ACS Flashcards
what is angina?
Features include? (three)
how many of the above symptoms do you need for it to be typical?
how many of the above symptoms do you need for it to be atypical?
Angina is a symptomatic reversible myocardial ischaemia
Features:
- Constricting/heavy discomfort to the chest/jaw/neck/shoulders or arms.
- Symptoms are brought on by exertion.
- Symptoms relieved within the 5min by rest or GTN.
All three = for typical angina
2 for atypical angins
Less likely to be stable angina if ?
continuous pain
Stable Angina
- ECG changes?
- Trop level?
Tx:
1st line?
- if can’t tolerate?
- if symptoms are unsatisfactorily controlled - what is the rule with combination?
- daily antiplatelet?
- add what if diabetic?
- PRN?
if patient has had a PCI if medical therapy is inadequate - what medication do you give post stent insertion ?
- ECG: normal/ST depression
- Trop : normal
Tx:
- 1st line: beta blocker or calcium channel blocker (verapamil)
- try the other option
- combine the two but has to be long acting dihydropyridine Ca blocker like Amlodipine otherwise risk of heart block -
- daily: aspirin 75mg OD
- diabetic: add ramipril (ACE-i)
- PRN: GTN spray
- dual antiplatelet therapy (aspirin + clopidogrel) for 12 months
Unstable Angina
- when does it occur?
- relief by GTN?
- ECG changes?
- Trop?
- angina symptoms at rest or with minimal exertion
- Yes
- normal/ST depression/T wave inversion
- Trop normal
NSTEMI
- features?
- reversible or irreversible ischaemic damage?
- ECG changes?
- Trop level?
- sudden, onset, severe crushing chest pain
not relieved by GTN - irreversible
- ST depression/T wave inversion
- +++ (but not as high as STEMI (1,000 instead of 10,000)
STEMI
- features?
- reversible or irreversible ischaemic damage?
- ECG changes?
- Trop level?
- sudden, onset, severe crushing chest pain
not relieved by GTN - irreversible
- ST elevation + new LBBB, pathological Q waves
- +++ (>10,000)
when does trop levels peak?
3 hours after onset
GRACE Score – Global Registry of Acute Coronary Events ?
- Risk score based on age, HR, BP, renal function and troponin.
- Used for unstable and NSTEMI mainly as no time for STEMI – need to get them straight to primary PCI.
ACS (in general) – Initial Management
ECG
Bloods: including Trop
Oxygen
Aspirin 300mg + Ticagrelor 180mg (dual antiplatelet therapy for ACS)
IV Morphine w/ antiemetic (IV metoclopramide)
GTN spray ( if not effective - give IV nitrate)
fondaparinux SC or LMWH SC
STEMI - Post Initial Tx
Primary PCI – should be offered to all patients with STEMI within what duration of first medical contact?
If not then do what till they wait to be transferred to primary PCI?
o Primary PCI – should be offered to all patients with STEMI within 120mins of first medical contact.
If not then they should receive thrombolysis until they can be transferred to primary PCI.
NSTEMI/Unstable Angina – Post-Initial Management
- what can you give for recurrent chest pain?
- • Then think about a prompt cardiologist review for angiography:
- urgent
- early
- late
IV nitrate
Cardiology review for angiography:
urgent (<120min from presentation) if ongoing angina and ongoing ST changes,
early (<24hrs in high-risk patients and GRACE score is >140),
late (<72hrs) for low risk patients.
ACS – Secondary Management
Cardioprotective Medications
- which antiplatelets + for how long?
- what will you give to reduce cholesterol <4?
- 2 more meds for cardioprotective reasons?
aspirin + clopidogrel for 12 months
high dose statin (atorvastatin 80mg)
Beta blocker and ACE-i
A 60-year-old man presents to A&E with a 3-day Hx of increasingly severe chest pain. The patient describes the pain as a sharp, tearing pain starting in the center of his chest & radiating straight through to his back between his shoulder blades. The patient looks in pain but there is no pallor, heart rate is 95, RR is 20, T 37°C, BP 155/95 mmHg. The most likely diagnosis is:
Myocardial infarction Myocardial ischaemia Aortic dissection Pulmonary embolism Pneumonia
Aortic dissection
An 84-year old man has central chest pain that has gradually worsened over the last month. He finds it is made worse on exertion – especially climbing the stairs to his flat. He has T2DM and a hiatus hernia.
T 37.1 °C, HR 95 bpm, BP 165/95 mmHg
An ECG and a CXR are both reported normal. Which is the single most likely diagnosis?
Angina Gastro-oesophageal reflux disease Heart failure Myocardial infarction Oesophageal spasm
Angina
A 76-year-old woman has been short of breath on minimal exertion for 5 days. On walking upstairs, she has had several twinges of central chest tightness. She had been pain free since being diagnosed with coronary artery disease 10 years previously.
Troponin (36h after onset of pain) 1.45 ng/mL.
ECG shows T wave inversion in the inferolateral leads. Which is the single most appropriate immediate step in management?
Aspirin 75mg PO Aspirin 300mg PO Aspirin 300mg PO + Clopidogrel 300mg PO Clopidogrel 75mg PO Clopidogrel 300mg PO
Aspirin 300mg PO + Clopidogrel 300mg PO
