ACS Flashcards
What is ACS
Acute Coronary Syndrome
Which conditions are included in ACS?
STEMI
NSTEMI
Unstable angina
What other organ systems can cause chest pain?
Resp - PE, pleuritic chest pain, pleural effusion, pneumonia, pneumothorax
Gastro - GORD, oesophageal rupture
Aorta - aortic dissection
Intrabdominal - pancreatitis, cholecystitis
Derm - skin
Why is ACS important?
750-1250 STEMIs/million per year
5% inpatient mortality
How does ACS present?
Pain
- acute onset
- central, crushing, severe, radiates to left arm or jaw/throat
- associated with autonomic symptoms, nausea and diaphoresis
Cardiac arrest/Arrythmia
- VT/VF (or rarely CHB - complete heart block)
What investigations would you do
Take Hx
Serial ECGs (this is key as waiting for blood tests may be too late)
- 60mins into symptoms = 50% of ischaemic myocardium lost
- 180mins into symptoms = 66% of ischaemic myocardium lost
Troponin
What are the ECG finding for a STEMI?
ST elevation
- 2mm in contiguous chest leads
- 1mm in contiguous limb leads
- new LBBB
What are the ECG finding for a NSTEMI?
ST depression
T-wave inversion
Exclusion of STEMI features
What are the ECG finding for an unstable angina?
May have no clear ECG findings
What is the ACS protocol?
Symptom relief/supportive
- Morphine
- O2
- Antiemetic
Modify pathophysiology
- Nitrates
- Dual antiplatelets (Aspirin 300mg + one of: Clopidogrel 600mg, Ticagrelor 180mg, Prasugrel 60mg)
- LMWH e.g., Fondaparinux 2.5mg S/C OD
- Atorvastatin 80mg
Senior review and cardio opinion
For the ACS protocol what drugs would you prescribe on the Once Only and Pre-anaesthetic medication part?
STAT Aspirin PO 300mg
STAT Clopidogel PO 600mg
For the ACS protocol what drugs would you prescribe on the Chemical Thromboprophylaxis part?
Fondaparinux SC 2.5mg
For the ACS protocol what drugs would you prescribe on the Regular Medicines part?
Aspirin 75mg PO OD
Clopidogrel 75mg PO OD
Lansoprazole 30mg PO OD
Atorvastatin 80mg PO OD
Bisoprolol 2.5mg PO OD
Ramipril 2.5mg PO OD
For the ACS protocol what drugs would you prescribe on the As Required part?
Paracetamol 1g PO/IV QDS (max dose = 4mg)
Morphine 5-10mg PO 4 hourly
GTN /\ S/L (sublingual) PRN
For STEMI, what are the criteria for offering coronary angiography with follow up primary PCI if indicated?
Presentation within 12 hours of Sx onset
Primary PCI can be given within 120 minutes of the time when fibrinolysis could have been given
For people with STEMI that present 12 hours after their Sx onset what Tx should you give/consider?
Consider coronary angiography, with follow‑on primary PCI if indicated
If someone with STEMI presents within 12 hours of Sx but primary PCI cannot be given within 120 minutes, what Tx should they be given?
Fibrinolysis
Give an antithrombin at the same time
Offer an electrocardiogram (ECG) to people with acute STEMI treated with fibrinolysis, 60 to 90 minutes after administration
If after given fibrinolysis the patient has residual ST‑segment what does this suggest and what Tx should be given?
Failed coronary perfusion
Offer immediate coronary angiography, with follow‑on PCI if indicated
Do not repeat fibrinolytic therapy
If a person has recurrent myocardial ischaemia after fibrinolysis what should you do?
Seek immediate cardiology advice
if appropriate, offer coronary angiography, with follow‑on PCI if indicated
What is the Mx for people with STEMI not being treated with PCI?
Offer ticagrelor, as part of dual antiplatelet therapy with aspirin, unless they have a high bleeding risk
Consider clopidogrel, as part of dual antiplatelet therapy with aspirin, or aspirin alone, if they have a high bleeding risk
Offer medical management to people with acute STEMI who are ineligible for any reperfusion therapy
What should be assessed in all patient with a STEMI and NSTEMI before discharge? Why?
Left ventricular function
Some people have heart failure because of damage to heart muscle and impaired contraction of the left ventricle.
This is known as left ventricular systolic dysfunction (LVSD). The effectiveness of drug treatment with ACEis, ARBs, aldosterone antagonists and beta‑blockers depends on LV function.
What are the different post MI complications?
<3 days (often within hours). Arrythmias, heart block, stroke
<7 days. Free wall rupture, VSD, papillary muscle rupture
> 14 days. Dresslers syndrome
What is Dressler’s syndrome?
Inflammation of the sac surrounding the heart (pericarditis).
Believed to occur as the result of the immune system responding to damage to heart tissue or damage to the sac around the heart (pericardium)
What scoring system is used to predict 6-month mortality for unstable angina or NSTEMI?
Global Registry of Acute Cardiac Events (GRACE)
What should be included in a formal risk assessment for unstable angina or NSTEMI?
a full clinical history (including age, previous myocardial infarction [MI] and previous PCI or coronary artery bypass grafting [CABG])
A physical examination (including measurement of blood pressure and heart rate)
A resting 12‑lead ECG, looking particularly for dynamic or unstable patterns that indicate myocardial ischaemia
Blood tests (such as troponin I or T, creatinine, glucose and haemoglobin)
When should immediate coronary angiography be offered to people with unstable angina or NSTEMI?
If their medical condition is unstable
What drugs should be used in the Mx of NSTEMI?
BATMAN
Betablockers (e.g., bisoprolol)
Apsirin 300mg
Ticagrelor 180mg
Morphine
Anticoagulant (LMWH) - Fondaparinux
Nitrates
Do not offer dual antiplatelet therapy to people with chest pain before a diagnosis of unstable angina or NSTEMI is made.
When would you consider PCI in patients with NSTEMI or unstable angina? Within what timeframe would you do the PCI?
If they have an intermediate or high risk of adverse cardiovascular events (according to GRACE or TIMI) - i.e., their predicted 6-month mortality is above 3.0%
PCI within 72 hours
N.B. Be aware that some younger people with low risk scores for mortality at 6 months may still be at high risk of adverse cardiovascular events and may benefit from early angiography
What are the contraindications to thrombolysis?
Bleeding disorder
High INR
Recent surgery
Pregnant
Stroke in last 6m
Known GI bleed
Sources
https://www.nice.org.uk/guidance/ng185/resources/visual-summary-stemi-pdf-8900623405
https://www.nice.org.uk/guidance/qs99/chapter/quality-statement-1-assessment-of-left-ventricular-function
https://www.nice.org.uk/guidance/qs68/chapter/quality-statement-6-primary-pci-for-acute-stemi#:~:text=Adults%20with%20acute%20ST%2Dsegment,fibrinolysis%20could%20have%20been%20given.
https://www.nice.org.uk/guidance/ng185/chapter/Recommendations#stemi-early-management
How does Dressler’s syndrome typically present?
1-6 weeks after the initial MI
Pain + fever that may suggest further infarction
Pain - often in left shoulder + often pleuritic and worse on lying down
May be malaise, fever and dyspnoea
Could cause a cardiac tamponade or acute pneumonitis = rare
Pericardial friction rub may be hear (typically described as being like the sound of boots walking over fresh snow)
