12 ) Acute coronary syndrome without ST-elevation. Flashcards
what is the progression of acute coronary artery syndrome ?
the artehrosclerotic place ruptures
patient suffers from unstable angina
treatment does not start soon enough unstable angina goes into a NSTEMI , and STEMI
these three are classified according to their presentation in ECG
and presence of blood markers such as tropinins
STEMMI will show positive blood marker ?
yes because cells have died it is an infraction
NSTEMI will show positive blood marker ?
yes because infraction
in unstable angina is the blood markers shown ?
no did not progress into myocardial infraction yet , erupted early enough
what are the clinical presentation for acute coronary heart syndrome without ST elevation.
unstable angina pectoris but different from chronic heart disease angina pectoris
it happens more frequent
more intense
requires more NG tablets
longer duration 15-30 min
it starts directly with maximal pain does not start gradulally and fall away gradually
provoked with small efforts and appearing at rest
nocturnal pain
what is the ECG READING in NSTEMMI and unstable angina ? and lab findings ?
PERSISTANT
st depression
negative t waves
normal or evelvated
Tr-I
Tr-T
detected at 4-8 hrs after MI
and peak around 12 hrs
the degree of elevation over correlates to the size of the infracts
myoglobin - rise in 1 hr - but non specific not used
CK-MB (4-9hrs) - more specific to also cardiac tissue
BUT BEST TO KNOW REINFRACTION
12-24hr maximum
elevated BNP , CRP , AST , LDH
what is the ecg in STEMI
st elevation
what is different to acute coronary syndrome ECG reading that to chronic ?
ECG changes usually only vanish after couple of weeks unlike with chronic coronary artery disease
in STEMI why is there an ST elevation and in NSTEMI there is not
STEMI it is a transmural infraction ,
NSTEMI it is infraction of the subendocardial tissue
persistent of ST elevation for more than 2 months show what ?
an aneurysm has formed
what are the risk factors for NSTEMI acute coronary syndrome ?
the same as in chronic for atherosclerosis
what is the the test for definitive diagnosis ?
coronary angiography - can identify the side and degree of vessel occlusion
what type of risk stratification do we do with NSTEMI and why do we do this ?
GRACE score
use your age heart rate or pulse systolic bp creatinin cardiac arrest at admission ? ST segment deviation ? abnormal cardiac enzymes ? Killip class = 1) signs of heart failure 2) rales 3) acute pulmonary edema 4) cardiogenic shock
low= less than 140 high = more than 140
what is the treatment management of patients with NSTEMI ?
1) give aspirin 75-100mg
with
2) = clopidrogel (evaluate the need for PPI) 300mg
this is dual antiplatelettherapy and should be continued for atleast 12 months
clopidrogel at 75mg daily
high risk or moderate risk can have instead of clopidrogel = ticagrelor / prasugral
3) ANTICOGULATION THERPAY - or low molecular weight heparin = enoxaprin
4) if patients with therapy resistant chest pain , ST changes more than 1mm
consider adding glycoprotein 2b and 3a inhibitors which are anti platelet therapy ( eptifibatide or tirofiban)
HOWEVER THE PLAN FOR REVASCULARISATION IS WITHIN 72 HOURS
because it should not be given before and invasive procedure
5) sublingual or IV nitroglycerin is given = for symptomatic relief of chest pain does not improve prognosis
6) morphine IV or subcutaneous = if severe and persistent pain
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VERY HIGH RISK such as hemodynamic instability
severe heart failure
life threatening angina
in less than 2hrs need coronary angiography with pic or CABG
high grace score more than 140
in less than 24 hour coronary angiography with pc or cabg
if low risk with grace score less than 140
within 72 hours you can perform coronary angiography with pic and CABG
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7) beta blocker = continued
within the first 24hrs
contra - hypotension , heart failure , large lv infract and cardiogenic shock
8) statins = continues
high intensity stain such as atorvastatin
in maximal doses
9) loop diuretic eg furosemide
if patients has flash pulmonary edema or heart failure
or LVEJ less than 40 percent
10) oxygen administration
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which type of drugs are not recommended in patients with unstable angina and NSTEMI ?
fibrinolytic treatment
