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6. Cardiovascular System > 3. IHD - Acute Coronary Syndromes (ACS) > Flashcards

3. IHD - Acute Coronary Syndromes (ACS) Flashcards

1
Q

What are acute coronary syndromes (ACS)?

A

ACS encompasses a spectrum of acute cardiac conditions including unstable angina, NSTEMI and STEMI.

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2
Q

What does the term acute coronary syndromes (ACS) include?

A

Unstable angina.
NSTEMI.
STEMI.

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3
Q

What is the common cause of ACS?

A

Rupture of an atherosclerotic plaque and subsequent arterial thrombosis.

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4
Q

What are uncommon causes of ACS?

A
  1. Coronary vasospasm.
  2. Drug abuse.
  3. Coronary artery dissection.
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5
Q

How would you differentiate between NSTEMI and unstable angina?

A

NSTEMI involves enough occlusion to cause myocardial damage - elevation of serum troponin and creatinine kinase.

Unstable angina doesn’t cause myocardial damage.

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6
Q

Name 3 modifiable risk factors for ACS

A

Smoking, hypertension, DM, hyperlipidaemia, obesity, sedentary lifestyle, cocaine use

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7
Q

Name 3 non-modifiable risk factors for ACS

A

Age.
Male gender.
FHx of IHD

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8
Q

Describe the common pathology behind ACS

A

1) Atherosclerosis

2) Rupture/erosion of fibrous cap of an atheroma plaque in a coronary artery

2) Platelet-rich clot forms (platelet aggregation)

3) Vasoconstriction due to chemicals released by platelets

4) Thrombosis formation

5) Ischaemia and infarction

6) Necrosis of cell

7) Permanent heart muscle damage and ACS

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9
Q

Describe type 1 MI.

A

Spontaneous MI with ischaemia due to plaque rupture.

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10
Q

Describe type 2 MI.

A

MI secondary to ischaemia due to increased O2 demand.

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11
Q

List 3 symptoms and 3 signs of ACS

A

Symptoms - central chest pain, sweating, dyspnoea, palpitations.

Signs - sweating, anxiety, tachycardia, pallor.

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12
Q

Give 3 signs of unstable angina.

A
  1. Cardiac chest pain at rest.
  2. Cardiac chest pain with crescendo patterns; pain becomes more frequent and easier provoked.
  3. No significant rise in troponin.
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13
Q

Give 6 signs/symptoms of MI.

A
  1. Unremitting and usually severe central cardiac chest pain.
  2. Pain occurs at rest.
  3. Sweating
  4. Breathlessness.
  5. Nausea/vomiting.
  6. 1/3 occur in bed at night.
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14
Q

Give 5 potential complications of MI.

A
  1. Heart failure.
  2. Rupture of infarcted ventricle.
  3. Rupture of interventricular septum.
  4. Mitral regurgitation.
  5. Arrhythmias.
  6. Heart block.
  7. Pericarditis.
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15
Q

List some possible complications following a MI

A

Heart failure, rupture of interventricular septum, mitral regurg, arrhythmias, heart block, pericarditis, thromboembolism, ventricular aneurysm

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16
Q

What investigations would you do on someone you suspect to have ACS?

A
  1. ECG.
  2. Blood tests; look at serum troponin.
  3. Coronary angiography.
  4. Cardiac monitoring for arrhythmias.
17
Q

What might the ECG of someone with unstable angina show?

A

The ECG from someone with unstable angina may be normal or might show T wave inversion and ST depression.

18
Q

What might the ECG of someone with NSTEMI show?

A

The ECG from someone with NSTEMI may be normal or might show T wave inversion and ST depression. There also might be R wave regression, ST elevation and biphasic T wave in lead V3.

19
Q

What might the ECG of someone with STEMI show?

A

The ECG from someone with STEMI will show ST elevation in the anterolateral leads. After a few hours, T waves invert and deep, broad, pathological Q waves develop.

20
Q

What would you expect to see on a 12 lead ECG in ACS?

A

Hyperacute (tall) T waves
ST elevation (STEMI) or ST depression (NSTEMI/unstable angina).
new LBBB.
after hrs-days - T wave inversion, Q waves.

21
Q

What biochemical markers would you test for in ACS?

A

Troponin, creatinine kinase, myoglobin

22
Q

What would the serum troponin level be like in someone with unstable angina?

A

Normal.

23
Q

What would the serum troponin level be like in someone with NSTEMI/STEMI?

A

Significantly raised.

24
Q

Why do you see increased serum troponin in NSTEMI and STEMI?

A

The occluding thrombus causes necrosis of cells and so myocardial damage. Troponin is a sensitive marker for cardiac muscle injury and so is significantly raised in reflection to this.

25
Q

A raised troponin is not specific for ACS. In what other conditions might you see a raised troponin?

A
  1. Gram negative sepsis.
  2. Pulmonary embolism.
  3. Myocarditis.
  4. Heart failure.
  5. Arrhythmias.
26
Q

Describe the initial management for ACS.

A
  1. Get into hospital ASAP - call 999.
  2. If STEMI, paramedics should call PCI centre for transfer.
  3. Aspirin 300mg.
  4. Pain relief e.g. morphine.
  5. Oxygen if hypoxic.
  6. Nitrates.
27
Q

What would be your immediate management of ACS?

A

MONA:
Morphine, Oxygen, Nitrates, Aspirin
± clopidogrel/ticragelor

28
Q

Describe the secondary prevention therapy for people after having a STEMI.

A
  1. Aspirin.
  2. Clopidogrel (P2Y12 inhibitor).
  3. Statins.
  4. Metoprolol (beta blocker).
  5. ACE inhibitor.
  6. Modification of risk factors.
29
Q

What is the treatment of choice for STEMI?

A

PCI.

30
Q

What is the function of P2Y12?

A

It amplifies platelet activation.

31
Q

Give 3 potential side effects of P2Y12 inhibitors.

A
  1. Bleeding.
  2. Rash.
  3. GI disturbances.
32
Q

What drugs might a patient be put on after an ACS, for secondary prevention?

A

Beta-blockers, ACE inhibitors, statins, aspirin

33
Q

What might the non-medical management of ACS be?

A

PCI - percutaneous coronary intervention

34
Q

Outline the NICE guideline for ACS (NSTEMI + STEMI).

A
  1. Pain relief: GTN spray
    Opiates – diamorphine
  2. Dual antiplatelet therapy:
    Aspirin plus ticagrelor or prasugrel or clopidogrel
  3. Antithrombin therapy: Fondaparinux
  4. Consider Glycoprotein IIb IIIa inhibitor (high risk cases): tirofiban, eptifibatide, abciximab
  5. Background angina therapy: beta blocker, long acting nitrate, calcium channel blocker
  6. Lipid lowering therapy: Statins
  7. Therapy for LVSD/heart failure as required: ACE-I, beta blocker, aldosterone antagonist

Most patients will undergo invasive management with coronary angiography and revascularisation (angioplasty or CABG)

6. Cardiovascular System (24 decks)

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