ACS Flashcards
What is Acute Coronary Syndrome (ACS)?
ACS is the acute presentation of ischaemic heart disease due to narrowing or blockage of coronary arteries
Also known as coronary artery disease.
What are the three main presentations of ACS?
- ST elevation myocardial infarction (STEMI)
- Non-ST elevation myocardial infarction (NSTEMI)
- Unstable Angina
What is the pathophysiology of ACS?
Atherosclerosis leading to:
* Gradual narrowing —> reduced blood flow and O2
* Sudden plaque rupture —> artery occlusion —> MI
What are early changes seen in Artheloclerosis?
- Endothelial dysfunction - inflammation
- Fatty infiltration of subendothelial space by LDL
What are the complications associated with plaque formation?
- Partial or complete vessel occlusion
- Plaque rupture
What are non-modifiable risk factors for ACS?
- Increasing age
- Male gender
- Family history
What are modifiable risk factors for ACS?
- Smoking
- Diabetes Mellitus (DM)
- Hypertension (HTN)
- Hypercholesterolaemia
- Obesity
What are common symptoms of ACS?
- Chest pain (central/left, radiates to jaw/left arm, heavy)
- Dyspnoea
- Sweating
- Nausea and vomiting
- Palpitations
True or False: Chest pain is always present in ACS.
False
Chest pain may not always be present, especially in females, the elderly, and diabetics.
What signs may be observed in a patient with ACS?
- Vital signs may be fine but may show tachycardia
- Pale and clammy skin
- Signs of heart failure if severe
What investigations are done for ACS?
- Cardiac markers (Troponin, CK-MB)
- ECG imaging
What ECG changes are present in an MI?
- ST-segment elevation (STEMI) or depression (non-STEMI)
- T-wave inversion
- Pathological Q-waves
What type of MI has ECG chnages in leads V1-V4 or V1-V6, I and aVL?
Anterior
What type of MI has ECG chnages in leads II, III and aVF?
Inferior
What type of MI has ECG chnages in leads I, V5-6?
Lateral
Where is the coronary ischemia located is an anterior MI?
Left anterior decending (LAD)
Where is the coronary ischemia located is an inferior MI?
Right Coronary
Where is the coronary ischemia located is a lateral MI?
Left circumflex
What is the emergency treatment acronym for ACS?
MOAN:
* Morphine (IV for severe chest pain)
* Oxygen (if sat <94%)
* Aspirin (300 mg)
* Nitrates (IV or sublingual)
What are the STEMI criteria based on ECG findings?
- ST elevation in leads V2-V3 (2.5mm-1.5mm)
- New Left Bundle Branch Block (LBBB)
What is Percutaneous Coronary Intervention (PCI)?
Also known as coronary angioplasty or stenting, performed via radial or femoral artery
Radial access is preferred.
What is the time limit in performing PCI on a patient with a STEMI?
Within 120mins
If a PCI can be performed for a patient with a STEMI, what is the management?
PCI within 120mins:
- Give praugrel (anti-platelet)
- Unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
If a PCI cannot be performed for a patient with a STEMI, what is the management?
Fibrinolysis:
* Thrombolytic agent for fibrinolysis: Streptokinase, alteplase, tenecteplase
* Prescribe with anti-platelet: Fondaparinux
What scoring system is used to decide the treatment pathway in a NSTEMI or unstabel angina
GRACE score
The Global Registry of Acute Coronary Events
What is the Global Registry of Acute Coronary Events (GRACE)?
A risk assessment score for NSTEMI or unstable angina based on multiple factors including:
* Age
* Heart rate and blood pressure
* Cardiac and renal function
* ECG findings
* Troponin levels
Initial treatment of an NSTEMI/unstabel angina
1) Aspiriin 300mg
2) Fondaparinux (if no immediate PCI planned
3) Estimate GRACE score
Fill in the blank: Conservative treatment for NSTEMI is indicated if GRACE score is _______.
less than 3%
What is the conservative management of unstabel angina/NSTEMI? (GRACE <3%)
‘Dual antiplatelet therapy’: Aspirin + Tricagrelor (pt. NOT high bleeding risk) OR Clopidogrel (pt. HIGH bleed risk)
What is the high risk management of unstable angina/NSTEMI? (GRACE >3%)
- PCI within 72hrs
- Drug treatment: unfractionated heparin + ‘dual antiplatelet therapy’ (aspirin + prasugrel/ticagrelor OR Clopidogrel) prior to PCI
What do raised troponin levels indicate?
Heart muslce damaged causing troponin release
What is the long term management for NSTEMI/STEMI (5 pillars of ACS)?
(1) Conservative: lifestyle change
(2) Medication:
- Dual antiplatelet therapy = Aspirin (lifelong) + 2nd antiplatelet for 12 months
- Secondary prevention medications: ACE inhibitor, statin, B-blocker
- PPI (due to aspirin)
What does the Killip Class system stratify?
It stratifies risk prognosis post-MI based on factors such as age, heart failure, and elevated cardiac markers.
What are some complications of ACS?
- Arrhythmias (e.g., AF, heart block)
- Ischaemia (further MI)
- Pericarditis
- LV thrombus
- Cardiogenic shock
- Sudden death
What advice is given post-MI regarding travel?
- Car: 1 week after successful angioplasty (LVEF >40%)
- Bus/HGV: inform DVLA, reapply in minimum of 6 weeks
- Flight: wait 7-10 days
