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Heart and lungs > ACS > Flashcards

ACS Flashcards

1
Q

Definition of a NSTEMI

A

Subtotal occlusion of coronary arteries leading to myocardial infarction. However there is no ST elevation however there may be T wave inversion or ST depression

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2
Q

Definition of a STEMI

A

Complete occlusion of a coronary artery causing myocardial infarction associated with an ST elevation

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3
Q

Definition of unstable angina

A

Chest pain provoked by minimal exercise or at rest caused by atheromatous plaque rupture causing platelet aggregation, lumen narrowing and tissue ischeamia. ST depression/T wave inversion may occur. No rise in troponin or CrK

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4
Q

Clinical features of ACS?

A

Severe anginal chest pain lasting longer than 20 minutes accompanied with autonomic symptoms of sweating, fatigue, vomiting and nausea. Some patients get pain radiating into back jaw and left arm.

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5
Q

Which patients may not suffer these symptoms as much or at all?

A

Elderly or poorly controlled/longstanding diabetics

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6
Q

What may you look for on examination?

A

Pulmonary oedema or systolic murmurs of aortic stenosis or mitral regurgitation

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7
Q

Investigations include what?

A

12 lead ECG, cardiac enzymes troponin I and T, FBC, BMs, echocardiogram, erect chest radiograph

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8
Q

What are you looking for on the ECG?

A

Any pathological Q waves, ST elevation, ST depression, T wave inversion. Normal ECG does not exclude ACS.

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9
Q

How long does it take for cardiac enzymes to become detectable?

A

6 hours

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10
Q

When does troponin I+T peak?

A

12-24 hours

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11
Q

How long do troponins remain raised?

A

Up to 14 days post MI

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12
Q

Why are troponins used over the old markers CK and myoglobin?

A

Troponins have greater sensitivity as a test in the first 6 hours

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13
Q

What are you looking for on a chest radiograph?

A

Pulmonary oedema as a result of ischeamia and any other diagnosis such as aortic dissection, aortic aneurysm, pneumothorax, PE

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14
Q

What might FBC show in ACS?

A

Shows if there is any anaemia. You might also test INR, CRP, TFT, RFTs

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15
Q

Lifestyle modification to prevent secondary attack includes what?

A

Smoking cessation, good glycemic control, hypertension control and cholesterol intake.

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16
Q

If diagnosis of NSTEMI or unstable angina is made what scoring system does NICE recocomment
For risk assessment for 6month mortality?

A

The GRACE scoring system (age, killip grade of CHF, HR, BP, previous interventions, history of MI etc)

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17
Q

Risk is split up into 3 groups which are?

A

Low (less than 3%), intermediate (3 to 6%) and high (above 6%)

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18
Q

Immediate management for suspected ACS

A

Resuscitation as required.
Pain relief: GTN and/or an intravenous opioid (use an antiemetic with opioids).
Single loading dose of 300 mg aspirin unless the person is allergic.
A resting 12-lead ECG - but don’t delay transfer to hospital.
Assess oxygen saturation, using pulse oximetry before hospital admission if possible. Give oxygen if oxygen saturation (SpO2) is less than 94% with no risk of hypercapnic respiratory failure; aim for SpO2 of 94-98% (aim for 88-92% for people with chronic obstructive pulmonary disease).

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19
Q

Secondary prevention of an MI if in the last year includes what drugs?

A
  • ACE (angiotensin-converting enzyme) inhibitor
  • Dual antiplatelet therapy (aspirin plus a second antiplatelet agent eg clopidogrel)
  • beta-blocker
  • statin
20
Q

First two things to do in intial treatment of a STEMI is?

A

ABC assesment/resus and a 12 lead resting ECG

21
Q

What do you do after attaching ECG?

A

Get IV access and take bloods for FBC, U+E, glucose, lipids, cardiac enzymes

22
Q

You have IV access and an ECG is running, what now?

A

History of Cardiovascular disease and examine (pulse, BP, JVP, signs of congestive cardiac failure=left send right failure), are there any scars from previous cardiac surgery?) and erect CXR if it won’t delay Rx

23
Q

What else MUST you ask the patient if not in records?

A

Any contraindications to PCI/fibrinolysis

24
Q

After the assessment stage what do you give?

A

300mg of aspirin of not given by paramedics, morphing 5-10mg IV AND anti emetic such as Metaclopramide 10mg IV

25
Q

The ECG confirms STEMI how soon do you need PCI to be available if it is to be used?

A

Less than 2 hours then PCI can be performed

26
Q

You’ve been told PCI won’t be ready for over 2 hours, what do you do?

A

Give fibrinolysis and transfer to PCI centre in case it is unsuccessful and rescue PCI needed or angiography

27
Q

Your patient stabilises what should the patient do now?

A

Bed rest for 48hours with continuous ECG monitoring
Daily examination and bloods
Warfarin may give LMWH for the first 3-5 days until it kicks in
Aspirin 75mg
Same drugs for secondary management

28
Q

When are patients followed up?

A

5 weeks for examination, exercise tolerance test and treatment eg CABG/angiography if necessary

3 months to check fasting lipids

29
Q

When might you do a CABG instead of a PCI?

A

Disease of the left main coronary artery (LMCA).
Disease of all three coronary vessels (LAD, LCX and RCA).
Diffuse disease not amenable to treatment with a PCI.

30
Q

What are the complications of MI?

A

Tachyarrythmias esp AF, bradyarrythmias, continuing angina, mitral regurgitation, ventricular septal defect, ventricular anneurysm, cardiac tamponade, cardiogenic shock

31
Q

What treatment would you give for an NSTEMI?

A

Admit to CCU and closely monitor

32
Q

When would you give low flow O2 to patient?

A

If oxygen sats fall below 90%

33
Q

What would you do next for an NSTEMI?

A

Give analgesia of morphine 5-10mg IV and metoclopromide 10mg IV

34
Q

Would you give nitrates?

A

Yes give GTN spray/tablets as required

35
Q

What would do next after nitrates?

A

Give 300mg of aspirin and clopidogrel 300mg unless contraindicated

36
Q

If LVEF is lower than 40%, hypertensive or tachycardic then what would you give them?

A

A beta blocker such as metoprolol 50mg/12hr

37
Q

What are the comtraindicztions of beta blockers

A

Asthma, LVF, bradycardia, coronary spasm

38
Q

What could you give if metoprolol is contraindicated?

A

A non dihydropyradine CCB such as vermapril

39
Q

What would you give as anti coagulation?

A

Factor 10a inhibitor such as Fondaparinux or LMWH

40
Q

The NSTEMI patient is still in pain, what could you give them?

A

IV nitrates

41
Q

You have conducted a GRACE score and the patient is low risk (less than 3% mortality in the next 6 months) what is your management plan?

A

Discharge and treat medically, follow up for tolerance test/angiogram

42
Q

If intermediate-high risk patient how soon should you thrombolyse?

A

Within 72hrs

43
Q

For high risk patients how soon should you thrombolyse?

A

Within 120 minutes with a NICE target of less than half am hour

44
Q

What are the three types of acute coronary syndrome?

A

NSTEMI, STEMI, unstable angina

45
Q

Which leads show the inferior part of the heart?

A

Leads 2, 3, AVF

46
Q

Which leads indicate the anterior part of the heart?

A

V2, V3, V4

47
Q

Which leads show the lateral parts of the heart?

A

I, aVL, V5, V6

Heart and lungs (28 decks)

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