Question 1

What is the safety of these ACS drugs in pregnancy?

Dr. Rohit Goel · Accepted Answer

Aspirin, clopidogrel, statins and beta blockers are safe in pregnancy and can be used. Low molecular weight heparin is also safe. ACE inhibitors should not be given, and thrombolysis is contraindicated in pregnant patients; these patients should 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 on glycoprotein IIb/IIIa inhibitors?

Dr. Rohit Goel · Accepted Answer

There are three glycoprotein IIb/IIIa inhibitors: abciximab, tirofiban and eptifibatide. They were used quite commonly about 10 years ago, when stent quality and the procedure were not well standardised. With greater awareness and wider availability of cath labs and good stents, their use has decreased. They are now reserved for high-risk patients, such as those with a high thrombotic burden or delayed presentation: when angiography shows a large thrombus, the patient is kept on a IIb/IIIa inhibitor. Use has fallen because of the increased risk of bleeding in the brain, in the 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. The outcome is 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. When it presents like an acute coronary syndrome, the key is to suspect it, confirm it on CT angiography, and avoid thrombolysis and antiplatelet loading. If the dissection involves the ascending aorta or the arch, it needs urgent surgical management. If it involves only the descending thoracic or abdominal aorta, percutaneous (endovascular) repair can be done.

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? Please give a summary of its management.

Dr. Rohit Goel · Accepted Answer

Echo is very important and is first-line alongside cardiac enzymes and ECG; it is done routinely in suspected heart attack at all tertiary care hospitals or wherever 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. The third drug is a high-intensity statin, atorvastatin or rosuvastatin 40 to 80 mg. Fourth, if blood pressure and heart rate allow, a beta blocker. Glyceryl trinitrate, short- or long-acting, is added for pain relief, along with oxygen. In ST-elevation MI, heparin is given and the patient is shifted for primary angioplasty; if angioplasty is not available, a thrombolytic agent (streptokinase, alteplase, tenecteplase or reteplase) is given depending on availability. Non-ST-elevation MI and unstable angina are managed the same way except that they are not thrombolysed: they receive heparin, low molecular weight heparin or fondaparinux. Once stabilised, or if at high risk of heart failure, ventricular arrhythmia or hypotension, these patients should go for coronary angiography followed by angioplasty or bypass surgery.

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. Initial management is medical, with beta blockers, calcium channel blockers, nicorandil or nitrates. If the patient continues to have chest pain despite medicines, the next step is bypass surgery: angioplasty is not successful in such cases, and only surgery will help.

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