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TCA 1 - Chest Pain > ACS > Flashcards

ACS Flashcards

1
Q

What are the differential diagnoses of chest pain?

A

CV - Myocardial ischaemia

  • Aortic stenosis
  • Tachyarrhythmias
  • Cocaine use
  • Anaemia
  • Thyrotoxicosis

CV - non-ischaemic

  • Aortic dissection
  • Pericarditis

Upper GI

  • GORD
  • Gallstones
  • Peptic Ulcers
  • Pancreatitis

Resp

  • Pulmonary embolism
  • Pneumothroax
  • Pneumonia
  • Pleurisy

Musculoskeletal

  • Costochondritis
  • Herpes zoster / Shingles
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2
Q

What is ACS?

A

Acute myocardial ischaemia/infarction due to partial or complete occlusion of a coronary artery.

It is divided into 3 clinical categories depending on

  • Presence of ST-segment elevation
  • Troponin or creatine kinase
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3
Q

What is an NSTEMI?

A

Partial occlusion of a vessel with likely no dead tissue and limited to the subendocardium

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4
Q

What is a STEMI?

A

Complete occlusion of a vessel with ischaemia (and likely infarction) being transmural

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5
Q

What is the pathophysiology of ACS?

A
  • Acute thrombosis induced by rupture of atherosclerotic plaque
  • Vasoconstriction
  • Critical decrease in blood flow
  • Clinical cascade
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6
Q

What is the stats regarding hospital mortality for NSTEMI and STEMI?

A 
NSTEMI = 3-5%
STEMI = 7%
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7
Q

What is more common, a STEMI or NSTEMI?

A

NSTEMI

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8
Q

What is the 6 month mortality for NSTEMI and STEMI?

A 
NSTEMI = 13%
STEMI = 12%
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9
Q

What are the clinical findings of unstable angina?

A
  • prolonged angina at rest (>20mins)
  • new onset of severe angina at rest
  • angina that increases in frequency, longer in duration or lower in threshold
  • Occurs after a recent MI
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10
Q

What can the ECG of a patient with unstable angina show?

A
  • ST-segment depression
  • T-wave inversion
  • Can be normal
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11
Q

Are there any clinical biomarkers of unstable angina?

A

No

- No elevation in troponin or creatine kinase-MB

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12
Q

What are the treatment aims of unstable angina?

A

Focus on initial interventions and triage according to presumptive diagnosis

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13
Q

What can the ECG of a patient with NSTEMI show?

A
  • ST-segment depression
  • Transient ST-segment elevation
  • T-wave inversion
  • Can be normal
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14
Q

What are the clinical biomarkers of a patient with NSTEMI?

A

elevated troponin at presentation or several hours after NSTEMI

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15
Q

What are the treatment aims for NSTEMI?

A
  • Relief of ischaemia
  • Prevention of further thrombosis or embolism
  • Stabilisation of haemodynamic status
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16
Q

What can the ECG initially show of a patient with STEMI?

A

STEMI?
- >20mins ST-segment elevation in 2 or more anatomically continuous leads
AND
- New LBBB

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17
Q

What can the ECG show over hours-days of a patient with STEMI?

A
  • T-wave inversion

- Pathological Q-waves

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18
Q

What are the clinical biomarkers of a patient with STEMI?

A

elevated troponin and creatine kinase-MB

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19
Q

What are the treatment aims for a patient with STEMI?

A
  • Percutaneous Coronary Intervention (PCI) within 120 minutes of first presentation
    OR
  • Thrombolysis within 12 hours of symptom onset
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20
Q

In STEMI, what does a posterior MI show on the ECG?

A
  • Anterior leads show ST depression

- Limb leads show ST elevation

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21
Q

In STEMI, how do you know the left coronary artery is occluded?

A

ST-segment elevation in leads I, aVL, V3-V6

These leads show the anterolateral portion of the heart

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22
Q

In STEMI, how do you know if the LAD is occluded?

A

ST-segment elevation in leads V1-V4

These leads show the anterior portion of the heart

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23
Q

In STEMI, how do you know if the Circumflex artery is occluded?

A

ST-segment elevation in leads I, aVL, V5-V6

These leads show the lateral portion of the heart

24
Q

In STEMI, how do you know if the Right Coronary Artery is occluded?

A

ST-segment elevation in leads II, III, aVF

These leads show the inferior position of the heart

25
Q

What are the symptoms of ACS?

A
  • New onset of chest pain at rest lasting >15 mins
  • High frequency chest pain
  • High severity of chest pain
  • Retrosternal chest pain radiating to the jaw, arm or neck
  • Dyspnoea
  • Nausea, vomiting, sweating
  • Can be ‘silent’
  • Common in elderly and diabetic patients
26
Q

What is the first investigation you order for ACS?

A

ECG

- either in ambulance or within 10 minutes of arriving at hospital

27
Q

Does a normal ECG exclude ACS?

A

NO

A normal ECG can be due to:

  1. Ischaemia in circumflex artery territory
  2. Isolated right ventricle ischaemia
  3. Transient LBBB or RBBB

1 and 2 are only detected using leads V7-V9, V3R and V4R

28
Q

What other investigations should you order for ACS a part from an ECG?

A
  • Cardiac Biomarkers
  • Troponin I and T
  • Creatine kinase-MB
  • CXR
  • Bloods
  • FBC
  • U&Es
  • Serum creatine
  • Blood Glucose
  • Lipids
  • Liver function tests
  • Echocardiogram
29
Q

What will the cardiac biomarkers show for NSTEMI and STEMI?

A

Raised troponin I and T

Raised Creatine kinase-MB

30
Q

What will a CXR show after an MI?

A

Potentially:

  • Cardiomegaly
  • Pulmonary oedema
  • Widened mediastinum
31
Q

What will an echocardiogram show after an MI?

A
  • Regional wall motion abrnormality (Part of the heart wall not thickening as well during systole)
  • Depressed left ventricular function
  • Decreased ejection fraction
32
Q

What could a FBC show?

A

Haemoglobin and haematocrit measurements may help to evaluate secondary causes of MI:

  • Acute blood loss
  • Anaemia

Evaluate thrombocytopenia to estimate risk of bleeding

33
Q

What could electrolytes show?

A

normal or deranged

- deranged - may predispose to cardiac arrhythmias

34
Q

Why order liver function tests and serum creatine?

A

LFTs
- useful when considering treatment with drugs that undergo hepatic metabolism

Serum creatinine
- Clearance of renal creatinine is estimated to allow adjusting for renal cleared drugs

35
Q

What are the risk factors for ACS?

A
  • Male gender
  • Increasing age
  • Positive family Hx
  • Hx of CAD
  • Hypertension
  • Diabetes
  • Hyperlipidaemia
  • Obesity
  • Smoking
  • Cocaine use
  • Hypercholesterolaemia
36
Q

What is the incidence of STEMI per annum?

A

5/1000

37
Q

What is the initial treatment for chest pain?

A 
- Nitrates 
GTN to relieve ischaemic pain
- Morphine (and antiemetic)
if pain continues
- Antiplatelet - Aspirin 300mg STAT
- Oxygen if SaO2 is <94%
MONA:
M - morphine
O - oxygen
N - nitrates
A - aspirin
38
Q

What do you give a patient if they are allergic to aspirin?

A
  • Clopidogrel - if no excessive bleeding risk
    OR
  • Prasugrel
  • Ticagrelor
39
Q

For an NSTEMI/unstable angina what else would you give?

A
  • Dual anti-platelet therapy
    300mg Aspirin loading followed by 75mg o.d.
    + Clopidogrel (if no excessive bleeding risk)
    OR Prasugrel
    OR Ticagrelor
  • Anticoagulation
    Fondaparinux 2.5mg o.d.
40
Q

For NSTEMI, what would you do after giving the initial treatment (MONA)?

A

Calculate the GRACE score

41
Q

What is the GRACE score?

A

Calculates ischaemic risk

Predicts the risk of future adverse CV events by predicting 6-month mortality

42
Q

Which patients with NSTEMI have coronary angiography (with PCI if necessary)?

A
  • Immediately if patient is unstable (hypotensive)

- Within 72 hours if GRACE score ≥3%

43
Q

For an NSTEMI patient what would you give them before PCI?

A

Unfractioned heparin regardless whether they have received fondaparinux

44
Q

For high risk patients with NSTEMI, what is the drug treatment pathway after a calculation a high-risk GRACE score?

A 
B - Beta Blockers
A - Aspirin 300mg
T - Ticagrelor 180mg (or clopidogrel 300mg)
M - Morphine titrated for pain
A - Antigoagulant (fondaparinux or LMWH)
N - Nitrites (GTN IV)

ACE inhibitors

45
Q

When can you not give Beta Blockers?

A

When patient has:

  • Cardiogenic shock
  • Heart Failure
  • Asthma
  • COPD
  • Heart block
46
Q

What can you give instead of ACE inhibitors, if a patient does not tolerate them well?

A

Angiotensin II receptor blockers (ARBs)

47
Q

What is the treatment pathway for STEMI patients?

A

Primary Percutaneous Coronary Intervention (PCI)
- Offered within 12hrs of symptom onset and if can be done within 120mins of medical contact

Thrombolysis
- If PCI cannot be offered within 120 mins

48
Q

What happens after 12hrs of STEMI symptom onset?

A

If there is evidence of ongoing ischaemia - PCI

49
Q

What drugs must be used with PCI?

A

Dual anti-platelet therapy

IV anticoagulant
- Bivilrudin (1st choice) and GPI
OR
- Unfractioned heparin and GPI

50
Q

What happens if thrombolysis is unsuccessful?

A

Get PCI

51
Q

What needs continual monitoring when a patient is in hospital for ACS?

A
  • Exacerbations in pain/symptoms
  • Pulse and BP
  • Heart rhythm
  • O2 sats by pulse oximetry
  • Repeated ECG
  • Checking if pain relief is effective
52
Q

What are the most common complications post-MI?

A

DREAD

D - Death
R - Rupture of heart septum or papillary muscles
E - Edema (Heart Failure)
A - Arrhythmia and Aneurysm
D - Dressler's syndrome
53
Q

What is Dressler’s syndrome?

A

It is a type of pericarditis

Inflammatory response from the immune system goes to heart just beneath the pericardium due to tissue necrosis

54
Q

What is secondary prevention after an MI?

A 
6 A's:
Aspirin (75mg once daily)
Another antiplatelet for 12 months
Atorvastatin (80mg once daily)
ACE inhibitor (ramipril)
Atenolol (beta blocker)
Aldosterone antagonist (for those with HF)
55
Q

What can you give if beta blockers are contraindicated?

A

Calcium channel blockers

56
Q

What is offered on the cardiac rehabilitation programme?

A
  • Exercise
  • Health education
  • Advice on work
  • Advice on travel
  • Stress management

TCA 1 - Chest Pain (7 decks)

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