ACS Flashcards
How do you diagnose ACS?
-Presence of cardiac biomarker, preferably troponin T
AND one of following above 99th percentile:
- Symptoms of MI
- New ischaemic ECG change
- PAthological Q waves develop on ECH
- Imaging - loss of viable myocardium/regional wallmotion abnoramlity
- Intracoronary thrombus detected on angiography or autospy
What other cardiac biomarkers suggest ACS other than troponin T?
Myoglobulin
Creatine Kinase
WHy is troponin t used when diagnosing ACS?
Most sensitive test for MI out of other biomarkers
When do you use Smith modified Sgarbossa criteria
When significant pre existing CVD eg CAD makes it difficult to differentiate between prev damage and current MI and there is LBBB or paced MI
What is teh SMith modified Sgarbossa criteria?
≥ 1 lead with ≥1 mm of concordant ST elevation
≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST depression
≥ 1 lead anywhere with ≥ 1 mm STE and proportionally excessive discordant STE, as defined by ≥ 25% of the depth of the preceding S-wave.
How much ST elevation is required to diagnose posterior MI - leads V7-9
0.5
What do you need to look for evidence of in an ECG of an inferior or lateral MI?
Posterior MI - often missed
Lack of obvious ST elevation - be vigilant
When does posterior MI often occur?
As an extension of an inferior or lateral infarct
Why are outcomes for posterior MI worse than others?
Majority of posterior MIs are extension of inferior or lateral, therefore finding implies much larger area of Myocardial damage, increasing risk of LV dysfunction and death
What is an isolated posterior infarction indication for?
Emergnecy coronary repurfusion eg stent
Early management for NSTEMI and unstable angina
Antiplatelet therapy - 300mg aspirin loading dose then continue
Fondiparinux
When dont give fondiparinux in NSTEMI/unstable angina
high bleeding risk or angiography immediately planned
Factors when determining bleeidng risk
Advancing age, renal impairment, bleeding ocmplications, on anticoags already, low body weight
When do you use unfractionated heparin instead of fondiparinux for antithrombin therapy
If creatinine above 265 micromoles/L or high bleeding risk
What score can you use to predict mortality + risk of CVS events from ACS?
GRACE - 6 month
Investigations for NSTEMI/ unstable angina after initial management
GRACE score
Hisotry
Exam
12 lead ECG
bloods - Troponin T
Creatinine
Glucose
Haemoglobin
What seperates low and intermediate to high risk for NTEMI/unstable angina?
3% mortality in next 6 months - under or above
What to do with low risk patients unstable angina/NSTEMI
Conservative management
(aware that some young people benefit from early angiography)
Offer ticagreolor with aspirin
Consider ischaemia test before discharge
When do you offer clopidogrel instead of ticagrelor/prasugrel for managment of NSTEMI/unstable angina?
When theres a high bleeding risk or patient is on oral anticoagulants
When consider angiography for NSTEMI/unstable angina
Ischaemia develops or shown on testing
What should you always assess as a last step before rehab in NSTEMI and consider in unstable angina?
Left ventricular function
Long term management for NSTEMI/unstable angina
Cardiac rehab and secondary prevention
Consider CABG - coronary artery bypass graft - if unable to stent
Lifestyle
When offer angiograph and PCI for NSTEMI/unstable angina
INtermediate or high riskm mortality >3% in next 6 month s
Immediate if unstable
If stable consider in next 72 hours if no contraindications eg comorbidity or active bleeding
What to give before PCI
Prasugrel (careful if theyre over 75)
Unfractionated heparin
Associated symptoms with MI
-SOB
-Collapse/syncope
-Nausea
-Fear of impending doom
-palpitations
How long does chest pain have to go on for to be an MI
> 20 minutes
What causes collapse in MI?
arrhytmia or hypotension
sIGNS OF MI
-Unwell
-Pallor/grey
-Sweaty
Signs of shock
-Hypotension
-Cool peripheries
-Raised cap refill
-Tachycardic
Signs of complications
-Pulmonary oedema
-New murmur
-Arrhtymias
-Hypoxia
Non modifiable risk factors MI
Male
Age
FHx CAD - before 50 sudden death
Premature menopause
Modifiable risk factors for ACS
Smoking
T2DM
Hypertension
Dyslipidemia
Obestiy
Physical inactivity
What is Troponin T evidence of?
Myocardial necrosis
What drugs are used for secondary preventuon of MI?
DABS
-dual antiplatelet therapy for 1 year - aspirin + ticagrelor, than aspirin lifelong
-ACEis ir ARB
-Beta blockers
-Statins
Aldosterone antagonist - acute MI, HF, LV systolic dysfunction
-Diabetic control and HPTN
What is a common cardiac side effect of cyclizine?
Tachycardia
MOA of fondaparinux
Inhibits factor X
Which Leads and myocardial area are affected when the proximal LAD is blocked?
V1-V2, septal
What artery is blocked when there are changes in V3-V4 and what section of the myocardium?
Anterior, LAD
What leads show changes when the LCx artery is occluded?
I + aVL as the lateral part of the myocardium is affected
What vessel is occluded in 10% of the population in an Inferior MI?
LCx
If there are ECG changes in 2, aVF, 3 then what part of the myocardium is affected? Which is the most likely artery to be occluded?
INferior, 90% RCA
Which arteries can be occluded that cause changes in V5-V6 and why?
Distal LAD, LCx or RCA because they supply the apical myocardium
Absolute contraindications for fibrinolytic therapy
Prev haemorrhagic stroke
Ischaemic stroke in prev 6 months
Central nervous system trauma or neoplasm
Recent <3months major surgery, head injury or major trauma
Active internal bleeding or GI bleeding in last month
Known or suspected aortic dissection
Known bleeding disorder
Relative contraindications for fibrinolysis
Refractory HPTN >180
TIA last 6 months
Oral anticoags
Pregnant or <1 week pp
Traumatic CPR
Active peptic ulcer disease
Advanced liver disease
Infective endocarditis
Prev allergy to fibrinolytic
Features of stable angina
- Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw and arms
- Precipitated by exertion
- Relieved by rest or GTN spray in 5 mins
- Patients with 2 features have atypical, with 1 have non anginal chest pain
- ECG, CT angiogram
Primary prevention of ACS
Aspirin 75mg OD
Statin
If diabetic, ACE inhibiotr
Angina prevention 1st line
Beta blocker or CCB
Alternatives - Isosorbide mononitrate, nicrandil, ivabradine, ranolazine
Angina prevention 2nd line
Add the type of drug
Why use a GTN spray sitting down
Vasodilation causes drop in BP, avoid dizziness and fainting
How to use GTN spray
1-2 puffs wait 5 mins for pain to subside, if doesn’t go again
If no relief on second spray + gets worse call 999
What are the sokow-lyon criteria? If positive what does it show?
Voltage of S wave in V1
R wave V5 or V6
If both are present >35mm
LVH
What is a type I MI
Plaque rupture/erosion
+ troponin, new ECG changes
Type 2 MI
Ishcaemic
+ve biomearkers, new ECG changes
Type 3 MI
Cardia death in patients with sus MI before cardiac biomarker smapling
Type 4 vs 5 MI
4 = PCI related
5 = Coronary artery bypass graft surgery related
What ST elevation required in standard leads for STEMI
1mm
What are the non standard leads in STEMI and what ST elevation required for diagnosis
V2-3 = 2mm in men > 40
>1.5mm in women
V7-9 - post leads - 0.5mm
Differentials for ST elevation groups of causes
Infection
Arrhytmia
Structural
Electolyte
Vascular
Infective and structural causes of ST elevation
- Pericarditis
- Myocarditis
-LV hypertrophy
-Takutsobos CM
Arrhythmias that can cause raised ST elevation
LBBB
Benigin early repolarisation
Brugada syndrome
RV pacin
Post direct current cardioversion
Pre-excitiation
Electrolyte causes of raised ST
Hyperkalaemia
Hypercalcemia
Hypothermia
Vascualr causes of ST elevation (non MI)
Subarrach or IC haemorrhage
Massive PE
Spontaneous Coronary dissection
Coronary vasospasm
Time restrictions on PCI for treating STEMI
Less than 2 hours from 1st medical contact
<12 hours since chest pain
Persistent ST elevation
When is revascularisation appropriate
- Clinical presentation
- Comorbidities
- Risk stratification
- Frailty
- Cognitive status
- Estimated life expectancy
- Functional and anatomical severity of Coronary Artery Disease (CAD).
What very high risk NSTEMIs do you treat with immediate invasive treatment within 2 hours
- Haemodynamically unstable
- Electrical instability
- Acute HF
- Refractory chest pain
- Mechanical complciation of MI
- Recurrent dynamic ST wave changes
2What high risk NSTEMI do you treat with early invasiv procedure within 24 hours
Established NSTEMI diagnosis and elevated troponins
Dynamic ST wave changes
GRACE score>140
What intermediate risk STEMI features mean you treat invascively within 73 hours
T2DM, CKD
LVEF<40% or CCF (congestive HF)
Early post infarct angina or prior PCI/ABG
GRACE score 109-140
Secondary preventatitve meds
- Statin
- Beta blocker
- ACEi/ARB/ARNi
- Antianginals - if residual coronary disease eg nitrates
