ACS Flashcards
Definition of a NSTEMI
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
Definition of a STEMI
Complete occlusion of a coronary artery causing myocardial infarction associated with an ST elevation
Definition of unstable angina
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
Clinical features of ACS?
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.
Which patients may not suffer these symptoms as much or at all?
Elderly or poorly controlled/longstanding diabetics
What may you look for on examination?
Pulmonary oedema or systolic murmurs of aortic stenosis or mitral regurgitation
Investigations include what?
12 lead ECG, cardiac enzymes troponin I and T, FBC, BMs, echocardiogram, erect chest radiograph
What are you looking for on the ECG?
Any pathological Q waves, ST elevation, ST depression, T wave inversion. Normal ECG does not exclude ACS.
How long does it take for cardiac enzymes to become detectable?
6 hours
When does troponin I+T peak?
12-24 hours
How long do troponins remain raised?
Up to 14 days post MI
Why are troponins used over the old markers CK and myoglobin?
Troponins have greater sensitivity as a test in the first 6 hours
What are you looking for on a chest radiograph?
Pulmonary oedema as a result of ischeamia and any other diagnosis such as aortic dissection, aortic aneurysm, pneumothorax, PE
What might FBC show in ACS?
Shows if there is any anaemia. You might also test INR, CRP, TFT, RFTs
Lifestyle modification to prevent secondary attack includes what?
Smoking cessation, good glycemic control, hypertension control and cholesterol intake.
If diagnosis of NSTEMI or unstable angina is made what scoring system does NICE recocomment
For risk assessment for 6month mortality?
The GRACE scoring system (age, killip grade of CHF, HR, BP, previous interventions, history of MI etc)
Risk is split up into 3 groups which are?
Low (less than 3%), intermediate (3 to 6%) and high (above 6%)
Immediate management for suspected ACS
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).
Secondary prevention of an MI if in the last year includes what drugs?
- ACE (angiotensin-converting enzyme) inhibitor
- Dual antiplatelet therapy (aspirin plus a second antiplatelet agent eg clopidogrel)
- beta-blocker
- statin
First two things to do in intial treatment of a STEMI is?
ABC assesment/resus and a 12 lead resting ECG
What do you do after attaching ECG?
Get IV access and take bloods for FBC, U+E, glucose, lipids, cardiac enzymes
You have IV access and an ECG is running, what now?
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
What else MUST you ask the patient if not in records?
Any contraindications to PCI/fibrinolysis
After the assessment stage what do you give?
300mg of aspirin of not given by paramedics, morphing 5-10mg IV AND anti emetic such as Metaclopramide 10mg IV
The ECG confirms STEMI how soon do you need PCI to be available if it is to be used?
Less than 2 hours then PCI can be performed
You’ve been told PCI won’t be ready for over 2 hours, what do you do?
Give fibrinolysis and transfer to PCI centre in case it is unsuccessful and rescue PCI needed or angiography
Your patient stabilises what should the patient do now?
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
When are patients followed up?
5 weeks for examination, exercise tolerance test and treatment eg CABG/angiography if necessary
3 months to check fasting lipids
When might you do a CABG instead of a PCI?
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.
What are the complications of MI?
Tachyarrythmias esp AF, bradyarrythmias, continuing angina, mitral regurgitation, ventricular septal defect, ventricular anneurysm, cardiac tamponade, cardiogenic shock
What treatment would you give for an NSTEMI?
Admit to CCU and closely monitor
When would you give low flow O2 to patient?
If oxygen sats fall below 90%
What would you do next for an NSTEMI?
Give analgesia of morphine 5-10mg IV and metoclopromide 10mg IV
Would you give nitrates?
Yes give GTN spray/tablets as required
What would do next after nitrates?
Give 300mg of aspirin and clopidogrel 300mg unless contraindicated
If LVEF is lower than 40%, hypertensive or tachycardic then what would you give them?
A beta blocker such as metoprolol 50mg/12hr
What are the comtraindicztions of beta blockers
Asthma, LVF, bradycardia, coronary spasm
What could you give if metoprolol is contraindicated?
A non dihydropyradine CCB such as vermapril
What would you give as anti coagulation?
Factor 10a inhibitor such as Fondaparinux or LMWH
The NSTEMI patient is still in pain, what could you give them?
IV nitrates
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?
Discharge and treat medically, follow up for tolerance test/angiogram
If intermediate-high risk patient how soon should you thrombolyse?
Within 72hrs
For high risk patients how soon should you thrombolyse?
Within 120 minutes with a NICE target of less than half am hour
What are the three types of acute coronary syndrome?
NSTEMI, STEMI, unstable angina
Which leads show the inferior part of the heart?
Leads 2, 3, AVF
Which leads indicate the anterior part of the heart?
V2, V3, V4
Which leads show the lateral parts of the heart?
I, aVL, V5, V6
