ACS Flashcards
Definition of ACS
Acute ischaemic chest pain either at rest or crescendo pain on minimal exertion associated with ECG changes showing ischaemia
Types of ACS
- STEMI/new onset LBBB
2. NSTEMI
What does ACS basically mean
Unstable angina and evolving MI
Pathophysiology
Gradual buildup of fatty plaque endothelium dysfunction caused by smoking hypertension and hyperglycaemia
This builds up within wall of coronary artery and narrows lumen and causes decreased oxygen supply to heart leading to angina or if no blood reaches myocardium get myocardial infarction
Modifiable risk factors
Hypertension diabetes smoking high cholesterol and obesity
Nonmodifiable risk factors
Male gender, increased Age,family history of premature CAD (male first-degree relative before 55 years old, female 1st° relative before 65 years old)
Signs and symptoms
Chest pain (central crushing pain lasting more than 20 minutes, may radiate to neck or arms, similar pain found in angina but people say that it is more severe and last longer than angina
Nausea vomiting and sweating
Distressed tachycardic cold and clammy
Variable blood pressure
Patient may be cyanosed
Mild pyrexia
Features of complications (LVF equals third heart sand, raised JVP, bibasal crepitations and dyspnoea and brackets; Papillary muscle dysfunction equals PSM)
30% have silent symptoms: syncope, delirium,stroke, hyperglycaemia
What investigations would you do
12 lead ECG, bloods, echocardiogram, chest x-ray
What ECG changes would you see for STEMI
First few hours: ST elevation and hyperacute T waves
First 24 hours:ST elevationstarting to resolve and T-wave inversion
More than 24 hours: pathological queue waves may occur within hours or 24 hours – indicating full thickness infarct
Long-term changes: persistent Q-waves (90%), persistent T-wave inversion, persistent ST elevation is rare and seen in ventricular aneurysm
What is e.g. changes would you see in NSTEMI
ST depression and T-wave inversion, no Q-waves present – indicating that the endothelial infarcts
N.b. deep and widespread ST depression is associated with hi mortality (higher than in people with unstable angina)
ECG leads and which areas and vessels of the heart the they correlate to
Inferior view: Leads two, three, avF – vessel: right coronary artery
Anterolateral view: leads one, aVL, V4 – V6: vessel is left circumflex artery
Anteroseptal view: V2-V3, LAD
Anterior view: V2– V6, L A.D
Posterior: V1, V2, V3: right coronary a
What bloods would you send for
And what other ix tests
- troponin T/I, peaks at 20 hours, ideal time to check is 6-9 hours post onset of pain and then at 12 to 24 hours (latter is optional)
- CK – MB is most specific for acute MI, peaks at 12 to 24 hours and remains high for half a day to 3 days
- LDH, high post MI and in myocarditis levels peak at 48 to 72 hours
- 🌟u &E, 🌟glucose [if >11mmol/L, call endocrinologist or diabetes nurse early], 🌟cholesterol(do within 24 hours of pain onset because it gives a reasonable indication of the values before the acute event-should be started on a statin regardless of basal lipids & assess any secondary causes of high lipids e.g.diabetes, alcohol abuse, renal disease, liver disease, badly treated hypothyroidism), 🌟FBC, 🌟🌟clotting Profile
- Echo= shows if LV damage, RV damage, cardiac rupture with the Tamponade, acute MR, ventricular septal rapture, extent of akinesis in transmural infarction
- CXR: May show heart failure (cardiomegaly, pulmonary oedema), helps exclude aortic dissection, widened mediastinum may show aortic rupture
How would you manage an acute Mi
🎀Attach ECG monitor
Record a 12 lead ECG
🎀Establish IV access and give oxygen if the levels are less than 95%/acute heart failure:aim for 94 to 98%, 88 to 92% if COPD patient
🎀Brief Assessment:
❤️history of CVD, rfs for IHD;
♥️examine:pulse, blood pressure both arms, JVP, murmurs, signs of CCF, scars from previous surgeries, chest x-ray
❤️check if contraindication to PCI/fibronolysis
🎀Aspirin 300 mg (unless already given by GP or paramedic), and Ticagrelor 180 mg PO (Superior alternative to the clopidogrel) OR Prasugrel 60 mg PO
🎀Morphine 5 to 10 mg IV, and anti-emetic with first dose of morphine (first line: metoclopramide 10 mg IV, second line cyclizine 50 mg IV)
🎀GTN is not recommended unless patient is hypertensive or in acute LVF
🎀the aim now is to restore cardiac profusion
🎀If stemi on the ECG and PCI available in two hours: yes: primary PCI -> angiographic identification of culprit blockages and revascularisation with deployment of stent, done if less than 12 hours since signs and symptoms or if patient can be transferred to a PCI Centre within 120 minutes of medical contact.
Must ensure pt is loaded with appropriate antiplatelet agent ie. aspirin & prasugrel/clop.
Must give an injectable anticoagulant (BIVALIRUDIN, a direct thrombin inhibitor) is preferred, if not present use ENOXAPARIN and or GPIIb/IIIa blocker
🎀 if primary PCI not possible, give patient Thrombolysis and transfer to PCI Centre for rescue PCI, (if residual ST elevation or angiography if successful)
🎀STEMI on ECG and PCI available in 120 minutes: no: fibrinolysis. This is systematically administered clot dissolving agent ( alteplase, reteplase,streptokinase,tenectoplase). INDICATION FOR USE IS PRESENTATION WITHIN 12 HOURS OF SYMPTOM ONSET + TYPICAL CARDIAC CHEST PAIN >30MINS. use more than 12 hours need specialist advice, it is contraindicated beyond 24 hours). DO ECG AFTER 90 MINS, SHOULD SEE >50% RESOLUTION IN ST ELEVATION.
- -> If no adequete resolution: RESCUE PCI [is superior to repeat thrombolysis]
- -> if thrombolysis is successful = PCI is still shown to be beneficial! (optimal timing of this is still being ix’d)
nb: glycemic control in pt with DM, recommendation = dose adjusted insulin infusion with regular blood glucose monitoring till <11 mmol/L
Fibrinolysis CI absolute
ANY ACTIVE BLEEDING
Prev ischemic hemorrhage Ischaemic stroke less than six months Cerebral malignancy Avm Recent major head trauma or injury less than 3weeks Gi bleeding less than 1mo Known bleeding disorders Aortic dissection Non compressible punctures eg, LP,liver biopsy
Fibrinolysis relative CI, STILL V SERIOUS
Tia less than 6mo Anticoagulant rx Preg Less than 1 week postpartum Refractory htn (>180/110) Advanced liver disease iE Active peptic ulcer Prolonged/traumatic resus
Continuing therapy
- Symptom control
🎈PRN gtn & opiates
🎈gtn infusion if above not helping
2. Modify rfs Stop smoking Identify and rx dm,htn,xol Diet Daily exercise Mental health screen for depression/anxiety
- Optimise cardio supportive Meds
🌟anti platelets ASPIRIN 75mg OD and 2 anti platelets: Ticagrelor, Prasugrel for at least 12 mo.to decrease risk of CV events. If can’t tolerate aspiri ,do clopi monotherapy
🌟anticoagulate: Fondaparineux till discharge
🌟 beta blocker: atenolol, bisoprolol, metoprolol (cardioselective, decreases cardiac excitation); CI’d? Use verapamil\diltiazem
🌟 ace I/arb
🌟 high dose statin eg. 80mg atorvastatin
🌟do echo to assess LV function (eplenerone improves MI outcomes in pts with heart failure by keeping EF <40%)
NB. OFFER ALL PT’S W/ HYPOGLYCEMIA AFTER ACS + WITHOUT KNOWN DM TESTS FOR:
- HbA1c levels before discharge
- fasting blood glucose elvels <4 d AFTER onset of ACS (no earlier)
- but this shouldnt delay discharge tho!
PCI Complication
Bleeding
Arrhythmias
Embolisation
Nstemi or ua mx
12 lead ECG while in pain
It’s SaO2 is less than 90% or breathless give low flow oxygen
Analgesias: morphine 5 to 10 mg and metoclopramide 10 mg IV
Nitrates: GTN spray or sublingual tablets as required
Aspirin 300 mg
If have confirmed ACS can give second antiplatelet e.g. ticagrelor or clopidogrel or Prasugrel
Measure troponin and clinical parameters to risk assess e.g. GRACE or TiMI
If low risk pt do conservative strategy (no recurrence of chest pain, no signs of heart failure, normal Ecg, negative baselines (with or without repeat troponins) ➡️ may be discharged ➡️ arrange further appt ix eg. Stress test
If high-risk patient then do yinvasive strategy approach: rise in Troponin,dynamic ST/T-wave changes, secondary criteria present (diabetes, ckd, left ventricular EF<40%, early angina post MI, recent PCI, prior CABG, intermediate to high risk GRACE score
➡️ anticoagulate Fondaparineux factor Xa inhibitor or ENOXAPARIN (lmwh) or unfractionated heparin (aim APtt 50-70s until discharge
➕ 2nd antiplatelet agent. Ticagrelor,clopi (if lower risk pts), Prasugrel (if preceding PCI)
➕ IV. Nitrate if pain continues eg.gtn 50mg in 50mL 0.9% saline at 2-10mL/hr [helps titration pain and maintain SBP >100mmhg]
➕ oral betablockers eg bisoprolol 2.5mg (CI if cardiogenic shock, heart failure,COPD,asthma,they should get rate limiting CCB eg verapamil/diltiazem
➡️ prompt cardiologist review for angiography/pci :
🍉urgent if <120mins of presentation with ongoing angina, evolving st changes, signs of cardiogenic shock, life threatening arrhythmias
🍉 early (<24hrs) if grace score >40 and a high risk pt
🍉within 72hrs if low risk pt
➡️ continuing therapy
- wean off gtn infusion when stable on oral drugs
- continue Fondaparineux/lmwh till discharge
– Observe cardiac monitor in case of dysrhythmia
Address modifiable risk factors: smoking hypertension high cholesterol diabetes
Ensure patient is on: Dual platelet therapy, beta-blocker, Acei,Statin, explains in symptoms re-occur: refer to cardiologist for urgent angiogram and PCI/CABG
how to rx complications
🍉arrhythmias- see cardiac arrhytmia guidelines
🍉cardiac failure- pt’s w/LVF or impair LV function: ACEi + arrange outpatient echo [to exclude LV aneurysm/thrombosis]
🍉pericarditis (pain with persistent/intermittent pericardial rub 2-5d after infarction)
- adequete analgesia [may need diamorphine]
- indometacin 25mg 8hrly (an nsaid) = if no CI, beware fluid retention + antagonism of loop diuretic.
🍉recurrent ischemic pain:
SR isosorbide mononitrate/GTN infusion if needed
refer to cardio team for: patient stress testing, coronary angiography, poss inpaitent revascularisation
🍉mx of cardiac failure post MI (see diagram)
- if new systolic murmur:echo/doppler US for VSD/MR
- well perfused but basal crackles: furosemide + consider ACEi
- SBP >90: furosemide, IV GTN, consider ACEi
- poor prognosis (SBP<90): IV dobutamine/dopamine [raises BP without evoking vasocontriction or tachycardia)
discharge/FU
discharge home in 3-7 d if no complications
check rfs for recurrent mi [smoking, htn, xol, obesity]
- stairs assessment for chestpain/SOB
- give advise booklet and patient alert card
- write to gp about intensive statin therapy
- warn about post infarct angina
- ensure gtn 400microgram spray for SL use has been prescribed TTO
- advise not to drive as per DVLA rules, taxi drivers must notify local council
- ensure referral to cardiac rehab team
- check FU diabetes clinic appt is made
what to ask in FU clinic
ask about smoking, exercise, wt loss
angina- occuring? if so consider angiography referral
s/s of HF and measure BP
check xol level
if pt not been to cath lab, consider treadmill exercise
encourage return to work after 1-3 mo after infarction
resume driving after 1 month after infarction
post STEMI, what drugs should pts be taking??
ASBA PC
acei- ramipril
statin - atovastatin 80mg unless hx of CKD
bb- target heart rate: 60bpm @ rest
asprin 75mg indefinitely
prasugrel 10mg daily for 12mo if rx’d by PCI + no prev hx of CVA/TIA/cerebral bleed + <75yo + weight >60kg
OTHERWISE
clop 75mg oral daily for 1 year
post NSTEMI, what drugs should pts be taking??
ASBA C
acei statin bb aspirin clopidogrel
