4.2. Acute coronary syndrome / syndrome coronaire aigu Flashcards
When to suspect ACS (3)
Rest angina, which is usually more than 20 minutes in duration
New onset angina that markedly limits physical activity
Increasing angina that is more frequent, longer in duration, or occurs with less exertion than previous angina
NSTEMI definition (tropo and ECG findings)
- tropo élevés
- ECG:
- PAS de ST elevation
could have:
- ST‐segment depression (STD)
- T‐wave inversion (TWI),
New onset angina should be considered as
UNSTABLE
types of MI (2 main)
1 = Spontaneous plaque rupture and thrombus
2 = Ischemic imbalance (demand excess)
Chest pain CAT (stable)
1) Labs (4)
- tropo x 2 3h apart
sauf si >12h DRS sx
- FSC (hb)
- E base + étendu (mg,k)
- INR
2) 12 lead ECG
3) CXR
4) Rx:
Everyone:
- ASA 325 PO chew x1
- atorvastatin 80mg PO die
PRN
- metoprolol 25mg PO x 1 prn - yes it does reduce mortality and morbidity if NO CI
- Nitro prn
- morphine prn
Nitro Contre indications (2 + 1 debunked)
- Hemodynamic compromise
- PDE5i
risk of hypotension
*** hypotension secondary to nitrate use in Right Vent MI is not significantly higher than in other territories (meta analyse)
metoprolol contre indications (5)
heart failure
hemodynamic compromise
bradycardia
severe asthma
cocaine
STEMI definition ECG
ST segment elevations at J point in 2 contiguous leads >1mm in all leads except V2 and V3
Men <40yo, ≥2.5 mm in V2 and V3
Men >40yo, ≥2 mm in leads V2 and V3
Women ≥ 1.5 mm ST elevation in V2 and V3
NSTEMI definition ECG
ST segment depressions or deep T wave inversions without Q waves or no ECG changes
Unstable Angina definition ECG
NO ECG changes
When taking chest pain history, ask for contraindications
Thrombolysis
Anticoagulation (eg. currently on anticoagulation)
Nitroglycerin (eg. PDE5-i, eg. Viagra)
Metoprolol (eg. cocaine)
Allergy to medications (eg. Aspirin)
score to evaluate risk of bleeding post MI
CRUSADE score
NSTEMI vs STEMI pathophysiology - type of blood vessel occlusion
STEMI - complete - myocardial infarct
NSTEMI - partial occlusion
Stable vs unstable angine pathophysiology - type of blood vessel occlusion
stable angina = luminal narrowing of coronary arteries
aka stable symptoms
unstable angina = plaque rupture and thrombus formation leading to stenosis
aka worsening sx with same activity
STEMI or Equivalent
management (big categories)
Reperfusion + Dual antiplatelet + Anticoagulant
Type of reperfusion in STEMI and when (time + ressources)
- Primary PCI (within 90 mins of medical contact) = if access to cath Lab
- If PCI unavailable,
<120mins of first medical contact,
<12h symptom onset (unless ongoing symptoms),
no contraindications (see at bottom of page)
FIBRINOLYSE
STEMI antiplatel antiplatelet + Anticoagulant tx
for PCI
Dual antiplatelet
- ASA 325 PO chew or by rectum if unable to take PO
- Ticagrelor 180mg
Anticoagulant
- UFH 50-70 units/kg IV (max 5000 units)
STEMI antiplatel antiplatelet + Anticoagulant tx
for Fibrinolysis
Dual antiplatelet
- ASA 325 PO chew or by rectum if unable to take PO
- Clopidogrel 300mg (75mg if age ≥ 75) +
Anticoagulant
- Enoxaparin 30mg IV (adjust for renal and age ≥ 75) or UFH (if possible PCI later)]
Reperfusion therapies (2)
Primary PCI
or
Fibrinolysis
Time contraindications for Reperfusion therapies
No reperfusion indicated
> 12h onset of symptoms for Fibrinolysis
> 24h for PCI,
Fibrinolysis Dual antiplatelet tx + posologie
Dual antiplatelet
- ASA 325 PO chew or by rectum if unable to take PO
- Clopidogrel 300mg (75mg if age ≥ 75)
Primary PCI Dual antiplatelet tx + posologie
- ASA 325 PO chew or by rectum if unable to take PO
- Ticagrelor 180mg
Fibrinolysis anticoagulant posology
Anticoagulant
- Enoxaparin 30mg IV (adjust for renal and age ≥ 75)
or UFH (if possible PCI later)]
UFH 50-70 units/kg IV (max 5000 units)
basically UFH works sur toute les sauces
PCI anticoagulant posology
Anticoagulant
- UFH 50-70 units/kg IV (max 5000 units)
If no reperfusion indicated which antiplatelets and anticoags
Ticagrelor 180mg + Enoxaparin or UFH
NSTEMI or Unstable Angina
