ACS Flashcards
What is acute coronary syndrome (ACS)?
ACS is an umbrella term covering a number of acute presentations of ischaemic heart disease.
What are the presentations included in ACS?
The presentations include ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina.
What is unstable angina?
Unstable angina is considered present in patients with ischaemic symptoms suggestive of ACS and no elevation in troponins, with or without ECG changes indicative of ischaemia.
How does ischaemic heart disease develop?
ACS generally develops in patients who have ischaemic heart disease, either known or previously undetected.
What is ischaemic heart disease synonymous with?
Ischaemic heart disease is synonymous with coronary heart disease and coronary artery disease.
What leads to angina?
Gradual narrowing of coronary arteries results in less blood and oxygen reaching the myocardium at times of increased demand, causing angina.
What are the two main problems caused by fatty plaque buildup?
- Gradual narrowing of arteries leading to angina. 2. Risk of sudden plaque rupture causing occlusion.
What are unmodifiable risk factors for ischaemic heart disease?
Unmodifiable risk factors include increasing age, male gender, and family history.
What are modifiable risk factors for ischaemic heart disease?
Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolaemia, and obesity.
What triggers initial endothelial dysfunction?
Initial endothelial dysfunction is triggered by factors such as smoking, hypertension, and hyperglycaemia.
What happens to monocytes in ischaemic heart disease?
Monocytes migrate from the blood and differentiate into macrophages, which phagocytose oxidized LDL, turning into foam cells.
What complications can develop from atherosclerosis?
Complications include physical blockage of the coronary artery causing angina and plaque rupture leading to myocardial infarction.
What is the classic symptom of ACS?
The classic symptom of ACS is chest pain, typically central/left-sided and may radiate to the jaw or left arm.
What are other symptoms of ACS?
Other symptoms include dyspnoea, sweating, nausea, and vomiting.
What are the two most important investigations for chest pain?
The two most important investigations are ECG and cardiac markers such as troponin.
What does an ECG show in STEMI?
An ECG in STEMI shows ST elevation in specific leads, indicating which coronary arteries are blocked.
What is the mnemonic for the treatment of ACS?
The mnemonic is MONA: Morphine, Oxygen, Nitrates, Aspirin.
What is the priority of management for STEMI?
The priority is to revascularise the blocked vessel.
What is the treatment for NSTEMI?
Risk stratification tools like GRACE are used to decide further management for NSTEMI patients.
What is included in standard therapy for secondary prevention after ACS?
Standard therapy includes aspirin, a second antiplatelet if appropriate, a beta-blocker, an ACE inhibitor, and a statin.
What is a common symptom of acute coronary syndrome (ACS)?
Chest pain
Classically on the left side of the chest.
Where may chest pain from ACS radiate?
To the left arm or neck.
What factors may lead to atypical presentations of ACS?
Being elderly, diabetic, or female.
What is another symptom of ACS besides chest pain?
Dyspnoea.
What gastrointestinal symptoms may accompany ACS?
Nausea and vomiting.
What is a common autonomic symptom of ACS?
Sweating.
What cardiovascular symptom may occur in ACS?
Palpitations.
What is acute coronary syndrome (ACS)?
ACS is a very common and important presentation in medicine.
How has the management of ACS evolved?
The management has evolved with the development of new drugs and procedures such as percutaneous coronary intervention (PCI).
What are the classifications of acute coronary syndrome?
- ST-elevation myocardial infarction (STEMI)
- Non ST-elevation myocardial infarction (NSTEMI)
- Unstable angina
What are the common management strategies for ACS?
- Initial drug therapy: aspirin 300mg, oxygen if saturations < 94%, morphine for severe pain, nitrates.
- Management depends on the ACS subtype.
What are the STEMI criteria?
Clinical symptoms consistent with ACS for ≥ 20 minutes with persistent ECG features in ≥ 2 contiguous leads.
What is the first step after confirming a STEMI?
Immediately assess eligibility for coronary reperfusion therapy.
What are the types of coronary reperfusion therapy for STEMI?
- Percutaneous coronary intervention (PCI)
- Fibrinolysis
When should PCI be offered for STEMI?
If presentation is within 12 hours of symptom onset and PCI can be delivered within 120 minutes.
What is dual antiplatelet therapy prior to PCI?
Aspirin + another drug (prasugrel if not on anticoagulant, clopidogrel if on anticoagulant).
What should be done if fibrinolysis fails?
If ST elevation persists after 60-90 minutes, consider transfer for PCI.
What is the management for NSTEMI/unstable angina?
Depends on individual patient factors and risk assessment.
What is the Global Registry of Acute Coronary Events (GRACE)?
A tool for risk assessment that considers age, heart rate, blood pressure, cardiac function, and troponin levels.
What are the risk stratifications based on GRACE score?
- 1.5% or below: Lowest
- > 1.5% to 3.0%: Low
- > 3.0% to 6.0%: Intermediate
- > 6.0% to 9.0%: High
- Over 9.0%: Highest
Who should have immediate coronary angiography?
Clinically unstable patients (e.g., hypotensive).
What is the further drug therapy for NSTEMI/unstable angina?
Antithrombin treatment: fondaparinux or unfractionated heparin.
What is the conservative management for NSTEMI/unstable angina?
Further antiplatelet therapy: ticagrelor if not at high risk of bleeding, clopidogrel if at high risk.
What study was used to derive regression models for predicting death in patients with acute coronary syndrome?
The 2006 Global Registry of Acute Coronary Events (GRACE) study.
What are some poor prognostic factors in acute coronary syndrome?
Age, development (or history) of heart failure, peripheral vascular disease, reduced systolic blood pressure, initial serum creatinine concentration, elevated initial cardiac markers, cardiac arrest on admission, ST segment deviation.
What is the Killip class?
A system used to stratify risk post myocardial infarction.
What are the features and 30-day mortality rates for Killip class I?
No clinical signs of heart failure; 30-day mortality is 6%.
What are the features and 30-day mortality rates for Killip class II?
Lung crackles, S3; 30-day mortality is 17%.
What are the features and 30-day mortality rates for Killip class III?
Frank pulmonary oedema; 30-day mortality is 38%.
What are the features and 30-day mortality rates for Killip class IV?
Cardiogenic shock; 30-day mortality is 81%.
