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
