ACS Flashcards
What is acute coronary syndrome
Any sudden cardiac event due to problem / occlusion of coronary
- STEMI
- NSTEMI
- Unstable angina
What causes ACS
Rupture of atheroma / thrombus formation that blocks coronary artery = most common Coronary vasospasm - cocaine Coronary dissection - young healthy female Vasculitis / inflammation Hyperviscosity RT to chest Strangulation / trauma Severe anaemia Congenital
What is unstable angina
Ischaemia of myocytes (due to rupture of plaque)
No troponin released
What does infarction (complete occlusion) cause
STEMI
NSTEMI
Troponin released
What are the symptoms of ACS
Cardiac chest pain Chest pain - radiating to left arm, neck, jaw Crushing / tight No improvement rest or GTN SOB - blood backs up in pulmonary Palpitations Syncope Confusion N+V / weakness./ dizzy - activation of vagal Anxiety Pale Sweaty / clammy - decreased CO so increased sympa
What are signs of ACS
Mild fever Tachycardia Tachypnoea Hypotension due to vagal overactivity JVP / 3rd HS / Inspiratory crackles if HF develop 4th HS Pan systolic murmur due to papillary rupture Pulmonary oedema
How can ACS present in the elderly / diabetic / F
Silent MI Syncope Pulmonary oedema Epigastric pain + vomit Post op hypotension or oliguria Confusion Stroke Anxiety N+V Hyperglycaemia
What are the RF for ACS
Age Male FH IHD Smoking Hypercholesterol Hypertension DM Obesity Alcohol Cocaine Angina HRT CAD
What is important in the PMH
Previous MI IHD DM High BP FH Drugs Smoke / alcohol
How do you Dx ACS
Typical Sx + RF
Ischaemic changes on ECG - do ECG always if cardiac sounding chest pain
Troponin - Cardiac enzymes elevated
Wall abnormalities on imaging
What do you look for in examination
Pulse BP - both arm JVP Murmur - if new worry HF Chest wall tenderness
Why do you worry about new murmur
Rupture of myocardium
How do you investigate ACS
Hx and exam
12 lead ECG (within 15 minutes) - to decide management
Cardiac monitor for arrhythmia
Bloods - FBC for anaemia, U+E, LFT, TFT, lipid, CRP, blood glucose for DM
Cardiac enzymes - troponin
What do the cardiac enzymes do
Troponin >40 = suggestive of MI (peaks at 12 hours and elevated 10 days) - want to see rise so repeat in 12-24 hours
Repeat 12-24 hours if -ve
Myoglobin = 1st to rise
What are further investigations
CXR to look for pulmonary oedema or pneumonia
Angiogram - CT or percutaneous
ECHO - post MI before discharge to look for myocardial dysfunction
What do you do when someone comes in with cardiac like chest pain straight away
ECG
Pulse oximetry
IV cannula as might arrest
Bloods
When would you do Mg
Arrythmia Seizure D+v Weakness NOT routine
When would you do clotting
Haemorrhage
Anti-coagulant
Evidence of disorder
What is the ACS protocol
ABCDE Morphine Oxygen if sats dropping Nitrates - GTN - IV if not improving Aspirin 300g unless CI 2nd anti platelet - ticagrelor = 1st line 180mg if no Hx stroke or TIA, clopidogrel if there is BB if not CI - metoprolol IV - Caution if HF / Brady
Work out GRACE score to see if high risk needing PCI during admission
How much morphine and what do you give with
5-10mg
Give with metaclopamide (anti-emetic)
When do you give oxygen
If sats <94% or 88-92% if COPD until blood gas available
15l non breath EVERYONE
What nitrates do you give
GTN - give before hospital if GP
IV nitrate if pain continues
Careful if ED or PPH as will be on sildenafil
Ensure you monitor BP
When do you give aspirin
Before hospital 300mg unless CI
What do you give as well as MONAB
Anti-coagulant - Fondaparinux or LMWH if renal - if no PCI / CABG / angiography within 24 hours
Management different depending on whether UAP, STEMI, NSTEMI
Who gets PCI
STEMI if within 2 hours of presentation
Thrombolysis then transfer if >2 hours
Who gets revascularisation (CABG / PCI)
STEMI
High risk NSTEMI calculated using GRACE score
What is given post MI
Aspirin 75mg life long
Dual anti platelet 12 months at least (Tisagrelor / Pragurel) -if no risk of stroke
Anti-coagulate (Fondaparinux / LMWH) until discharge or until revascularised
If long term anti-coag needed e.g. AF then must use clopidogrel post ACS
BB to reduce demand- continue for 12 months or forever if HF
ACEI / ARB if LV dysfunction / DM / high BP
High dose statin 80mg
Other
Aldosterone antagonist (eplerone) if HF on ECHO
Anti-arrhythmia
What are prognostic drugs
ACEI
BB
What else should patient get
ECHO as inpatient or ETT
Follow up 6-8 weeks
Patient education and support (lifestyle, cardiac rehab)
What is most important determinant in survival
Age
LV ejection fraction
What should you never use in ACS
CCB
What has poor prognosis
Age >65 Development of CF - oedema / shock Peripheral vascular disease Reduced systolic - SHOCK Elevated cardiac marker Elevated initial creatinine Cardiac arrest ST deviation
What is UAP
Angina with increasing severity and frequency
No troponin rise
Abnormal ECG
What is a NSTEMI
Abnormal ECG
Troponin rise
NO ST elevation
What is shown on ECG
ST depression
T wave inversion
What causes UAP or NSTEMI
Partial occlusion of coronary artery.
What puts you at higher risk
Previous Hx
Previous MI
Previous CABG / PCI
How do you Dx UAP
Same investigation as above
ECG changes tend to resolve after pain
If troponin -ve repeat after 3 hours
If still -ve not a MI
What is it if increased troponin but normal ECG
NSTEMI
Type 1 = partial occlusion
Type 2 = secondary to insult (troponin not as high)
How do you classify UAP and NSTEMI into risk
Do GRACE score
Ideally angio within 48 hours
What do you do after initial management
Decide if high risk needing invasive Rx in admission or low risk GRACE score = Mx of NSTEMI - Medical - Non urgent PCI - Urgent PCI HEART score - A+E whether ACS is likely Cardiac monitor for arrhythmia ECG + troponin repeat
What are very high risk, high risk patients and low risk
Very high risk = unstable, shock, arrhythmia, arrest, mechanical complication, ongoing pain after Rx
High risk High GRACE HEART Score >7 Age >70 Acute HF HR and BP Raised troponin Dynamic ST or T wave changes DM CKD LVEF <40% Recent PCI / CABG
Low risk
- No recurrence pain
- No signs of HF
- Normal ECG
What does GRACE and HEART look at and when would you not use
GRACE
- BP
- Creatinine
- CCF
HEART
- History
- ECG
- Age
- RF
- Tropnoni
If STEMI or unstable as require immediate PCI
If patient not for PCI / CABG within 24 hours what do you give
SC Fondaparinux or LMWH
What do you do for low risk patient / UAP
Medical mamnegement Outpatient follow up ECHO ETT = 1st line Myocardial perfusion scan Outpatinet angiogram if found to have ischaemia
What do you do for high risk NSTEMI or UAP
Follow ACS protocol
Early intervention with PCI./ CABG within <2 hours
If intermediate risk
Do within 3 days
What do you not give if going for angio
Anti-coagulant
What is a STEMI
When artery becomes completely occluded
Why is cardiac muscle so sensitive
High metabolic demand
How do you Dx STEMI
ST elevation in vascular territory = diagnostic
- > 1mm in limb leads
- > 2mm in chest leads
Suggestive
- BBB
How do you treat STEMI
ACS protocol
REFER TO CCU FOR PCI
When do you refer for PCI
If available within 2 hours of presentation and 12 hours of symptom onset
What do you give before PCI
GP IIB/IIa inhibitor (epifeitibdie)
When would you thrombolyse
If no PCI within 2 hours
Always transfer after as risk of re-occluding
Alteplase (conversion of plasminogen to plasmin in absence of fibrin) - tPA
What do you do after thrombolyse
Repeat ECG
PCI if no resolution to ST after 90minutes don’t antiocagulate
if stable then do routine PCI within 24 hours
When do you do CABG
Three vessel disease
Left main stem
PCI unsuccessful
Mechanical complications
What are CI to thrombolysis
Prior intracranial haemorrhage Recent trauma or surgery Coagulation / bleeding disorder Known brain tumour / CVA lesion or trauma Ischaemic stroke within 3 months Aortic dissection Active bleeding Head trauma Pregnancy
What are the SE of thrombolysis
Haemorrhage
Hypotension
Allergy
What do you do if ST elevation but arrhythmia
Treat as peri-arrest
ACS could have caused but can’t treat due due to tachy
What is needed
DC cardioversion
Treat as whether Brady or tachy
What else is offered to patient
Cardiac Rehab
What else can raise troponin
Chronic renal Sepsis PE Dissection Myocarditis
What are the types of MI
1 = thrombus or embolus 2 to plaque rupture 2 = ischaemia 2 to anaemia / hypoxia in sepsis / spams 3 = dead with no biomarker 4 = PCI / stent thrombosis - if don't take anti-platelet 5 = CABG
DDX of ACS
Aortic dissection - very unwell and tearing pain between pack / scapula PE Pericarditis - Relief forward Heartburn MSK
