1. Chest Pain and ACS Flashcards
What conditions are covered by the term Acute Coronary Syndrome?
- unstable angina
- NSTEMI
- STEMI
- What is the difference between unstable angina and NSTEMI?
- What is the difference between NSTEMI and STEMI?
- in NSTEMI, the occluding thrombus leads to myocardial necrosis
- In NSTEMI, occlusion is partial, therefore only a small area of the heart is ischaemic; in STEMI, there is total occlusion of an artery, meaning a large area of the myocardium is ischaemic
Describe the pathophysiology of ACS
rupture/erosion of fibrous cap of atheromatous plaque in coronary artery
platelet aggregation and adhesion > thrombus formation and localised vasoconstriction > reduced coronary blood flow > myocardial ischaemia
Name 6 diagnostic criteria for Acute MI
- rise and/pr fall of troponin
- symptoms of ischaemia
- new or presumed new ST/T wave changes or new LBBB
- development of pathological Q waves
- imaging evidence of loss of viable myocardium/regional wall motion abnormality
- indication of intracoronary occlusion (angiogram)
What scoring system is used to assess long term risks in patients with ACS?
GRACE score
Name 7 likely mechanisms of heart muscle damage, that will cause a raised troponin, chest pain and ECG changes
- loss of blood supply - e.g. occlusion
- downstream strain - e.g. PE
- Inflammation - myocarditis, pericarditis
- haemodynamic strain - sepsis, haemorrhage
- fast heart rate
- strain within the heart - aortic stenosis, cardiomyopathies
- Trauma
Name 3 likely mechanisms of loss of coronary blood supply
- thrombus formation
- coronary artery spasm
- coronary artery dissection
What are the following types of MI caused by:
- Type I
- Type II
- Type III
- Type IV
- Type V
- coronary artery occlusion - NSTEMI/STEMI
- ischaemic change in heart due to secondary cause - e.g. sepsis, severe anaemia
- sudden cardiac death including signs of MI but occurs before investigations can be formed
- Ischaemia produced by PCI
- Ischaemia produced by CABG
What investigations would you perform to investigate ACS?
- ECG
- cardiac biomarkers - troponin
- negative in unstable angina; positive in NSTEMI and STEMI - FBC - to rule out anaemia as cause
- echocardiogram
- myocardial perfusion study
- coronary angiography
What non-pharmacological methods are used in the management of ACS?
Cardiac Rehabilitation:
- smoking cessation
- regular physical activity
- healthy diet
- weight reduction
What is the acute management of non-ST ACS?
- oxygen, nitrates, morphine
- beta blocker/ non-dihydropyridine Ca channel blocker
- Statin
- dual antiplatelet therapy - ticagrelor and aspirin
- ACE inhibitor
What is the ongoing management of ACS following stabilisation
- Dual antiplatelet therapy
- ACE inhibitor
- beta blocker
- statin
- Cardiac rehabilitation
- eplenerone or spironolactone if LVEF <35%
In a patient with STEMI, when must PCI be performed?
- if the patient presents within 12 hours of onset of symptoms
- as soon as possible from presentation, but within 2hrs of when thrombolysis could have been given
What is the pharmacological management of stable angina? (3 drugs)
- Beta blocker/Ca channel blocker
- Aspirin
- Statin
- In patients with stable angina, which drugs can be given if beta blockers and calcium channel blockers are inadequate/contraindicated? (4)
- When is revascularisation considered in patients with stable angina?
- long acting nitrate - isosorbide mononitrate
ivabradine
nicorandil
ranolazine - when optimal medical therapy proves inadequate
