ACS Flashcards
How are the plaques formed in atherosclerosis?
Injury triggers lipoproteins to be oxidised and taken up by macrophages causing foam cell formation. Cytokines are released leading to accumulation of fat and smooth muscle proliferation. Plaque is formed
How does a plaque cause myocardial ischaemia?
Rupture of the plaque causes platelet adhesion and aggregation, localised thrombus and vasoconstriction.
What are the non modifiable risk factors for ACS?
Increasing age
Gender (Male)
FH
Ethnic origin
What are the modifiable risk factors for ACS?
Smoking
Diabetes
HTN
Hypercholesterolaemia
How would you initially manage a patient with ACS?
A-E 12 lead ECG M - Morphine (Usually Diamorphine 2.5-10mg) plus antiemetic O - Oxygen if needed N - Nitrates (GTN 2 sprays) A - Aspirin (300mg)
What initial investigations need to be done in a patient with ACS?
Bloods - FBC, Troponin, U&Es, Glucose, Lipids, Creatinine Kinase, LFTs
CXR
What are the symptoms of a STEMI?
Chest pain, central & crushing not relieved by GTN. May radiate into neck, face, arms
N&V, Sweating (Pallor - activation of sympathetic nervous system)
Syncope
SOB - Especially as may present with acute pulmonary oedema
Diabetics can have painless/atypical presentations of STEMIs
What are the possible ECG findings in a STEMI?
ST evelation
New onset LBBB
T wave inversion
Pathological Q waves
How would an Anteroseptal STEMI show on ECG?
ST elevation in V1-4 (LAD)
How would a Lateral STEMI show on ECG?
V5-6 (Circumflex)
How would a High lateral STEMI show on ECG?
I, aVL (Circumflex)
How would a Inferior STEMI show on ECG?
II, III, aVF (RCA)
How would a Posterior STEMI show on ECG?
ST depression in V1-4 due to seeing the reciprocal changes
What are the treatment options for a STEMI?
Primary coronary intervention - within 90 minutes of onset of symptoms
Thrombolysis - within 12 hours of onset of symptoms. Usually Alteplase or Reteplase used
What are the absolute contraindications to Thrombolysis?
Haemorrhagic or Ischaemic stroke within the last 6 months CNS neoplasia Recent trauma or surgery GI bleed within the last month Any bleeding disorders Aortic dissection
What are the relative contraindications to Thrombolysis?
Warfarin
Pregnancy
Advanced liver disease
Infective endocarditis
What are some of the complications of Thrombolysis?
Bleeding Hypotension Intracranial haemorrhage Reperfusion arrhythmias Systemic embolisation of the thrombus Allergic reaction - especially if streptokinase is used
What are the complications of a STEMI?
S - Sudden death P - Pump failure/Pericarditis R - Ruptured papillary muscles/septum E - Embolism A - Aneurysm/Arrhythmias D - Dressler's syndrome (Secondary form of Pericarditis)
What drugs should a patient who has had an MI be discharged on?
A - ACEi (Helps with remodelling of the heart). Aspirin (Lifelong). Address modifiable risk factors
B - B Blocker (Atenolol, Bisoprolol)
C - Clopidogrel (12 months). Cholestoral lowering - Statin (80mg Atorvastatin)
Minimum of 1 month off work
Inform the DVLA, no driving for 4 weeks
How can you differentiate between an NSTEMI and Unstable Angina?
An NSTEMI will have a positive Troponin
What ECG changes are present in an NSTEMI and Unstable Angina?
T wave inversion
ST depression
How do you manage a patient with suspected Unstable angina or NSTEMI?
Analgesia - Morphine and Anti emetic
Anti Ischaemic - GTN infusion, ACEi, B BLOCKERS, Ca2+ channel antagonists, Statins
Antiplatelet - Apirin, Clopidogrel
Antithrombotic - LMWH
When would you consider invasive management (PCI) of an NSTEMI or unstable angina?
Increased Troponin
Recurrent angina or ischaemic changes on ECG despite medical therapy
Features of HF
Poor LV function
Haemodynamic instability
PCI within the last 6 months or a previous CABG
