Question 1

What is the safety of these ACS drugs in pregnancy?

Dr. Rohit Goel · Accepted Answer

Aspirin, clopidogrel, statins and beta blockers are all safe in pregnancy and can be used without hesitation. Low molecular weight heparin is also safe. ACE inhibitors should not be given, and thrombolysis is contraindicated outright in pregnant patients; these patients should instead be referred for primary angioplasty. The mother's life takes priority, though the fetal risk should be explained to the family before proceeding.

Question 2

Can you elaborate more on glycoprotein 2b3a inhibitors and low molecular weight heparin?

Dr. Rohit Goel · Accepted Answer

There are three glycoprotein 2b3a inhibitors: abciximab, tirofiban and eptifibatide. These were used far more commonly a decade ago, before stents and catheterization labs were as standardized and widely available as they are now. Today their use has decreased and they are reserved for high-risk patients, such as those with a high thrombotic burden or delayed presentation, because of the increased risk of bleeding in the brain, stomach and at the local puncture site.

Question 3

What is the prognosis of patients with ST-elevation MI if thrombolysis is not done, especially when there are contraindications?

Dr. Rohit Goel · Accepted Answer

The prognosis is poor when a patient with ST-elevation MI cannot be thrombolyzed because of a contraindication. Ideally these patients should be sent for primary angioplasty; if that is also unavailable, they should be managed medically in an ICU with aspirin, clopidogrel or ticagrelor, statins, beta blockers, ACE inhibitors, nitrates and heparin or low molecular weight heparin, using whatever resources are available. Outcomes can be described as roughly 50/50: some patients respond well to this treatment, while others deteriorate and need referral to a higher-level facility.

Question 4

What is the approach for aortic dissection presenting like acute coronary syndrome?

Dr. Rohit Goel · Accepted Answer

Management of aortic dissection depends on which part of the aorta is involved. If the dissection involves the ascending aorta or the arch, it needs surgical management. If it involves the descending thoracic aorta or the descending abdominal aorta, percutaneous repair of the aneurysm is possible instead.

Question 5

What is the lag time between the onset of symptoms and ST elevation on ECG?

Dr. Rohit Goel · Accepted Answer

Once symptoms begin, the earliest ST elevation can appear on ECG within 15 to 30 minutes. This ST elevation persists if there is complete occlusion of the artery, and can still be present up to 48 hours later. If blood flow is restored spontaneously, whether from medicines or other reasons, the ST elevation resolves; otherwise it persists until the artery is reopened.

Question 6

What is the mortality rate for patients with ST-elevation MI?

Dr. Rohit Goel · Accepted Answer

Mortality in ST-elevation MI can be quite high if the patient is not treated properly, up to 30 to 50%, which is why adequate and timely treatment matters so much. Cardiac echo, alongside ECG and cardiac enzymes, is very important and can pick up early signs of heart damage; it is now one of the first-line investigations at tertiary care hospitals in suspected cases.

Question 7

Is cardiac ultrasound of no importance in ischemic heart disease, and could you give a summary of its management?

Dr. Rohit Goel · Accepted Answer

Cardiac echo is important and is now done routinely, alongside cardiac enzymes and ECG, in suspected cases of heart attack at every tertiary care hospital where it is available. In summary, once ischemic heart disease is confirmed, every patient is loaded with aspirin (325 mg) along with clopidogrel (300 mg), prasugrel (60 mg) or ticagrelor (180 mg), a statin (atorvastatin or rosuvastatin, 40 to 80 mg), a beta blocker if blood pressure and heart rate allow, and glyceryl trinitrate for pain relief alongside oxygen. From there, ST-elevation MI patients receive heparin ahead of primary angioplasty, or are thrombolyzed if angioplasty is unavailable; non-ST-elevation MI and unstable angina patients are managed medically with low molecular weight heparin or fondaparinux instead of thrombolysis, and are escalated to coronary angiography and angioplasty or bypass surgery if they are high-risk or not improving.

Question 8

Can myocardial bridging cause acute coronary syndrome, or can it be a risk factor?

Dr. Rohit Goel · Accepted Answer

Myocardial bridging can cause chest pain and can act as a risk factor. The initial approach is medical management with beta blockers, calcium channel blockers or nitrates. If the patient's chest pain continues despite medication, the next step is bypass surgery rather than angioplasty, since angioplasty is not successful in a bridged segment of artery.

Diagnosis and Management of Ischemic Heart Disease

Questions Doctors Asked Dr. Rohit Goel