ACS Flashcards
What is included in ACS?
Unstable Angina
NSTEMI
STEMI
Pathophys of an NSTEMI or unstable angina?
Ruptured coronary plaque with subocclusive thrombus
Pathophy of a STEMI?
Ruptured coronary plaque with occlusive thrombus
What is the treatment for STEMI?
Emergency reperfusion preferable with primary percutaneous intervention
Difference in ECGs between STEMI and NSTEMI/unstable angina?
- STEMI = ECG ST elevation or new LBBB
- NSTEMI/unstable angina = ECG normal or ST depression
Troponin
Biomarker for cardiac necrosis
Isoforms I and T
Definition of an MI
Rise and/or fall of troponin with at least 1 value >99th percentile of the URL plus 1 of
- myocardial ischaemia symptoms
- ECG changes
- loss of myocardium/wall motion abnormality by imaging
- angiography/autopsy showing intracoronary thrombus
Type 1 AMI
Spontaneous
Plaque Rupture
Type 2 AMI
Ischaemic imbalance
Coronary spasm, embolism, dissection, hypotension
Type 3 AMI
Cardiac death
Presumed AMI
Type 4a AMI
Related to PCI
>5 times URL for troponin
Type 4b AMI
Caused by stent thrombosis
Confirmed at angiography or autopsy
Type 5 AMI
Related to CABG
>10 times URL for troponin
What is the AMI pathway?
2-7 day long
Emergency admission, diagnose, hospital admission to treat, stay to manage comp., discharge with prevention and rehab
Danger in delay in calling help
33% die from AMI before reaching hospital
elderly, women, nocturnal pain, no previous AMI, diabetic > risk
Anatomical determinants of infarct size
- occluded artery distribution
- proximity of coronary occlusion
Physiological determinants of infarct size
- thrombotic response to plaque rupture
- thrombolysis effectiveness
Logistical determinants of infarct size
- time to call help, arrive to hospital, delivery of reperfusion therapy
Therapeutic determinants of infarct size
- reperfusion therapy (thrombolysis vs. PPCI)
- antiplatelets
- drugs to prevent against LV remodelling
A&E ACS Urgent treatment
- consider alternative sinister illness
- ECG, oxygen, bloods, aspirin, GTN
- if STEMI = PPCI straight away
- if unstable angina/NSTEMI = troponin, ECG, symptom, risk scores
- nondiagnostic = continue evaluation until seek cardiology help
When to admit a patient in A&E for chest pain?
- diagnostic ECG
- typical chest pain/HF/unstable rhythm
- troponins positive
STEMI Treatment
PPCI Aspirin + Ticagrelor Gp IIb/IIIa inhibitor UH/LMWH Give all drugs with cath lab to have procedure
Ticagrelor
P2Y12 receptor antagonist
Higher antiplatelet activity
Fast onset action
180mg loading dose then 90mg twice daily
P2Y12 receptor antagonists
Clopidogrel lowest activity then prasugrel then ticagrelor
NSTEMI low risk <3% treatment
conservative management
aspirin
fondoparinux/UFH
Ticagrelor
NSTEMI intermediate risk 3-6% and high risk >6% treatment
aspirin fondoparinux/UFH ticagrelor consider tirofiban/eptifibatide coronary angiography within 96 hours to assess PCI or CABG
Complication Treatment of HF
- diuretics = IV furosemide, haemofiltration if diuretic resistant
- RAS inhibiton = ACEi, ARB, eplerenone
- ionotropes = NA, dobutamine
- LV support device = balloon pump, LVAD
What bradyarrthymias can you get from AMI?
Complete AVN block
Wenckebach Mobitz 1
Intermittent block of both bundle branches (Mobitz 2)
Complete block of both bundle branches
How to treat Mobitz 1 and complete AVN block?
Atropine
Good prognosis
Spontaneous recovery <7d
How to treat Mobitz 2 and complete BBB both sides?
Pacing
Poor prognosis
What tachyarrythmias do yo get from AMI?
AF
VT - in first 12-24hrs
VF
How to treat AF from AMI?
Beta blocker
DC cardioversion if haemodynamically unstable
Anticoagulation if persists
How to treat VT and VF from AMI?
DC shock for rhythm control
If corrected = minor prognostic impact
>24 hours occur bad prognosis
AMI secondary prevention
Lifestyle = smoking, diet, exercise Drugs = aspirin, P2Y12 receptor antagonists, statins, beta blocker, ACEi Prevention = ICD
Which treatments do you give for life?
Aspirin Statins Beta blockers ACEi All except P2Y12 receptor ant.
What to do if patient death pre hospital?
Defib ASAP
Most due to VF
What to do if hospital death from LVF?
Initiate reperfusion therapy ASAP
Aldosterone antagonists
Avoid calcium antagonists
Treat HTN and renal failure
What artery is affected in a lateral STEMI?
Circumflex artery
What artery is affected in an anterior STEMI?
LAD
What artery is affected in an inferior STEMI?
RCA
Causes of high troponin
Cardiac procedures HTN associated heart disease CKD Tachycardias Myocarditis Cardiomyopathies AF
When do troponin levels change?
Increase in 3-12 hours
Peak in 24-48 hours
Return to normal in 5-14 days
Which drugs are given for pain
morphine
GTN
CK levels change how?
Rises in 3-12 hours
Peaks in 24 hours
Returns to baseline in after 48-72 hours
Symptoms
Typical Chest Pain
Complications = arrhythmia
HF
LVF
