ACS Flashcards
What conditions does AXS encompass?
STEMI
NSTEMI
unstable angina
Unmodifiable RFs for ACS
Inc age
Male
FH
Modifiable RFs for ACS
Smoking DM HTN Hypercholesterolaemia Obesity
Pathophysiology of IHD
Initial endothelial dysfunction
Pro-inflammatory, pro-oxidant, proliferative and reduced NO
Fatty infiltration of sub endothelial space for LDL particles
Monocytes migrate from blood and become macrophages
These phagocytose LDL–> foam cells
Smooth muscle proliferation and migration from tunica media into intima
Results in a fibrous capsule covering fatty plaque
Symptoms of ACS
Central/L chest pain
Radiate to jaw or left arm
Heavy
Dyspnoea
Sweating
N+V
Different presentation of ACS in diabetic/elderly pts?
Silent! Asymptomatic!
Signs of ACS
Slight tachy
Pt may appear pale and clammy
2 most important Ix when assessing chest pain
ECG
Cardiac markers eg trop
ECG changes in V1-V4. Type of MI and coronary artery involved
Anterior, LAD
ECG changes in II,III, aVF. Type of MI and coronary artery involved
Inferior, right coronary
ECG changes in I, V5-6. Type of MI and coronary artery involved
Lateral, left circumflex
Diagnostic features of a STEMI
Clinical symptoms consistent w ACS
ECG changes in > 2 contiguous leads
2.5 mm (i.e ≥ 2.5 small squares)
ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm (i.e ≥ 2 small squares)
ST elevation in leads V2-3 in men over 40 years
1.5 mm ST elevation in V2-3 in women
1 mm ST elevation in other leads
New LBBB
Diagnostic features NSTEMI
Needs 2 of following
1)Cardiac chest pain
2) No ST elevation
ST depression or
T wave inversion or
Pathological Q waves
3) raised trops
When can we rule out STEMI/NSTEMI and diagnose unstable angina?
If trops are normal and ECG shows no pathological changes
Causes of raised trops (other than ACS)
Chronic renal failure Sepsis Myocarditis Aortic dissection PE
Acute STEMI treatment
Targeted O2 therapy aim >90%
Loading 300mg aspirin
Can also add 2nd antiplatelet such as clopidogrel 300mg or ticagrelor 180mg
Sublingual GTN spray
Morphine
Primary PCI (if available within 2 hrs AND within 12 hours of onset) Thrombolysis (if PCI not available within 2 hrs)
Thrombolysis medication examples?
Streptokinase, alteplase and tenecteplase
Acute NSTEMI treatment
Targeted O2 therapy
Aspirin 300mg and fondaparinux
GRACE score calculated: anything other than lowest risk need ticagrelor or prasugrel
If high brisk bleed then PO clopidogrel 300mg
Morphine
Nitrates
What type of drug do patients undergoing fibrinolysis also need
antithrombin
Common management of ACS
PO Aspirin 300mg
O2 if <94
Morphine if severe pain
Nitrates- symptom relief
If pt is hypotensive what medication should we be cautious of in ACS treatment?
Nitrates
Management for NSTEMI is based on what tool?
GRACE
Age, HR, BP, cardiac and renal func, cardiac arrest on presentation
ECG findings
Trop levels
Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)?
Immediate: the clinically unstable
Within 72 hrs: GRACE score >3% risk of future CV events
If ischaemia is experienced, angiography considered
When do we do trops
Performed at least 3 hours after pain started and 6-12 hours after start of pain
