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A- Resp and cardio > ACS > Flashcards

ACS Flashcards

1
Q

How do you diagnose ACS?

A

-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

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2
Q

What other cardiac biomarkers suggest ACS other than troponin T?

A

Myoglobulin
Creatine Kinase

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3
Q

WHy is troponin t used when diagnosing ACS?

A

Most sensitive test for MI out of other biomarkers

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4
Q

When do you use Smith modified Sgarbossa criteria

A

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

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5
Q

What is teh SMith modified Sgarbossa criteria?

A

≥ 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.

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6
Q

How much ST elevation is required to diagnose posterior MI - leads V7-9

A

0.5

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7
Q

What do you need to look for evidence of in an ECG of an inferior or lateral MI?

A

Posterior MI - often missed
Lack of obvious ST elevation - be vigilant

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8
Q

When does posterior MI often occur?

A

As an extension of an inferior or lateral infarct

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9
Q

Why are outcomes for posterior MI worse than others?

A

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

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10
Q

What is an isolated posterior infarction indication for?

A

Emergnecy coronary repurfusion eg stent

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11
Q

Early management for NSTEMI and unstable angina

A

Antiplatelet therapy - 300mg aspirin loading dose then continue
Fondiparinux

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12
Q

When dont give fondiparinux in NSTEMI/unstable angina

A

high bleeding risk or angiography immediately planned

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13
Q

Factors when determining bleeidng risk

A

Advancing age, renal impairment, bleeding ocmplications, on anticoags already, low body weight

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14
Q

When do you use unfractionated heparin instead of fondiparinux for antithrombin therapy

A

If creatinine above 265 micromoles/L or high bleeding risk

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15
Q

What score can you use to predict mortality + risk of CVS events from ACS?

A

GRACE - 6 month

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16
Q

Investigations for NSTEMI/ unstable angina after initial management

A

GRACE score
Hisotry
Exam
12 lead ECG
bloods - Troponin T
Creatinine
Glucose
Haemoglobin

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17
Q

What seperates low and intermediate to high risk for NTEMI/unstable angina?

A

3% mortality in next 6 months - under or above

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18
Q

What to do with low risk patients unstable angina/NSTEMI

A

Conservative management
(aware that some young people benefit from early angiography)

Offer ticagreolor with aspirin
Consider ischaemia test before discharge

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19
Q

When do you offer clopidogrel instead of ticagrelor/prasugrel for managment of NSTEMI/unstable angina?

A

When theres a high bleeding risk or patient is on oral anticoagulants

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20
Q

When consider angiography for NSTEMI/unstable angina

A

Ischaemia develops or shown on testing

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21
Q

What should you always assess as a last step before rehab in NSTEMI and consider in unstable angina?

A

Left ventricular function

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22
Q

Long term management for NSTEMI/unstable angina

A

Cardiac rehab and secondary prevention
Consider CABG - coronary artery bypass graft - if unable to stent
Lifestyle

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23
Q

When offer angiograph and PCI for NSTEMI/unstable angina

A

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

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24
Q

What to give before PCI

A

Prasugrel (careful if theyre over 75)
Unfractionated heparin

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25
Q

Associated symptoms with MI

A

-SOB
-Collapse/syncope
-Nausea
-Fear of impending doom
-palpitations

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26
Q

How long does chest pain have to go on for to be an MI

A

> 20 minutes

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27
Q

What causes collapse in MI?

A

arrhytmia or hypotension

28
Q

sIGNS OF MI

A

-Unwell
-Pallor/grey
-Sweaty
Signs of shock
-Hypotension
-Cool peripheries
-Raised cap refill
-Tachycardic
Signs of complications
-Pulmonary oedema
-New murmur
-Arrhtymias
-Hypoxia

29
Q

Non modifiable risk factors MI

A

Male
Age
FHx CAD - before 50 sudden death
Premature menopause

30
Q

Modifiable risk factors for ACS

A

Smoking
T2DM
Hypertension
Dyslipidemia
Obestiy
Physical inactivity

31
Q

What is Troponin T evidence of?

A

Myocardial necrosis

32
Q

What drugs are used for secondary preventuon of MI?

A

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

33
Q

What is a common cardiac side effect of cyclizine?

A

Tachycardia

34
Q

MOA of fondaparinux

A

Inhibits factor X

35
Q

Which Leads and myocardial area are affected when the proximal LAD is blocked?

A

V1-V2, septal

36
Q

What artery is blocked when there are changes in V3-V4 and what section of the myocardium?

A

Anterior, LAD

37
Q

What leads show changes when the LCx artery is occluded?

A

I + aVL as the lateral part of the myocardium is affected

38
Q

What vessel is occluded in 10% of the population in an Inferior MI?

A

LCx

39
Q

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?

A

INferior, 90% RCA

40
Q

Which arteries can be occluded that cause changes in V5-V6 and why?

A

Distal LAD, LCx or RCA because they supply the apical myocardium

41
Q

Absolute contraindications for fibrinolytic therapy

A

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

42
Q

Relative contraindications for fibrinolysis

A

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

43
Q

Features of stable angina

A
  1. Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw and arms
  2. Precipitated by exertion
  3. 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
44
Q

Primary prevention of ACS

A

Aspirin 75mg OD
Statin
If diabetic, ACE inhibiotr

45
Q

Angina prevention 1st line

A

Beta blocker or CCB
Alternatives - Isosorbide mononitrate, nicrandil, ivabradine, ranolazine

46
Q

Angina prevention 2nd line

A

Add the type of drug

47
Q

Why use a GTN spray sitting down

A

Vasodilation causes drop in BP, avoid dizziness and fainting

48
Q

How to use GTN spray

A

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

49
Q

What are the sokow-lyon criteria? If positive what does it show?

A

Voltage of S wave in V1
R wave V5 or V6
If both are present >35mm
LVH

50
Q

What is a type I MI

A

Plaque rupture/erosion
+ troponin, new ECG changes

51
Q

Type 2 MI

A

Ishcaemic
+ve biomearkers, new ECG changes

52
Q

Type 3 MI

A

Cardia death in patients with sus MI before cardiac biomarker smapling

53
Q

Type 4 vs 5 MI

A

4 = PCI related
5 = Coronary artery bypass graft surgery related

54
Q

What ST elevation required in standard leads for STEMI

A

1mm

55
Q

What are the non standard leads in STEMI and what ST elevation required for diagnosis

A

V2-3 = 2mm in men > 40
>1.5mm in women
V7-9 - post leads - 0.5mm

56
Q

Differentials for ST elevation groups of causes

A

Infection
Arrhytmia
Structural
Electolyte
Vascular

57
Q

Infective and structural causes of ST elevation

A
  • Pericarditis
  • Myocarditis
    -LV hypertrophy
    -Takutsobos CM
58
Q

Arrhythmias that can cause raised ST elevation

A

LBBB
Benigin early repolarisation
Brugada syndrome
RV pacin
Post direct current cardioversion
Pre-excitiation

59
Q

Electrolyte causes of raised ST

A

Hyperkalaemia
Hypercalcemia
Hypothermia

60
Q

Vascualr causes of ST elevation (non MI)

A

Subarrach or IC haemorrhage
Massive PE
Spontaneous Coronary dissection
Coronary vasospasm

61
Q

Time restrictions on PCI for treating STEMI

A

Less than 2 hours from 1st medical contact
<12 hours since chest pain
Persistent ST elevation

62
Q

When is revascularisation appropriate

A
  • Clinical presentation
  • Comorbidities
  • Risk stratification
  • Frailty
  • Cognitive status
  • Estimated life expectancy
  • Functional and anatomical severity of Coronary Artery Disease (CAD).
63
Q

What very high risk NSTEMIs do you treat with immediate invasive treatment within 2 hours

A
  • Haemodynamically unstable
  • Electrical instability
  • Acute HF
  • Refractory chest pain
  • Mechanical complciation of MI
  • Recurrent dynamic ST wave changes
64
Q

2What high risk NSTEMI do you treat with early invasiv procedure within 24 hours

A

Established NSTEMI diagnosis and elevated troponins
Dynamic ST wave changes
GRACE score>140

65
Q

What intermediate risk STEMI features mean you treat invascively within 73 hours

A

T2DM, CKD
LVEF<40% or CCF (congestive HF)
Early post infarct angina or prior PCI/ABG
GRACE score 109-140

66
Q

Secondary preventatitve meds

A
  • Statin
  • Beta blocker
  • ACEi/ARB/ARNi
  • Antianginals - if residual coronary disease eg nitrates

A- Resp and cardio (58 decks)

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