ACS Flashcards
What is ACS?
• Acute coronary syndrome (ACS) is usually the result of a thrombus from an atherosclerotic plaque blocking a coronary artery.
What is a thrombus mainly formed of if it is formed in a fast flowing artery e.g. coronary artery?
Platelets
.: antiplatelets best meds
What are the 3 types of ACS?
○ Unstable angina
○ ST-elevation myocardial infarction (STEMI)
○ Non-ST-elevation myocardial infarction (NSTEMI)
What are the signs and symptoms of ACS? (8)
Central, constricting chest pain
• Pain radiating to the jaw or arms
• Nausea and vomiting
• Sweating and clamminess
• A feeling of impending doom
• Shortness of breath
• Palpitations
• Tachycardia
How long do symptoms last in ACS?
Continue at rest for more than 15 mins
Which patients are most at risk of silent MIs?
Diabetes
What ecg changes can be seen in a STEMI? (2)
• ST-segment elevation
• New left bundle branch block
What ecg changes can be seen in an NSTEMI or unstable angina? (2)
• ST segment depression
• T wave inversion
What do pathological Q waves suggest on an ecg in suspected ACS?
suggest a deep infarction involving the full thickness of the heart muscle (transmural) and typically appear 6 or more hours after the onset of symptoms.
What artery and heart area are associated with ecg leads I, aVL, V3-6?
Left coronary artery
Anterolateral
What artery and heart area are associated with ecg leads V1-4?
Left anterior descending
Anterior
What artery and heart area are associated with ecg leads I, aVL, V5-6?
Circumflex
Lateral
What artery and heart area are associated with ecg leads II, III, aVF?
Right coronary artery
Inferiro
What heart area and ecg leads are associated with the left coronary artery?
Anterolateral
I, aVL, V3-6
What heart area and ecg leads are associated with the left anterior descending artery?
Anterior
V1-4
What heart area and ecg leads are associated with the circumflex artery?
Lateral
I, aVL, V5-6
What heart area and ecg leads are associated with the right coronary artery?
Inferior
II, III, aVF
Where is troponin released from?
Cardiac and skeletal muscle
What type of ACS is troponin used to diagnose?
NSTEMI
• They are not required to diagnose a STEMI, as this is diagnosed based on the clinical presentation and ECG findings.
What are some alternative causes of raised troponin aside from an NSTEMI? (5)
○ Chronic kidney disease
○ Sepsis
○ Myocarditis
○ Aortic dissection
○ Pulmonary embolism
What are the modifiable risk factors of ACS? (5)
High cholesterol
Hypertension
Smoking
Diabetes
Obesity
What are the non-modifiable risk factors of ACS? (4)
Age
Family history
Male sex
Premature menopause
What pneumonic is used to remember the key complications of an MI?
Dread
D – Death
R – Rupture of the heart septum or papillary muscles
E – “oEdema” (heart failure)
A – Arrhythmia and Aneurysm
D – Dressler’s Syndrome
When does Dressler’s syndrome usually occur?
around 2 – 3 weeks after an acute myocardial infarction.
What is Dressler’s syndrome?
• It is caused by a localised immune response after an MI that results in inflammation of the pericardium, the membrane that surrounds the heart (pericarditis).
What is the presentation of Dressler’s syndrome? (3)
○ pleuritic chest pain
○ low-grade fever
○ pericardial rub on auscultation = rubbing, scratching sound that occurs alongside the heart sounds.
What investigates are used to diagnose Dressler’s syndrome? (3)
ECG = global ST elevation and T wave inversion
Echo - pericardial effusion
Raised inflammatory markers
What is the management of Dressler’s syndrome? (3)
○ NSAIDs (e.g., aspirin or ibuprofen)
○ in more severe cases, steroids (e.g., prednisolone).
○ Pericardiocentesis may be required to remove fluid from around the heart, if there is a significant pericardial effusion.
What are the 4 types of MI?
• Type 1: Traditional MI due to an acute coronary event
• Type 2: Ischaemia secondary to increased demand or reduced supply of oxygen (e.g. secondary to severe anaemia, tachycardia or hypotension)
• Type 3: Sudden cardiac death or cardiac arrest suggestive of an ischaemic event
Type 4: MI associated with procedures such as PCI, coronary stenting and CABG
What is the initial management of suspected acs?
Mona
M - IV Morphine - with an antiemetic e.g. Metoclopramide (only if in significant pain as can increase mortality)
O - Oxygen (if under 94 OR under 88 with hypercapnic retention)
N – Nitrate (sublingual GTN = vasodilator)
A – Aspirin 300mg
When does pci need to be done in STEMI management?
Within 2 hours of presenting
When is Thrombolysis used in management of STEMI?
If pci is not available within 2 hours
What are some examples of fibrinolytic agents?
Streptokinase
Alteplase
Tenectoplase
What is the management of an NSTEMI?
B – Beta blockers
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose then 90mg BD (clopidogrel if high bleeding risk, or prasugrel if having angiography)
M – Morphine titrated to control pain
A – Antithrombin therapy with fondaparinux 2.5mg subcutaneous (unless high bleeding risk or immediate angiography)
N – Nitrate (sublingual GTN)
What dose of aspirin is given in NSTEMI management?
300mg stat dose
What dose of ticagrelor is given in NSTEMI treatment?
180mg stat dose then 90mg BD
What is the GRACE score?
What is considered low, medium and high risk?
• The GRACE score gives a 6-month probability of death after having an NSTEMI.
• 3% or less is considered low risk
• Above 3% is considered medium to high risk
When is angiography used in NSTEMI?
• Patients at medium or high risk are considered for early angiography with PCI (within 72 hours).
What is the ongoing management required after a STEMI or NSTEMI? (3)
• Echocardiogram once stable to assess the functional damage to the heart, specifically the left ventricular function
• Cardiac rehabilitation
○ Advise on lifestyle, driving, flying and sex
○ Tailored physical activity
○ Stress management
○ Health and lifestyle education
• Secondary prevention
What are the medications for secondary prevention of ACS?
Aspirin 75mg once daily indefinitely
Another Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months
Atorvastatin 80mg once daily
ACE inhibitors (e.g. ramipril) titrated as high as tolerated
Atenolol (or another beta blocker – usually bisoprolol) titrated as high as tolerated
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
