ACS Flashcards
What is ACS usually a result of?
A thrombus from an atherosclerotic plaque blocking coronary artery
What are the mainstays of treatment, why?
- antiplatelets (aspirin, clopidogrel, ticagleror)
- when a thrombus forms in fast-flowing artery it’s made of many platelets
What does the Left coronary artery (LCA) become?
1) circumflex
2) left anterior descending (LAD)
What does the RCA supply?
RCA curves around R side of the heart + under:
- -> R atrium
- -> R ventricle (RMA)
- -> inferior aspect L ventricle (PDA)
- -> posterior aspect septum (PDA)
What does the circumflex supply?
Cx curves around top, L and back of heart:
- -> L atrium
- -> posterior aspect L ventricle
What does the left anterior descending artery supply?
LAD travels down the middle:
- -> anterior aspect L ventricle
- -> anterior aspect septum
3 types of ACS?
1) unstable angina
2) ST elevation myocardial infarction (STEMI)
3) Non-STEMI
symptoms?
Central, constricting chest pain assoc w/:
- n&v
- sweating & clammy
- impeding doom feeling
- SOB
- palpitations
- pain radiates to jaw/neck
How long should symptoms continue for?
Sx should continue at rest for at least 20 mins - otherwise consider stable angina
What’s a ‘silent MI’
diabetic patients not experiencing typical chest pain during ACS
Initial investigation?
ECG
- -> diagnose STEMI if (1) ST elevation or (2) new LBBB
- -> perform drops if no ST-elevation
If no ST elevation on ECG, what’s next investigation?
Troponin blood tests
Diagnosis of NSTEMI?
1) raised troponin +/OR
2) other ECG changes:
- -> ST depression
- -> T wave inversion
- -> pathological Q wave
Diagnosis of unstable angina (or another cause such as MSK chest pain)?
1) normal troponin +
2) no pathological ECG changes
Specific regions of MI for left coronary artery (LCA) infarct?
LCA = anterolateral
Changes in I, aVL, V3-V6
Specific regions of MI for left anterior descending (LAD) infarct?
LAD = anterior
Changes in V1-4
Specific region of MI for circumflex infarct?
Cx = lateral
Changes in I, aVL, V5-6
Specific region of MI for right coronary artery (RCA) infarct?
RCA = inferior
Changes in II, III, aVF
Troponins:
1) What measurements are required for diagnosis?
2) What is a rise in troponin consistent with?
1) Serial trops - at baseline (3hrs after symptoms) then at 6-12 hrs after symptom onset
2) Myocardial ischaemia - but non-specific
Other causes of raised trops?
1) chronic kidney failure
2) sepsis
3) myocarditis
4) aortic dissection
5) PE
Baseline investigations?
Obviously ECG –> trops
- FBC (anaemia)
- U&Es (renal function)
- LFTs (statins)
- lipid profile
- TFTs
- HbA1c and fasting glucose
Additional investigations (alongside baseline, ECG + trops)
1) CXR - pulmonary oedema?
2) Echo - after event to assess functional damage
3) CT coronary angiogram - assesses coronary artery disease
Examples of fibronlytic agents / thrombolysis?
Alteplase, streptokinase or tenecteplase
Acute management of MI (STEMI)?
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
PCI vs. thrombolysis for MI (STEMI)?
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
Acute management of NSTEMI?
BATMAN:
- Beta-blocker (NOT ACUTE)
- Aspirin 300mg PO
- Ticagrelor 180mg (or clopidogrel 300mg)
- Anticoagulate: treatment dose LMWH (enoxiparin or Fondaparinux)
- Nitrates: GTN spray
Anti-platelet to use if MI patient going for PCI?
Add prasugrel if patient not on anti-coagulation OR
Add clopidogrel if on anti-coagulation
How would you assess need for PCI following NSTEMI?
GRACE score - predicts 6-month risk of death or repeat MI after having NSTEMI:
<5% low risk
5-10% medium risk
>10% high risk
What would you offer if GRACE score was high risk?
offer angiogram within 96 hrs (4 days) of symptoms onset
Complications of MI?
DREAD:
- death
- rupture of heart septum or papillary muscles
- oEdema –> Heart failure
- Dressler’s syndrome
What is Dressler’s syndrome?
Post-MI syndrome, occurs 2-3 weeks after, caused by localised immune response resulting in pericarditis
How does Dressler’s syndrome present?
- pleuritic CP
- low grade fever
- pericardial rub on auscultation
can cause –> pericardial effusion or tamponade
Diagnosis of Dressler’s syndrome?
ECG –> global ST elevation, T wave inversion
Echo –> pericardial effusion
Raised inflammatory markers (CRP, ESR)
Management of Dressler’s syndrome?
1) NSAIDs (aspirin, ibuprofen)
2) steroids if severe
3) pericardiocentesis
Secondary Prevention medical management?
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)
Secondary prevention lifestyle advice?
- stop smoking
- stop drinking alcohol
- advise on diet, exercise, weight loss (mediterranean)
- optimise co-morbidities
- cardiac rehabilitation
Types of MI?
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)
