1. Chest pain - Angina and ACS Flashcards
What is angina
Narrowing of coronary arteries, reducing blood flow to myocardium so at times of high demand ie exercise there isn’t enough blood supply to the heart
what are the typical symptoms of angina
Constricting discomfort in the front of the chest, or in neck, shoulders, jaw or arms
Precipitated by physical exertion
Relieved by rest or GTN within about 5 minutes
when would angina be classified as unstable
when the symptoms come on randomly whilst at rest
When investigating angina what is the gold standard investigative procedure
CT coronary angiography
Name some of the baseline investigations when trying to diagnose Angina
- Physical Examination (heart sounds, signs of heart failure, BMI)
- ECG
- FBC (check for anaemia)
- U&Es (prior to ACEi and other meds)
- LFTs (prior to statins)
- Lipid profile
- Thyroid function tests (check for hypo / hyper thyroid)
- HbA1C and fasting glucose (for diabetes)
Name some differential diagnosis of chest pain apart from angina
GORD
musculoskeletal pain
anxiety
when should a patient with angina ring for an ambulance
Take GTN, then repeat after 5 minutes. If there is still pain 5 minutes after the repeat dose – call an ambulance
What are the long term symptomatic relief options for patients with angina
Beta blocker (bisoprolol 5mg once a day) or calcium channel blocker (amlodipine 5mg)
{other options that aren’r t first line are long acting nitrates, ivabradine, nicorandil and ranolazine}
What are the 4 A’s in the secondary prevention of angina
Aspirin ( ie 75mg once daily)
atorvastatin 80mg once daily
ACE inhibitor
already on beta-blocker for symptomatic relief
Name 2 procedural/surgical interventions for people with coronary artery disease
- percutaneous coronary intervention (PCI) with coronary angioplasty by placing catheter in the femoral artery or brachial
- Coronary artery bypass graft (CABG)
A patient with a midline sternotomy scar and great saphenous vein harvesting will have had what procedure (think cardiac)
coronary artery bypass graft (CABG)
A patient with a brachial artery access scar or femoral artery access scar have had what kind of cardiac procedure
percutaneous coronary intervention (PCI)
What is acute coronary syndrome usually a result of
a thrombus from an athersclerotic plaque blocking a coronary artery (made up of mostly platelets)
Which coronary artery becomes the circumflex and left anterior descending artery (LAD)
left coronary artery
which coronary artery branch supplies the R atrium and ventricle as well as the inferior aspect of the left ventricle and the posterior septal area
right coronary artery
which coronary artery branch supplies the left atrium and posterior aspect of the left ventricle
circumflex artery
which coronary artery branch supplies the anterior aspect of the left ventricle and the anterior aspect of the septum
left anterior descending (LAD) artery
name the 3 types of acute coronary syndromes (ACS)
unstable angina
Non-STEMI
STEMI
Making a diagnosis with possible ACS symptoms:
On an ECG if there is ST elevation or new LBBB then what is the diagnosis
STEMI
Making a diagnosis with possible ACS symptoms:
If there is no ST elevation on an ECG what investigation should be performed
Troponin blood test
Making a diagnosis with possible ACS symptoms:
If there are raised troponin levels and/or other ECG changes such as ST depression, T wave inversion or pathological Q waves what should you diagnose
NSTEMI
Making a diagnosis with possible ACS symptoms:
If troponin levels are normal and the ECG does not show pathological changes what could the diagnosis be
unstable angina
or
other causes such as musculoskeletal pain
Symptoms of ACS: what accompanying things are associated with the central, constricting chest pain
nausea and vomiting sweating and clamminess feeling of impending doom SOB palpitations pain radiating to jaw or arms
Symptoms of ACS should continue at rest for more than 20 minutes, what would you consider if they settle
angina
diabetic patients may not experience typical chest pain during ACS, what is this referred to as
silent MI
what does a normal ECG not exclude
ACS
how do you exclude ACS after a normal ECG
cardiac troponin test
if you suspect ACS what medication do you need to give and at what dose
loading dose of aspirin 300mg
what are the ECG changes in ACS for a STEMI
ST segment elevation in leads consistent with an area of ischemia
what are the ECG changes in ACS for a NSTEMI
ST segment depression in a region
deep T wave inversion
pathological Q waves
Clinical findings in which ECG leads would indicate a LCA blockage which supplies the anterolateral heart
I, aVL, V3-6
clincal findings in which ECG leads would indicate a LAD blockage which supplies the anterior heart area
V1-4
clinical findings in which ECG leads would indicate a circumflex artery blockage which supplies the lateral heart area
I, aVL, V5-6
clinical findings in which ECG leads would indicate a RCA blockage which supplies the inferior heart area
II, III, aVF
Name some alternative causes of increase troponin levels
chronic renal failure sepsis myocarditis aortic dissection PE
what are the treatments for an acute STEMI within 12 hours of symptom onset
primary PCI (if available within 2 hours of presentation) thrombolysis (if PCI not available within 2 hours)
name some examples of thrombolysis therapy
streptokinase and alteplase
What is the treatment of an acute NSTEMI
the mnemonic is BATMAN
B- beta blockers
A- aspirin 300 stat dose
T- ticagrelor 180mg stat dose (clopidogrel 300mg is the alternative)
M- morphine titrated to control the pain
A- anticoag such as LMW heparin
N- nitrates (eg GTN) to relieve coronary artery spasm
what is the scoring system used to access for PCI in NSTEMI
GRACE score
<5% low risk
>10% high risk
what are the complications of MI
mnemonic is heart failure DREAD
D- Death R- Rupture of the heart septuum or papillary muscles E- edema A- arrhythmias and aneurysm D- dresslets syndrome
what is dressler’s syndrome (AKA post-MI syndrome)
localised immune response and causes pericarditis
what does dressler’s syndrome present with
pleuritic chest pain
low grade fever
pericardial rub on auscultation
How is dressler’s syndrome diagnosed
ECG (global ST elevation and T wave inversion
Echocardiogram (pericardial effusion)
raised inflammatory markers (CRP and ESR)
what is the management of dressler’s syndrome
NSAIDs (aspirin/ibuprofen) and in more serious cases steroids (prednisolone)
Name the 6 As in the secondary prevention medial management of ACS
Aspirin 75mg once daily
Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months
Atorvastatin 80mg once daily
ACE inhibitors (e.g. ramipril titrated as tolerated to 10mg once daily)
Atenolol (or other beta blocker titrated as high as tolerated)
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
Name some secondary lifestyle preventative measures for ACS
stop smoking reduce alcohol mediterranean diet cardiac rehab optimise treatment of other medical conditions
Atypical presentation of ACS is common in which age group
over 75s
troponin levels rise with _______ hours of an infaract or ischemia and may be elevated for up to _____ weeks
2-4 hours
2 weeks
Treatment of NSTEMI/unstable angina what should youu offer
aspirin 300mg stat
fondaparinux (anticoag) if not planning coronary angiography in 24 hours
