ACS**** Flashcards
3 types
STEMI
NSTEMI
Unstable angina
STEMI:
Marker in blood for change
Rise of troponin
NSTEMI:
Troponin is the obvious marker for change.
What 2 other features need to be present?
Rise of troponin
ECG changes and ischamuic symptoms
Unstable angina:
Features - 2
Prolonged, severe angina
Usually at rest
Pain Hx:
What would you find in SOCRATES?
S - central O - usually sudden but can be more gradual C - tight, crushing but not sharp R - left arm, neck, jaw A - sweating, clamminess, SOB, dizziness, faint T - >15 minutes E - Exertion, emotion, eating S - high but can be low
Who tend to have more atypical presentations? -2
What symptoms do they have in these atypical presentations?
Elderly or diabetic patients
High blood sugar, high blood pressure and cholesterol problems raise risk for heart events, but nerve damage can make warning signs of an attack impossible to feel. “People with diabetes may have an impaired perception of chest pain, a key symptom that compels people to go to the hospital,” he says.
Little or no chest pain SOB Sweating N&V Silent MI - not symptoms at all
Signs
HR
BP
Colour
Heart sounds
Can be high or low
Pallor
S3 AND S4 heart sounds
Investigations:
ECG changes in STEMI
Acute
Within days
Long term
Peaked T waves
THEN ST elevation
Elevated Q wave
THEN T wave inversion
Elevated Q wave + ST changes
What else can cause ST elevation?
- infection of what surrounds the heart
- heart tissue gets bigger and which side
- aorta
- bundle block
- lungs
- potassium
Pericarditis LVH Aortic dissection LBBB, RBBB PE Hyperkalaemia
Investigations:
ECG changes in NSTEMI and unstable angina
What may be seen in a posterior MI?
ST depression and/or T-wave inversion
ST depression and Tall R waves in anterior leads
A good way to think about reciprocal change is an ‘upside down’ ST elevation seen in leads opposite to the site of infarction.
Investigations:
Troponin:
- how long after admission should it be tested?
- when does it peak?
- over what centile is acute MI diagnosed?
Other causes of raised troponin - HEART DIES
3-6 hrs
12-24 hrs
99th centile
HF AF Embolus Renal failure Thrombus
Dissection
Inflammation
Exercise
Sepsis
Investigations:
Why are:
- FBC
- U&E
- Glucose
- Lipids
- CXR
- Exercise tolerance test
DONE
Low Hb may exacerbate heart strain and baseline Hb and PLT needed before anticoagulation
Baseline before anticoagulants and ACEi given
Screens for co-morbid renal disease from HTN
Tight control improves outcomes
Check on admission as cholesterol
Can dip 24 hours post-MI
Rule out other causes and check for signs of HF
Considered in lower risk patients
Management:
Symptom management - MONA
Morphine IV
Oxygen
Nitrates - GTN spray/sublingual
Aspirin 300mg PO
Management:
What is added for dual antiplatelet therapy?
What can be added to oxygen therapy if tachycardic/hypertensive?
P2Y12 inhibitors - clopidogrel, ticagrelor or prasugrel
Beta blockers
Management:
What anticoagulation is used?
Unfractionated heparin IV
Enoxaparin SC
Fondaparinux SC
Reperfusion:
STEMI presenting within 12 hr of onset:
Immediate (within 90-120 mins) - PCI is done - what does ti stand for and what is it?
What if above is not available in 120 mins?
What is beyond 12 hrs?
Primary PCI - percutaneous coronary intervention
Dilation of artery with balloon catheter +/- stents
Thrombolysis - alteplase, reteplase, tenecteplase and transfer to PCI centre
Manage like NSTEMI
Reperfusion for NSTEMI and unstable angina - 1
What is the GRACE score?
What else is considered on top of that if GRACE score is high?
What is given if they are unstable, they have refractory chest pain or acute severe HF?
The GRACE Score is a prospectively studied scoring system to risk stratifiy patients with diagnosed ACS to estimate their in-hospital and 6-month to 3-year mortality.
Angiography +/- revascularisation within 48 hrs
Immediate PCI
Management:
Another mneumonic that is used is BATMAN. What does it stand for?
Others issues:
What happens to the anticoagulation?
What are they discharged with?
What med should be avoided?
Beta-blocker Aspirin Thrombolysis Morphine ACE inhibitors Nitroglycerin
Glucose maintenance <11 mmol/L - may require insulin infusion
Statin
Stopped post-PCI or continued until discharge - continued for 3 months for anterior MI
Secondary prevention meds and offer cardiac rehab
NSAID’s
Complications:
Electrical - 4
Heart block
Sinus bradycardia
Bundle branch block
Ventricular fibrillation
Complications:
Structural - 5
Acute mitral regurgitation Papillary muscle rupture Ventricular free wall rupture leading to haemopericardium Ventricular septal rupture Ventricular aneurysm
Complications:
Inflammatory - 1
What is Dresslers syndrome?
Long term
Peri-infarction pericarditis
Pericarditis weeks post MI
Myocyte death Low SV, low HR and low BP Sympathetic response to try and compensate LV changes HF
Right sided HF
2 big features:
- supply to body
- see on neck
Rx - 1
What should be avoided?
Low cardiac output
Raised JVP
Fluids
Vasodilators or diuretics
Pericarditis
What type of pain would you have?
How is the pain relieved?
What would you see on ECG?
How painkiller is given to Rx?
Central chest pain
Relieved by sitting forward
Saddle shaped ST elevation
NSAID’s
Systemic embolism:
Where might it come from?
Rx - 2 choices and you are on one of them for 3 months?
LV mural thrombus
Anticoagulation
Warfarin for 3 months
Cardiac tamponade:
What happens to CO?
You can get Kussmaul’s sign. What is it?
Drops
A paradoxical (weird/absurd) rise JVP on inspiration, or a failure in the appropriate fall of the JVP with inspiration due to reduced RV filling
Cardiac tamponade?
You get pulses paradoxus with this. What is this?
What happens to the heart sounds?
How is it diagnosed?
What is needed to treat it?
Paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus.
Muffled heart sounds
Echocardiogram
Pericardial aspiration - pericardiocentesis
Mitral regurgitation:
What feature would you find in the lungs?
Rx?
Pulmonary oedema
Valve replacement
Treat left ventricular filling problems first
Ventricular septal defect:
What type of murmur would you hear?
Other sign on neck?
Diagnosis?
Rx
Pansystolic murmur
Raised hVP
Echo
Surgery
