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Cardiovascular > ACS > Flashcards

ACS Flashcards

1
Q

What is ACS usually a result of?

A

A thrombus from an atherosclerotic plaque blocking coronary artery

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2
Q

What are the mainstays of treatment, why?

A
  • antiplatelets (aspirin, clopidogrel, ticagleror)

- when a thrombus forms in fast-flowing artery it’s made of many platelets

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3
Q

What does the Left coronary artery (LCA) become?

A

1) circumflex

2) left anterior descending (LAD)

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4
Q

What does the RCA supply?

A

RCA curves around R side of the heart + under:

  • -> R atrium
  • -> R ventricle (RMA)
  • -> inferior aspect L ventricle (PDA)
  • -> posterior aspect septum (PDA)
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5
Q

What does the circumflex supply?

A

Cx curves around top, L and back of heart:

  • -> L atrium
  • -> posterior aspect L ventricle
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6
Q

What does the left anterior descending artery supply?

A

LAD travels down the middle:

  • -> anterior aspect L ventricle
  • -> anterior aspect septum
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7
Q

3 types of ACS?

A

1) unstable angina
2) ST elevation myocardial infarction (STEMI)
3) Non-STEMI

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8
Q

symptoms?

A

Central, constricting chest pain assoc w/:

  • n&v
  • sweating & clammy
  • impeding doom feeling
  • SOB
  • palpitations
  • pain radiates to jaw/neck
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9
Q

How long should symptoms continue for?

A

Sx should continue at rest for at least 20 mins - otherwise consider stable angina

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10
Q

What’s a ‘silent MI’

A

diabetic patients not experiencing typical chest pain during ACS

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11
Q

Initial investigation?

A

ECG

  • -> diagnose STEMI if (1) ST elevation or (2) new LBBB
  • -> perform drops if no ST-elevation
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12
Q

If no ST elevation on ECG, what’s next investigation?

A

Troponin blood tests

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13
Q

Diagnosis of NSTEMI?

A

1) raised troponin +/OR
2) other ECG changes:
- -> ST depression
- -> T wave inversion
- -> pathological Q wave

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14
Q

Diagnosis of unstable angina (or another cause such as MSK chest pain)?

A

1) normal troponin +

2) no pathological ECG changes

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15
Q

Specific regions of MI for left coronary artery (LCA) infarct?

A

LCA = anterolateral

Changes in I, aVL, V3-V6

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16
Q

Specific regions of MI for left anterior descending (LAD) infarct?

A

LAD = anterior

Changes in V1-4

17
Q

Specific region of MI for circumflex infarct?

A

Cx = lateral

Changes in I, aVL, V5-6

18
Q

Specific region of MI for right coronary artery (RCA) infarct?

A

RCA = inferior

Changes in II, III, aVF

19
Q

Troponins:

1) What measurements are required for diagnosis?
2) What is a rise in troponin consistent with?

A

1) Serial trops - at baseline (3hrs after symptoms) then at 6-12 hrs after symptom onset
2) Myocardial ischaemia - but non-specific

20
Q

Other causes of raised trops?

A

1) chronic kidney failure
2) sepsis
3) myocarditis
4) aortic dissection
5) PE

21
Q

Baseline investigations?

A

Obviously ECG –> trops

  • FBC (anaemia)
  • U&Es (renal function)
  • LFTs (statins)
  • lipid profile
  • TFTs
  • HbA1c and fasting glucose
22
Q

Additional investigations (alongside baseline, ECG + trops)

A

1) CXR - pulmonary oedema?
2) Echo - after event to assess functional damage
3) CT coronary angiogram - assesses coronary artery disease

23
Q

Examples of fibronlytic agents / thrombolysis?

A

Alteplase, streptokinase or tenecteplase

24
Q

Acute management of MI (STEMI)?

A

MONA:

  • Morphine (w/ metoclopramide)
  • Oxygen - according to BTS guidelines, aim >90%
  • Nitrates - GTN spray
  • Aspirin 300mg PO (
  • -> dual anti platelet w/ clopidogrel or ticagleror

THEN consider PCI or thrombolysis is meet criteria

25
Q

PCI vs. thrombolysis for MI (STEMI)?

A

If presents within 12 hours of pain onset, discuss with local cardiac team:

1) Primary PCI - if <2hrs since first medical contact
2) Thrombolysis - if >2hrs

26
Q

Acute management of NSTEMI?

A

BATMAN:

  • Beta-blocker (NOT ACUTE)
  • Aspirin 300mg PO
  • Ticagrelor 180mg (or clopidogrel 300mg)
  • Anticoagulate: treatment dose LMWH (enoxiparin or Fondaparinux)
  • Nitrates: GTN spray
27
Q

Anti-platelet to use if MI patient going for PCI?

A

Add prasugrel if patient not on anti-coagulation OR

Add clopidogrel if on anti-coagulation

28
Q

How would you assess need for PCI following NSTEMI?

A

GRACE score - predicts 6-month risk of death or repeat MI after having NSTEMI:
<5% low risk
5-10% medium risk
>10% high risk

29
Q

What would you offer if GRACE score was high risk?

A

offer angiogram within 96 hrs (4 days) of symptoms onset

30
Q

Complications of MI?

A

DREAD:

  • death
  • rupture of heart septum or papillary muscles
  • oEdema –> Heart failure
  • Dressler’s syndrome
31
Q

What is Dressler’s syndrome?

A

Post-MI syndrome, occurs 2-3 weeks after, caused by localised immune response resulting in pericarditis

32
Q

How does Dressler’s syndrome present?

A
  • pleuritic CP
  • low grade fever
  • pericardial rub on auscultation
    can cause –> pericardial effusion or tamponade
33
Q

Diagnosis of Dressler’s syndrome?

A

ECG –> global ST elevation, T wave inversion
Echo –> pericardial effusion
Raised inflammatory markers (CRP, ESR)

34
Q

Management of Dressler’s syndrome?

A

1) NSAIDs (aspirin, ibuprofen)
2) steroids if severe
3) pericardiocentesis

35
Q

Secondary Prevention medical management?

A

6 A’s:

1) Aspirin 75mg OD
2) Atorvastatin 80mg
3) ACEi (ramipril, titrate to 10mg OD)
4) Atenolol (bisoprolol)
5) Another anti platelet - ticagleror or clopidogrel
6) aldosterone antagonist if clinical heart failure (eplerenone)

36
Q

Secondary prevention lifestyle advice?

A
  • stop smoking
  • stop drinking alcohol
  • advise on diet, exercise, weight loss (mediterranean)
  • optimise co-morbidities
  • cardiac rehabilitation
37
Q

Types of MI?

A

T1 - traditional MI due to acute coronary event
T2 - ischaemia secondary to increased demand or reduced oxygen supply (severe anaemia, tachycardia, hypotension)
T3 - sudden cardiac death or cardiac arrest (ischaemic event)
T4 - MI requiring procedures (PCI, CABG, stenting)

Cardiovascular (6 decks)

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