DAY 3 - Acute Coronary Syndromes

Definition

Unstable Angina - High risk chest pain (worsening of stable angina or angina at rest) +/- ECG changes - NO troponin elevation

NSTEMI - Elevated Troponin + Chest pain +/- ECG changes (no ST elevation)

STEMI - ECG changes with ST elevation in 2 or more continuous leads that are territorial in nature

Acute Management for STEMI

  • Call PCI centre immediately! Treatment options will depend on ability to transport to cardiac catheterization center

  • Accepted door to needle time: <90 min for patients from community, <120 min from hospital to hospital - transfer to PCI centre immediately

  • If unable to get to cath in that time - fibrinolysis is recommended (consult cardiology for dosing and subsequent anticoagulation, as well as transfer to cardiac cath centre after for rescue PCI)

Sub-Acute Management for STEMI

  • Antiplatelet therapy: ASA 81mg PO daily + Ticagrelor 90mg PO BID

  • Initiate Cardiac Medications and Titrate up to Highest effective dose

    • Beta Blocker

      • Metoprolol 25-100mg PO BID

    • ACE inhibitor

      • Ramipril 1.25 - 10mg PO daily

      • Perindopril 2 - 16 mg PO daily

    • Statin

      • Atorvastatin 20-80mg PO qhs

      • Rosuvastatin 5-20mg PO qhs

  • Refer to Cardiac Rehabilitation

  • Cardiology Referral

Acute Management for UA and NSTEMI

  • IV access, Supplemental Oxygen if SaO2 < 92%, Cardiac monitors, Morphine and nitrogen for chest pain

  • ASA 162 mg PO x 1 (chewed) + Plavix 300mg PO x 1 OR Ticagrelor 180 mg PO x 1 loading dose

  • Investigations: CBC, Electrolytes, Creatinine, HS-Troponin, ECG, CK

  • TIMI score for risk stratification

  • Cardiac stress testing/Angiography depending on TIMI score

Sub-Acute Management for UA and NSTEMI

  • DAPT + Anticoagulation

  • If no stent - ASA 81mg PO daily + Plavix 75mg PO daily + LMWH (Enoxaparin) or Fondaparinux

  • If stent - ASA 81mg PO daily + Ticagrelor 90mg PO BID

  • Risk stratification

    • HbA1C - DM treatment for target < 7.0%

    • Dyslipidemia - Target LDL<2.0

      • Statin drugs: Atorvastatin 40mg PO qhs, Rosuvastatin 20mg PO qhs, Pravastatin 10mg PO qhs

    • Smoking cessation

    • Weight management programs

Frequently Asked Questions:

  1. What if my patient has Atrial Fibrillation and is on anticoagulation and has a new stent?

    1. Guidelines change rapidly with respect to anticoagulation. Assessment of both bleeding risk and risk of recurrent ACS should be made. CCS pocket guidelines can be found here for anti-platelet guideline.

  2. What is the Duration of DAPT in patients with ACS who undergo PCI

    1. Generally at least 1 year! Assessment of bleeding risk after 1 year should be made - DAPT can be continued up to 3 years afterwards if bleeding risk is low

  3. What if my patient just had PCI with ongoing DAPT therapy and requires surgery?

    1. Ideally, all non-urgent or elective surgeries will be delayed for at least 3 months if the patient received a drug eluting stent. If emergent surgery is required, cardiology consultation should be considered, and risk and benefit of continuing dual anti-platelet therapy should be assessed.

gr3_lrg.jpg
The Intern at Work -