatment with these antiplatelet agents in NSTE-ACS patients?

    <p>No strong recommendation for or against it (D)</p> Signup and view all the answers

    In patients with heart block, caution is advised when administering which medication?

    <p>Ticagrelor (B)</p> Signup and view all the answers

    Which patient population is included in the heterogenous group of NSTE-ACS patients?

    <p>Patients with normal coronary arteries (C)</p> Signup and view all the answers

    Which anticoagulant is recommended as the preferred option for patients over 75 years old with renal impairment?

    <p>Unfractionated Heparin (UFH) (C)</p> Signup and view all the answers

    What is the recommended duration of anticoagulant therapy for patients treated medically?

    <p>2-8 days (D)</p> Signup and view all the answers

    In NSTE-ACS patients managed with an early invasive approach, which anticoagulant has similar efficacy to enoxaparin?

    <p>Unfractionated Heparin (UFH) (C)</p> Signup and view all the answers

    Which agent is not recommended as the sole anticoagulant during PCI?

    <p>Fondaparinux (C)</p> Signup and view all the answers

    For patients treated conservatively, which anticoagulant is considered best?

    <p>Fondaparinux (D)</p> Signup and view all the answers

    Which of the following agents is classified under anti-Xa inhibitors?

    <p>Fondaparinux (B)</p> Signup and view all the answers

    Which class of anticoagulants might result in catheter-related thrombus and angiographic complications when used alone?

    <p>Anti-Xa inhibitors (B)</p> Signup and view all the answers

    Which of the following is not an agent included in the category of glycoprotein IIb/IIIa inhibitors?

    <p>Enoxaparin (B)</p> Signup and view all the answers

    What is the main advantage of using fondaparinux over enoxaparin in patients with NSTE-ACS?

    <p>It is associated with less short and midterm bleeding events. (A)</p> Signup and view all the answers

    Which statement accurately reflects the use of β-blockers in patients with NSTE-ACS?

    <p>They may be given after stabilization and prior to hospital discharge. (B)</p> Signup and view all the answers

    What was the outcome of adding Direct Oral Anticoagulants (DOAC) to Dual Antiplatelet Therapy (DAPT) in patients with NSTE-ACS?

    <p>It did not show significant treatment effect and increased bleeding risk. (C)</p> Signup and view all the answers

    What is the recommended timing for administering β-blockers according to the provided guidelines?

    <p>After stabilization and prior to hospital discharge. (C)</p> Signup and view all the answers

    Which patient category should ideally undergo an immediate invasive strategy in NSTE-ACS management?

    <p>Patients at very high risk for a Major Adverse Cardiac Event (MACE). (C)</p> Signup and view all the answers

    What is a relative contraindication for the administration of β-blockers?

    <p>Marked first-degree AV block. (C)</p> Signup and view all the answers

    What is the implication of the timing of invasive coronary angiography for patients with NSTE-ACS?

    <p>Optimal timing is guided by the individual's risk for MACE. (B)</p> Signup and view all the answers

    Which drug is currently under evaluation for use in NSTE-ACS alongside existing therapies?

    <p>Direct Oral Anticoagulants (DOACs). (D)</p> Signup and view all the answers

    Flashcards

    NSTE-ACS

    Non-ST Elevation Acute Coronary Syndrome, a type of heart condition.

    STEMI

    ST Elevation Myocardial Infarction, a serious heart attack seen on ECG.

    Aspirin administration

    If ACS is suspected, 300mg aspirin is recommended if no allergy exists.

    ECG training for responders

    Ambulance personnel should be trained to perform ECGs.

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    Heart disease awareness

    Public outreach is essential for early treatment and symptom recognition.

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    12 lead ECG

    A comprehensive heart monitoring test that should occur within 10 minutes of ED arrival.

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    Triage zones

    Patients are categorized into red or yellow zones based on severity using Malaysian Triage Scale.

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    PCI-capable hospital

    A facility equipped for Percutaneous Coronary Intervention, necessary for treating certain heart conditions.

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    Anti-thrombotic therapy

    Treatment to prevent blood clots, including antiplatelet and anticoagulant medications.

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    Coronary care unit (CCU)

    Specialized hospital area for high-risk heart patients.

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    Type 1 MI

    A heart attack caused by plaque rupture and thrombosis.

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    Type 2 MI

    A heart attack caused by supply and demand imbalance, not primarily by blockage.

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    Oxygen therapy

    Administration of oxygen to patients with low saturation levels (< 95%).

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    Pharmacotherapy in NSTE-ACS

    Use of medications to treat non-ST elevation acute coronary syndrome effectively.

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    Risk stratification

    The process of determining the risk level of patients for appropriate care.

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    P2Y12 inhibitors

    Medications used to prevent blood clots in patients, each with unique characteristics.

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    Clopidogrel dosing

    Loading dose: 300-600mg; maintenance dose: 75mg daily.

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    Prasugrel advantages

    Significantly reduces MACE but increases severe bleeding compared to clopidogrel in PCI patients.

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    Ticagrelor vs Clopidogrel

    Ticagrelor significantly reduces MACE compared to Clopidogrel; bleeding rates are similar.

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    Long-term Clopidogrel use

    Beneficial in NSTE-ACS patients undergoing various treatments for up to a year.

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    Prasugrel contraindications

    Not recommended for patients >75 years, <60kg, or with prior TIAs/strokes.

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    DAPT strategy

    Dual Antiplatelet Therapy, combining aspirin with agents like Clopidogrel or Prasugrel.

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    Major adverse cardiac events (MACE)

    Serious complications such as death, myocardial infarction, or stroke.

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    Fondaparinux in NSTE-ACS

    Fondaparinux is more cost-effective and causes less bleeding compared to enoxaparin in NSTE-ACS patients.

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    Direct Oral Ant-Coagulants (DOAC)

    DOACs added to Dual Antiplatelet Therapy (DAPT) in NSTE-ACS did not significantly improve outcomes but increased bleeding risk.

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    β-blockers in NSTE-ACS

    Limited trials exist, but β-blockers are recommended for patients with heart failure or low LVEF (<40%).

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    Early invasive strategy

    An early invasive strategy is safe and reduces the risk of refractory ischemia and hospital stay duration.

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    Risk for MACE

    The timing of invasive coronary angiography should depend on the individual’s risk for Major Adverse Cardiac Events (MACE).

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    Contraindications for β-blockers

    High-risk patients like those with AV block or asthma should avoid β-blockers due to potential complications.

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    Patient stabilization

    β-blockers may be given after patient stabilization and before discharge if there are no contraindications.

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    Elevated troponins in older adults

    The conventional troponin cut-off may have low specificity in older adults; a threshold adjustment may be necessary.

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    Stent thrombosis

    A blood clot that forms in a stent, potentially causing occlusion.

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    Ticagrelor

    An antiplatelet drug with a loading dose of 180mg and maintenance of 90mg twice daily.

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    Dyspnoea

    A potential side effect of ticagrelor characterized by difficulty breathing.

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    Ventricular pauses

    Temporary cessation of ventricular electrical activity; potential side effect of ticagrelor.

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    Dual Antiplatelet Therapy (DAPT)

    A combination therapy involving two antiplatelet medications to prevent clot formation.

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    Pre-treatment in NSTE-ACS

    Administering antiplatelet agents before angiography, though recommendations vary.

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    Clinical judgement

    The decision-making process of a physician based on clinical experience and evidence.

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    Invasive strategy

    Treatment involving procedures like angioplasty or stenting in managing cardiac conditions.

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    Abciximab

    A glycoprotein IIb/IIIa inhibitor used in managing NSTE-ACS.

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    Tirofiban

    An antiplatelet agent that blocks glycoprotein IIb/IIIa receptors.

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    Eptifibatide

    A synthetic cyclic peptide that inhibits platelet aggregation.

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    Anticoagulant Therapy Duration

    Varies between 2 to 8 days for medically treated NSTE-ACS.

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    Unfractionated Heparin (UFH)

    Used in high-risk NSTE-ACS patients, similar in efficacy to enoxaparin.

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    Low Molecular Weight Heparin (LMWH)

    Best for NSTE-ACS patients treated conservatively, e.g., enoxaparin.

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    Fondaparinux

    An Anti-Xa inhibitor used for conservative NSTE-ACS treatment; not sole anticoagulant during PCI.

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    Invasive Strategy Support

    UFH should be administered if fondaparinux is used during PCI.

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    Study Notes

    Management of Non-ST Elevation Myocardial Infarction (NSTE-ACS)

    • Identify patients with NSTE-ACS and STEMI based on history and ECG changes, after consultation with ED physician.
    • Assess, stabilize, and monitor patient hemodynamics continuously before and during transfer to a hospital.
    • Public awareness about heart disease should be increased, to promote early treatment and reduce time to first medical contact (FMC).
    • If a person is suspected to have an ACS and isn't on regular aspirin, give 300mg aspirin; chewable/soluble formulations preferred.
    • Ambulance responders should be trained and equipped to perform ECGs.
    • If ECG shows STEMI or patient with NSTE-ACS has ongoing/recurrent chest pain, transfer immediately to a PCI-capable hospital. High-risk unstable patients should be taken to the nearest hospital for stabilization first.

    Emergency Department Management

    • Prompt evaluation and initial management upon arrival.
    • Patients can be triaged to red or yellow zone using the Malaysian Triage Scale.
    • Detailed targeted history and vital signs noted.
    • 12-lead ECG within 10 minutes of arrival; compare with pre-hospital/earlier ECGs if available.
    • Assess patient for definite STEMI or NSTE-ACS with ongoing chest pain.
    • If initial ECG does not show ST elevation but suspected STEMI due to prolonged (>30 minutes) ischaemic chest pain and recurrent/ongoing chest pain, perform steps to confirm/rule out STEMI.
    • Repeat ECGs at 15-minute intervals to detect evolving changes.
    • Additional posterior and right precordial leads may be helpful in detecting unusual STEMI locations or concomitant RV infarction.
    • Patients may fall into three categories: very low likelihood of ACS, definite NSTE-ACS, or possible or suspected NSTE-ACS.

    In-Hospital Management

    • Venous access established and blood sampled for cardiac biomarkers (hs-cTn preferred).
    • Aspirin (300mg) if not already taken.
    • Oxygen if SpO2 ≤ 90%.
    • GTN sublingual tablet (0.3-0.6mg) or spray (0.4-0.8mg) every 5 minutes for up to three doses if no contraindications.
    • Serial ECGs every 10-15 minutes.
    • Consider IV GTN and/or morphine as needed.
    • Anti-emetic (e.g., metoclopramide, promethazine) administration.
    • Monitor for adverse events during morphine administration.
    • Consider IV fentanyl as an alternative to IV morphine.
    • Use of anti-ischemic drug therapy as needed (consider β-blockers, ACEIs/ARBs, nitrates).
    • Consider antiplatelet therapy (clopidogrel, prasugrel, ticagrelor) depending on patient risk.

    Antiplatelet Therapy

    • ASA (acetylsalicylic acid) recommended loading dose (300mg, chewed/crushed), maintenance dose (75-100mg daily).
    • Enteric-coated aspirin not suitable for initial loading dose.
    • ASA dose ≤100mg daily if patient taking ticagrelor.
    • Consider PPI with DAPT for high-risk gastrointestinal bleeding.
    • If allergic/intolerant to aspirin consider alternative P2Y12 inhibitors (e.g., clopidogrel, prasugrel, or ticagrelor) or desensitisation.

    P2Y12 Inhibitors

    • Clopidogrel, Prasugrel, Ticagrelor are P2Y12 inhibitors.
    • loading dose and maintenance doses vary.
    • Use of these agents should be considered as part of dual antiplatelet therapy (DAPT).
    • Consider duration of DAPT (typically up to 12 months) but consider patient bleeding risk as a factor.
    • Choose appropriate P2Y12 based upon patient characteristics (e.g age, weight, bleeding history etc).
    • Switching from one P2Y12 inhibitor to another (e.g., ticagrelor to clopidogrel) may be necessary in some situations.

    Anticoagulant Therapy

    • Consider UFH or LMWH (such as enoxaparin).
    • The type and duration of anticoagulation will depend on whether the patient is managed conservatively or invasively, cost and local practice.
    • Consider fondaparinux as an alternative anticoagulant.

    Other Anti-ischemic Agents

    • Beta blockers (β-blockers) are useful in NSTE-ACS patients for managing heart failure and/or left ventricular dysfunction.

    Lipid Modifying Drugs (Statins)

    • Use statins at high doses (e.g. Atorvastatin 40-80mg or Rosuvastatin 20-40mg).
    • Statin therapy should be intensified in patients already taking a low/moderate intensity statin.
    • Target LDL-C to be ≤1.8mmol/L (or reduction of 50% from baseline; lower value is better).
    • Addition of non-statin therapy (such as ezetimibe and PCSK-9 Inhibitors) may be considered to lower LDL-C if already taking high-dose statins are not effective.

    Revascularization Strategies

    • Patients at intermediate/high risk for cardiovascular events should be considered for early revascularization.
    • Urgent intervention (within 24 hours of hospital admission) is indicated for high-risk patients.
    • Routine invasive coronary angiogram not recommended for low-risk patients.

    NSTE-ACS in Older Persons

    • Age is a significant risk factor for adverse outcomes.
    • Older persons with NSTE-ACS more frequently present with symptoms other than chest pain.
    • ECGs may be non-diagnostic.
    • Cardiac troponins often elevated even without acute coronary syndrome.

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