ACS Flashcards
How to take cardiac chest pain history - key questions?
- Site - show me where, do not point to own chest, keeps hands still
- Onset - what were you doing, was it sudden/gradual?
- Character - how would I make you have this pain eg stab, pin prick, sit on top of chest
- Radiation - jaw? L arm?
- Associated symptoms eg nausea, sweating, breathless
- Time/duration - have you had it before too?
- Exactebating/relieving - walking around? if lying down is pericarditis like pain always ask is it worse when you breathe in
- Severity - was it frightening?
Questions to ask in PMH for chest pain
Anyone ever told you you have…
* High blood pressure
* Diabetes
* High cholesterol
* Do you smoke? Have you ever smoked?
If any of these, are they on medication for them and if so for how long…well managed?
What to ask for FH for chest pain?
- Have your parents or any of their children or any of your children ever had any heart problems or strokes?
- Are your parents still alive? If not, what did they die of?
What is ACS?
Ruptured plaque - chance determines whether it will present with STEMI, NSTEMI or unstable angina
Least dangerous ACS
NONE - they are all dangerous
Treatment for STEMI - acute
- O2 and analgesia (O2 for healthy part of heart that is ok still, analgesia relieves pain and vasodilates)
- 300mg aspirin
- 2nd antiplatelet - Ticagrelor
- Then for primary PCI
Treatment for all ACS’s post discharge
- ACEi - Ramipril
- Beta blocker - eg Bisoprolol
- Cholesterol lowering - Atorvastatin 80mg
- Dual antiplatelet therapy - aspirin and ticagrelor/clopidogrel
ABCD
Additional medications soemone may need post STEMI apart from classic bundle
Medications for heart failure - eg furosemide, dapagliflozin
When can we stop the medications given after ACS?
- Can reduce statin dose to 20mg after 1yr
- Can stop second drug (eg ticagrelor) of dual antiplatelet therapy after 1 year
- ACEi, beta blocker and aspirin is for life usually
PCI vs thrombolysis
PCI is better because:
* Less risky
* More effective - TIMI 2 and 3 flow is higher percentage of pts
* Treatment is straight away
* Can see flow there and then - knowledge is power, can treat other impaired vessels
* Cheaper
Management for NSTEMI and unstable angina
- O2 and analgesia
- Aspirin 300mg
- Ticagrelor or Clopidogrel
- LMWH - 4 doses only, 1mg/kg BD
- Cath lab for PCI within 72hrs
How to decide between ticagrelor or clopidogrel for NSTEMI/unstable angina management
- Clopidogrel given when low eGFR (renal impairement) OR if older than 75
- Ticagrelor given if going straight to lab or diabetic
Reasons for somoeone not suitable/having PCI
- Pt doesn’t want it
- Dementia - mild is ok but need to be still
- Actively bleeding - use IV heparin before stent - look out for iron def anaemia, could signal this
- Renal impairement - use contrast for angiogram
- Frailty score >5
Renal impairement and no PCI
- If Cr more than 150 - think about not doing it
- If more than 200 - more thinking about not doing it
- If more than 300 - do not take
Bystander disease and PCI
- Guidelines are now if it’s suitable time to treat, consider treating all disease present in all coronary arteries
- Not just artery causing STEMI etc
- If other disease present, consider placing stent here too
