ACS Flashcards
Myocardial infarction (MI)
necrosis of myocardial tissue following occlusion of a coronary artery and subsequent ischaemia.
Initial Mx on suspicion of ACS
GTN 1-2 puffs 400-800mcg ( repeat every 5min pro, caution ifs <90SBP)
Aspirin 300mg stat
STEMI
completely occluded coronary artery
- Chest pain at rest or minimal exertion, lasting >15 minutes
- ECG changes (new ST-elevation or left bundle branch block)
- Rise in troponin: myocardial necrosis
Diagnosis of STEMI
- new ST-segment elevation in 2 or more contiguous leads.
- The ST elevation should be ≥2mm in the precordial leads or ≥1mm in the limb leads.
Treatment of STEMI
MMONAC Morphine 1-1-mg IV if pain Metoclopramide 10mg IV Oxygen (if sats <94%) Nitrates (GTN spray) Aspirin 300 mg (stat) Clopidogrel 300 mg (Although, in practice, other similar drugs such as Ticagrelor 180mg are increasingly being used)
Percutaneous Coronary Intervention (PCI) for STEMI can be considered if
- patients present within 12 hours of symptom onset and within 2 hours/120minutes of medical contact.
- They should be haemodynamically stable.
Drug therapy during PCI
heparin (unfractionated)
glycoprotein IIb/IIIa inhibitor (GPI)
Thrombolysis offered if
Patients present within 12 hours of symptom onset but after 2 hours of medical contact
provided they are stable and have no contraindications to its use, If there are contraindications PCI can be done
Contraindications to thrombolysis
Aortic Dissection GI bleed Allergic reaction Iatrogenic: recent surgery Neurological disease: recent stroke (within 3 months), malignancy Severe HTN (>200/120) Trauma, including recent CPR
NSTEMI
partially occluded coronary artery
- Chest pain at rest or minimal exertion lasting >15 minutes
- ECG changes (new ST-depression of T wave inversion)
- Rise in troponin: myocardial necrosis
Diagnosis NSTEMI
- typical symptoms of an ACS
- no ST segment elevation on ECG
- raised cardiac biomarkers.
NSTEMI stratification systems
Thrombolysis in Myocardial Infarction (TIMI) score or GRACE model
Global Registry of Acute Coronary Events (GRACE)
age
heart rate, blood pressure
cardiac (Killip class) and renal function (serum creatinine)
cardiac arrest on presentation
ECG findings
troponin levels
Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)?
immediate: patient who are clinically unstable (e.g. hypotensive)
within 72 hours: patients with a GRACE score > 3% i.e. those at intermediate, high or highest risk
coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission
NSTEMI low risk Mx
conservatively with medications.
Antithrombin therapy with fondaparinux sodium (2.5mg OD) should also be offered, Heparin (unfractionated) if renal impaired
Post ACS secondary prevention advice
cardiac rehabilitation programme including advice for lifestyle changes, stress management and health education.
Lifestyle-specific interventions to reduce their cardiovascular risk should include
- healthy eating
- reducing alcohol consumption,
- regular physical exercise(at least 150 min/week)
- smoking cessation
- weight management
ALL patients post-MI patients should be started on the following 5 drugs:
Dual antiplatelet therapy -aspirin (75mg) plus clopidogrel (75mg) /ticagrelor (90mg) usually given
Statin
Beta blocker
ACEi
Unstable angina
critical narrowing of coronary artery causing ischaemia
- Chest pain at rest or minimal exertion lasting >15 minutes
- ECG changes (new ST-depression or T wave inversion)
- NO rise in troponin: no myocardial necrosis
Unstable angina Mx
Treated same way as NSTEMI
Possible complications following a myocardial infarction (MI) include:
Acute/chronic heart failure
Post-infarction angina
Stroke
Depression
Anxiety disorders
Anxiety disorders
Sudden death
Angina
chest pain (or constricting discomfort) caused by an insufficient blood supply to the myocardium
occurs predictably with physical exertion or emotional stress, and is relieved within minutes of rest, or with a dose of sublingual glyceryl trinitrate
Angina Mx
Conservative: explain dx & mx, modify lifestyle/RF, when to call 999
Medical
GTN spray
primary
1. B blocker to slow down heart ( bisoprolol) or Ca blocker to reduce vessel constriction and BP ( Amlodipine)
2. long-acting nitrate (for example isosorbide mononitrate), nicorandil, ivabradine, or ranolazine.
Secondary prevention
1. antiplatelet (aspirin)
2. ACEi if comorbidities
3. statin if high lipids
