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CVS > ACS > Flashcards

ACS Flashcards

1
Q

What is acute coronary syndrome

A

Any sudden cardiac event due to problem / occlusion of coronary

  • STEMI
  • NSTEMI
  • Unstable angina
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2
Q

What causes ACS

A 
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
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3
Q

What is unstable angina

A

Ischaemia of myocytes (due to rupture of plaque)

No troponin released

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4
Q

What does infarction (complete occlusion) cause

A

STEMI
NSTEMI
Troponin released

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5
Q

What are the symptoms of ACS

A 
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
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6
Q

What are signs of ACS

A 
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
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7
Q

How can ACS present in the elderly / diabetic / F

A 
Silent MI 
Syncope
Pulmonary oedema 
Epigastric pain + vomit 
Post op hypotension or oliguria 
Confusion 
Stroke
Anxiety
N+V
Hyperglycaemia
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8
Q

What are the RF for ACS

A 
Age
Male 
FH IHD
Smoking
Hypercholesterol
Hypertension
DM
Obesity 
Alcohol 
Cocaine
Angina 
HRT 
CAD
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9
Q

What is important in the PMH

A 
Previous MI 
IHD
DM
High BP
FH
Drugs
Smoke / alcohol
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10
Q

How do you Dx ACS

A

Typical Sx + RF
Ischaemic changes on ECG - do ECG always if cardiac sounding chest pain
Troponin - Cardiac enzymes elevated
Wall abnormalities on imaging

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11
Q

What do you look for in examination

A 
Pulse
BP - both arm
JVP
Murmur - if new worry
HF
Chest wall tenderness
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12
Q

Why do you worry about new murmur

A

Rupture of myocardium

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13
Q

How do you investigate ACS

A

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

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14
Q

What do the cardiac enzymes do

A

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

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15
Q

What are further investigations

A

CXR to look for pulmonary oedema or pneumonia
Angiogram - CT or percutaneous
ECHO - post MI before discharge to look for myocardial dysfunction

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16
Q

What do you do when someone comes in with cardiac like chest pain straight away

A

ECG
Pulse oximetry
IV cannula as might arrest
Bloods

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17
Q

When would you do Mg

A 
Arrythmia
Seizure
D+v
Weakness
NOT routine
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18
Q

When would you do clotting

A

Haemorrhage
Anti-coagulant
Evidence of disorder

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19
Q

What is the ACS protocol

A 
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

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20
Q

How much morphine and what do you give with

A

5-10mg

Give with metaclopamide (anti-emetic)

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21
Q

When do you give oxygen

A

If sats <94% or 88-92% if COPD until blood gas available

15l non breath EVERYONE

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22
Q

What nitrates do you give

A

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

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23
Q

When do you give aspirin

A

Before hospital 300mg unless CI

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24
Q

What do you give as well as MONAB

A

Anti-coagulant - Fondaparinux or LMWH if renal - if no PCI / CABG / angiography within 24 hours

Management different depending on whether UAP, STEMI, NSTEMI

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25
Q

Who gets PCI

A

STEMI if within 2 hours of presentation

Thrombolysis then transfer if >2 hours

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26
Q

Who gets revascularisation (CABG / PCI)

A

STEMI

High risk NSTEMI calculated using GRACE score

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27
Q

What is given post MI

A

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

28
Q

What are prognostic drugs

A

ACEI

BB

29
Q

What else should patient get

A

ECHO as inpatient or ETT
Follow up 6-8 weeks
Patient education and support (lifestyle, cardiac rehab)

30
Q

What is most important determinant in survival

A

Age

LV ejection fraction

31
Q

What should you never use in ACS

A

CCB

32
Q

What has poor prognosis

A 
Age >65
Development of CF - oedema / shock
Peripheral vascular disease
Reduced systolic - SHOCK 
Elevated cardiac marker
Elevated initial creatinine
Cardiac arrest 
ST deviation
33
Q

What is UAP

A

Angina with increasing severity and frequency
No troponin rise
Abnormal ECG

34
Q

What is a NSTEMI

A

Abnormal ECG
Troponin rise
NO ST elevation

35
Q

What is shown on ECG

A

ST depression

T wave inversion

36
Q

What causes UAP or NSTEMI

A

Partial occlusion of coronary artery.

37
Q

What puts you at higher risk

A

Previous Hx
Previous MI
Previous CABG / PCI

38
Q

How do you Dx UAP

A

Same investigation as above
ECG changes tend to resolve after pain
If troponin -ve repeat after 3 hours
If still -ve not a MI

39
Q

What is it if increased troponin but normal ECG

A

NSTEMI
Type 1 = partial occlusion
Type 2 = secondary to insult (troponin not as high)

40
Q

How do you classify UAP and NSTEMI into risk

A

Do GRACE score

Ideally angio within 48 hours

41
Q

What do you do after initial management

A 
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
42
Q

What are very high risk, high risk patients and low risk

A

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
43
Q

What does GRACE and HEART look at and when would you not use

A

GRACE

  • BP
  • Creatinine
  • CCF

HEART

  • History
  • ECG
  • Age
  • RF
  • Tropnoni

If STEMI or unstable as require immediate PCI

44
Q

If patient not for PCI / CABG within 24 hours what do you give

A

SC Fondaparinux or LMWH

45
Q

What do you do for low risk patient / UAP

A 
Medical mamnegement 
Outpatient follow up 
ECHO 
ETT = 1st line
Myocardial perfusion scan
Outpatinet angiogram if found to have ischaemia
46
Q

What do you do for high risk NSTEMI or UAP

A

Follow ACS protocol

Early intervention with PCI./ CABG within <2 hours

47
Q

If intermediate risk

A

Do within 3 days

48
Q

What do you not give if going for angio

A

Anti-coagulant

49
Q

What is a STEMI

A

When artery becomes completely occluded

50
Q

Why is cardiac muscle so sensitive

A

High metabolic demand

51
Q

How do you Dx STEMI

A

ST elevation in vascular territory = diagnostic

  • > 1mm in limb leads
  • > 2mm in chest leads

Suggestive
- BBB

52
Q

How do you treat STEMI

A

ACS protocol

REFER TO CCU FOR PCI

53
Q

When do you refer for PCI

A

If available within 2 hours of presentation and 12 hours of symptom onset

54
Q

What do you give before PCI

A

GP IIB/IIa inhibitor (epifeitibdie)

55
Q

When would you thrombolyse

A

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

56
Q

What do you do after thrombolyse

A

Repeat ECG
PCI if no resolution to ST after 90minutes don’t antiocagulate
if stable then do routine PCI within 24 hours

57
Q

When do you do CABG

A

Three vessel disease
Left main stem
PCI unsuccessful
Mechanical complications

58
Q

What are CI to thrombolysis

A 
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
59
Q

What are the SE of thrombolysis

A

Haemorrhage
Hypotension
Allergy

60
Q

What do you do if ST elevation but arrhythmia

A

Treat as peri-arrest

ACS could have caused but can’t treat due due to tachy

61
Q

What is needed

A

DC cardioversion

Treat as whether Brady or tachy

62
Q

What else is offered to patient

A

Cardiac Rehab

63
Q

What else can raise troponin

A 
Chronic renal 
Sepsis
PE
Dissection
Myocarditis
64
Q

What are the types of MI

A 
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
65
Q

DDX of ACS

A 
Aortic dissection 
- very unwell and tearing pain between pack / scapula 
PE 
Pericarditis 
- Relief forward 
Heartburn
MSK

CVS (30 decks)

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