ACS Flashcards
What is the immediate management for confirmed STEMI?
ECG + BLOOD MARKERS!! IV Access Morphine 2-5mg IV + Metoclopramide 10mg IV O2: Sats <94% Nitrates: GT spray 2 puffs + BB STAT Aspirin: 300mg PO Ticagrelor: 180mg Fondaparinux: Pre-PCI if <12hrs of Sx onset
In an NSTEMI how long is LMWH given for?
2-5days
What aftercare is given post-NSTEMI/STEMI and how long for?
ABC'S A: ACEi = indefinitely B: Beta-blocker = 12m C: Dual antiplatelet = Aspirin & Ticagrelor/Clopidogrel = 12m S: Statin = indefinite
What are the signs of an Atypical MI?
Epigastric/back pain "Silent infarct" Dyspnoea- pulmonary oedema Syncope Coma Confusion
Who is at risk of a silent MI?
Elderly
Diabetic
HTN
What are the essential investigations for a suspected MI?
ECG
↑Troponin: ↑3 hrs, peaks 12 hrs, 24-48hrs
Raised if ONE is above reference range
↑CK: ↑4-8 hrs, peak at 24hrs, fall 3-4d
What are the signs on an ECG of a STEMI?
ST elevation >1mm in a limb lead OR >2mm in 2 consecutive chest leads OR New LBBB
Where do the LAD, Circumflex & RCA supply?
LAD: Anterior heart & LV
C: Lateral heart
RCA: Inferior heart
What leads correspond to the RCA, LAD & Circumflex?
RCA: II, III, AVF
LAD: V1-V4
C: I, AVL, V5-V6
What are you at risk of with a STEMI caused by a blockage in the RCA?
High risk of heart block
What ECG changes are seen in an NSTEMI?
T inversion (normal in aVR)
ST depression
Q waves
What would ST depression in V1-V4 make you consider?
Posterior STEMI
What are the coronary repercussion therapy options?
Angiography & PCI
Fibrinolysis
What are the indications for PCI?
Present <12hr of Sx onset
AND
PCI can be given within 2hrs of ECG diagnosis
If PCI cannot be delivered within the indications what is the next best option?
Fibrinolysis: Alteplase
- If PCI not available in 2hrs but still in 12hr window of Sx onset
- If thrombolysis successful then PCI can be done within 24hrs
- Repeat ECG after 60-90mins
Other than an MI what conditions can cause a raised troponin?
Cardiac: cHF, CAD, Myo/endo/pericarditis, heart block, HTN, Aortic dissection, AV disease, Hypertrophic cardiomyopathy
Non-Cardiac: PE, severe pulmonary HTN, RF, COPD, DM, Acute neurological event Drugs and Toxins
What is the TIMI risk score?
Scored out of 7
- Likelihood of adverse events
- Identifies who will benefit from certain interventions (including PCI): Higher the risk = Greater the benefit
What is the GRACE risk score?
Predicts 6month mortality post-MI
>9% = High risk
Treatment strategies recommended depending on risk
What are the 3 distinctive features of an NSTEMI on presentation?
Resting angina
New-onset severe angina
Increasing angina (prevention diagnosed)
Why is troponin helpful in NSTEMI?
Differentiates between UA (normal troponin) & NSTEMI (a) ↑Trop)
In an NSTEMI what do high risk patients require?
Inpatient angiography PCI
AND
Glycoprotein iib/iiia
In NSTEMI what is the time frame for PCI?
<12hours
What needs to be stopped before a CABG and for how long?
Ticagrelor/Clopidogrel 5-7d pre-CABG
What are the complications of an MI?
VF → Cardiac arrest: MOST COMMON cause of death post-MI Cardiogenic shock Chronic HF Tachy/bradyarrhythmias Pericarditis Dressler's syndrome LV free wall rupture Ventricular septal defect Acute mitral regurg LV aneurysm
How does cardiogenic shock occur post-MI?
Large part of ventricular myocardium damaged
Usually after anterior MI
↓EF
Systemic hypoperfusion (tachy, ↓sBP, cool peripheries & ↓renal output)
Adequate central venous filling pressures.
Also caused by LV free wall rupture
How is cardiogenic shock treated?
PCI
Inotropes +/- intra-aortic balloon pump
What type of MI is most likely to cause a bradyarrhythmia?
Inferior MI
When does pericarditis post-MI usually present?
First 48hrs
Following transmural MI
What is Dressler’s syndrome?
2-6w post-MI
Autoimmune reaction against antigenic proteins formed by recovering myocardium
FEVER + PERICARDITIS + EFFUSION + PLEURITIC PAIN w/↑ESR
Tx: NSAIDs
What sign on ECG may indicate an LV aneurysm?
Persistent ST elevation
What is someone with an LV aneurysm at risk of?
Thrombus may form in aneurysm
Stroke = Anticoagulated
How does an LV free wall rupture present? How is it treated?
1-2w post-MI
Acute HF secondary to tamponade (↑JVP, pulses paradoxes, ↓BP, ↓EF, ↓HS)
Tx: URGENT Pericardiocentesis & thoracotomy
How does ventricular septal defect present post-MI? How is it investigated & treated?
First week
Acute HF + Pan-systolic murmur
Ix: ECHO
Tx: Surgical repair
In what type of MI is acute mitral regurg most commonly seen?
Infero-posterior MI
May be due to ischaemia or rupture of papillary muscle
Tx: Surgical repair
What is unstable angina?
Absence of biochemical evidence of myocardial damage
Prolonged angina at rest/ new onset severe angina/ angina increasing in frequency/ inc duration/ angina post-MI
How is a diagnosis of unstable angina chosen over an NSTEMI?
NSTEMI:
ECG = T-wave changes/ST depression/ no ECG changes
Biochem = Trop RISE
UA:
ECG = T-wave changes/ST depression/ no ECG changes
Biochem = No elevation
How is unstable angina investigated?
ECG
Bloods: Troponin, FBC, U&E, Glucose, LFTs, lipids, Coag
CXR
ECHO
