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QUESTIONS1. A 64-year-old male presents to the emergency department with ongoing crushing
left-sided chest pain radiating to the jaw which started four hours ago. He has a past
medical history of atrial fibrillation, which is managed with rate control and warfarin.
You perform an electrocardiogram and serum troponin which confirm an inferior
non-ST-elevation myocardial infarction (NSTEMI). Percutaneous coronary
intervention (PCI) is performed two days after presentation.
options?
clopidogrel
digoxin
furosemide
prasugrel
ticagrelor
answer: clopidogrel
explanation
NSTEMI (managed with PCI) antiplatelet choice:
if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor
if taking an oral anticoagulant: clopidogrel
This patient is presenting with NSTEMI, which was managed with PCI. In patients
without aspirin sensitivity, dual-antiplatelet therapy is recommended post-acute
coronary syndrome (ACS) for up to 12 months. Medication options to achieve this
alongside aspirin are prasugrel, ticagrelor or clopidogrel. However, as this patient is
warfarinised (due to their comorbid AF), clopidogrel is the best medication of choice.
Digoxin is incorrect, this is an anti-arrhythmic that may occasionally be used for rate
control of AF. It is not indicated in this patient.
Furosemide is a loop diuretic commonly used in the management of heart failure
with associated fluid overload. As this patient is not showing signs of impaired
ventricular function and is not oedematous, furosemide is not indicated.
QUESTIONS 1
, Prasugrel is incorrect as the patient is currently taking warfarin.
Ticagrelor is incorrect as the patient is currently taking warfarin.
notes
Acute coronary syndrome: initial management
Acute coronary syndrome (ACS) is a very common and important presentation in
medicine. The management of ACS has evolved over recent years, with the
development of new drugs and procedures such as percutaneous intervention
(PCI).
Emergency departments often have their own protocols based on local factors such
as the availability of PCI and hospital drug formularies. The following is based on
the 2020 update to the NICE ACS guidelines.
Acute coronary syndrome can be classified as follows:
ST-elevation myocardial infarction (STEMI): ST-segment elevation + elevated
biomarkers of myocardial damage
non ST-elevation myocardial infarction (NSTEMI): ECG changes but no ST-
segment elevation + elevated biomarkers of myocardial damage
unstable angina
The management of ACS depends on the particular subtype. NICE management
guidance groups the patients into two groups:
1. STEMI
2. NSTEM/unstable angina
Common management of all patients with ACS
Initial drug therapy
aspirin 300mg
oxygen should only be given if the patient has oxygen saturations < 94% in
keeping with British Thoracic Society oxygen therapy guidelines
morphine should only be given for patients with severe pain
previously IV morphine was given routinely
QUESTIONS 2
, evidence, however, suggests that this may be associated with adverse
outcomes
nitrates
can be given either sublingually or intravenously
useful if the patient has ongoing chest pain or hypertension
should be used in caution if patient hypotensive
The next step in managing a patient with suspected ACS is to determine whether
they meet the ECG criteria for STEMI. It is, of course, important to recognise that
these criteria should be interpreted in the context of the clinical history.
STEMI criteria
clinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with
persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of:
2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under
40 years, or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in
men over 40 years
1.5 mm ST elevation in V2-3 in women
1 mm ST elevation in other leads
new LBBB (LBBB should be considered new unless there is evidence
otherwise)
QUESTIONS 3
, Once a STEMI has been confirmed the first step is to immediately assess
eligibility for coronary reperfusion therapy. There are two types of coronary
reperfusion therapy:
primary coronary intervention
should be offered if the presentation is within 12 hours of the onset of
symptoms AND PCI can be delivered within 120 minutes of the time
when fibrinolysis could have been given (i.e. consider fibrinolysis if
there is a significant delay in being able to provide PCI)
if patients present after 12 hours and still have evidence of ongoing
ischaemia then PCI should still be considered
drug-eluting stents are now used. Previously 'bare-metal' stents were
sometimes used but have higher rates of restenosis
radial access is preferred to femoral access
fibrinolysis
should be offered within 12 hours of the onset of symptoms if primary
PCI cannot be delivered within 120 minutes of the time when fibrinolysis
could have been given
a practical example may be a patient who presents with a STEMI to a
small district general hospital (DGH) that does not have facilities for
PCI. If they cannot be transferred to a larger hospital for PCI within 120
minutes then fibrinolysis should be given. If the patient's ECG taken 90
minutes after fibrinolysis failed to show resolution of the ST elevation
then they would then require transfer for PCI
If patients are eligible this should be offered as soon as possible.
Primary coronary intervention for patients with STEMI
Further antiplatelet prior to PCI
this is termed 'dual antiplatelet therapy', i.e. aspirin + another drug
if the patient is not taking an oral anticoagulant: prasugrel
if taking an oral anticoagulant: clopidogrel
QUESTIONS 4
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