ACS Flashcards
Unstable angina
Ischemic chest pain that occurs at previously tolerated levels of exertion or at rest
ECG findings: None or ST segment depression
Laboratory findings: None
NSTEMI
Non-ST segment elevation myocardial infarction
ECG findings: None or ST segment depression
Laboratory findings: Troponin elevation
STEMI
ST segment elevation myocardial infarction
There is irreversible necrosis of the heart
ECG findings: ST segment elevation
Laboratory finding: Troponin elevation
Symptoms
Severe chest pain radiating from arm, neck and jaw, dyspnea, weakness, nausea, sweating, tachycardia, low BP and cold sweating
Initial management of NSTEMI
- Oxygen given to those with p<94, hypoxia, pulmonary oedema or ongoing MI
- Nitrates - if glycerly trinitrate sublingual ineffective administer intravenous or buccal or intravenous isosorbide dinitrate
- For continuing pain, give morphine/diamorphine hydrochloride IV injection with an anti-emetic i.e. metoclopramide
- Aspirin or clopidogrel. Prasugrel given to those undergoing a pci or ticagrelor
- May receive unfractionated heparin, low mw heparin or fondaparinux
- Verapamil/diltiazem is given or otherwise a beta-blocker in those who it is contra-indicated
Management of NSTEMI at high risk
The glycoprotein IIb/IIIa inhibitor is given:
1. Efitibatide + Aspirin + heparin + clopidogrel
2. In patients undergoing a pci abciximab/efitibatide + unfractionated heparin + aspirin
OR
Tirofaban + unfractionated heparin + aspirin + clopidogrel
3. Bivalirudin + heparin if an early intervention is planned
Initial management of STEMI
- Oxygen
- Nitrates
- IV injection of morphine/diamorphine with anti-emetic i.e. metoclopramide/cyclizine
- Aspirin + clopidogrel/prasugrel or ticagrelor if undergoing pci
- Glycoprotein IIb/IIIa inhibitor
- Patients undergoing pci recieve unfranctionated heparin for max 2 days, low mw heparin or fondaparinux
- Patients not undergoing pci should recieve fondaparinux or unfractionated heparin
- ACE inhibitor started within 24 hour of MI and continued for 5-6 weeks or consider ARB’s
- Diabetics should recieve insulin
Long term management of STEMI
- Life long aspirin
- Clopidogrel, prasugrel or ticagrelor
- Aspirin may be given in combination with warfarin
- Those who cannot take aspirin and clopidogrel, may take warfarin alone
- If all above increase bleeding risk, give low dose rivoroxaban with aspirin alone or aspirin and clopidogrel
- Beta blocker given to those who it isn’t contra-indicated otherwise give verapamil/diltiazem
- ACE inhibitor considered in those with left ventricular dysfunction or ARB’s is an alternative
- Eplerenone is for those who just had an MI with left ventricular dysfunction
- Statins to help regulate lipids
Pathway leading to ACS
- Endothelial damage in presence of irritants causes local inflammatory response
- LDL floating in blood comes in contact with damaged vessel where it deposits and gets oxidised.
- Immune system recruits monocytes which convert to macrophages which take up the oxidised LDL
- They become full of LDL and begin to die forming foam cells
- This keeps repeating and overtime LDL and wbc form plaque that keeps growing
- Smooth muscle detects this and secretes a fibrous cap to cover the plaque and shield it from the blood stream as well as secreting Ca2+ into the plaque
- Eventually plaque ruptures and exposes its contents
- Tissue factor located in the necrotic core of the plaque activates clotting cascade and thrombosis occurs
Key notes
- Prasugrel cannot be given to patients over 75 years or under 60kg
- Thrombolysis is carried out within 12 hours for those who are not recieving a pci i.e. streptokinase, tenecteplase and alteplase
