ACS

Question 1

What are Acute Coronary syndromes (ACS) ?

How do you distinguish between the 2.

Answer 1

collection of pathologies :

0 ST-elevated STEMI - complete occulsion of coronary artery.

0 Non ST - elevated STEMI - partial occulsion of coronary artery resulting in reduced blood flow to the heart———–> myocardial injury ———————–> infraction.

0 Unstable angina

ACS ————————-> ECG ((ST elevation = STEMI ) , no ST elevation = Non STEMI) ———————–> Raised cardiac biomarkers = Non STEMI vs unstable angina

Question 2

Diagnosis of ST - elevation (STEMI)

Answer 2

0 persistent ST - segment elevation in at least 2 anatomically contingous ECG leads

Rise in cardiac - at least one value above 99th percentile - specific Troponin - has a rising / falling pattern that can distinguish it from other pathologies e.g. myocarditis , aortic dissection.

cTnT
cTnI
( do not wait for laboratory results before starting treatment )

cardiac - myosin binding protein C (cMyC )-emerging test - might become gold standard (just to know for future)

Symptoms
0 Classically Central pain retrosternal, crushing, heavy, severe, and diffuse in nature

0 Might be described by the patient as ‘pressing or squeezing’

0 can happen with rest or on activity

0 constant or intermittent, or wax and wane in intensity

can radiate to the left arm, neck, or jaw

0 May be associated with : 
      - nausea, 
      - vomiting,
      - dyspnoea, 
      -diaphoresis, 
      - lightheadedness, 
      - palpitations,  
      - syncope 
        (passing out )

• note - 12-ECG done within first 10 mins of medical contract (if in community a pre-hospital ECG done and sent to the hospital )

Question 3

Important treatment in Acute MI - ST elevation ?

Answer 3

0 Cardiac repurfusion therapy - widen blocked coronoary artery to restore blood flow.

e. g Fibrinolytic therapy e.g
- Streptakinase
- Altepase
- Retepase
- Tenectepase

• Primary percutaneous intervention (Primary PCI )/ coronary angioplasty - balloon catheter inserted into narrowed artery under local anathestic to widen it.

Question 4

Management of unstable angina & Non STEMI

Answer 4

Aspirin - to prevent plaque build up (further )———————————————————–> assess future risk of other cardiovascular events (Full history ,physical exam (BP, HR ), resting 12 lead ECG , Blood test - tropnonin , CK, glucose , Haemoglobin )——————————————————————>

• consider coronary angiography - if high risk of cardiovascular events & no contraindications or ischemia experienced
• if Coronary angiography indicated - give dual antiplatelet therapy :

Aspirin + Prasugel or ticagrelor

give clopidgrel + aspirin instead if separate indication or ongoing oral anti coagulation therapy

AFTER EVENT

drug managment plan drawn up :

ACE inhibitors

• Antiplatelet therapy
• Beta blockers
• Statins
• Calcium channel blockers or Potassium channel activators.

cardiac rehabilitation

Question 5

cardiac troponin

Answer 5

detectable : about 2 hours after cardiac cell necrosis &

Highest level : around 14 hours

Duration - stay elevated for 14 days.

CTnI - best one.

CK -MB
Dectable - 3-4 Hours after necrosis

Peaks - 24 hours

• normal within 72 hours.

Myoglobulin

Dectable - 1-3 hours after MI

Peaks - 6-9 hours

Normal - within 24-36 hrs

H- FABP
- released form injured myocardium

Detectable - 1.5 hrs after MI

Peaks - 4 - 6 hrs

Normal after 20 hrs

can be used in a panel of cardiac biomarkers.

Question 6

Natriuretic proteins

Answer 6

used in diagnosis of Heart failure ]]- secreted in response to atrial stretch , ventricular volume overload

BNP - B - type NP - raised in systolic & diastolic HF

( synthesized as a pro-hormone (NT-proBNP - is elevated too )

0 intermediate raised levels of both - indicated non - cardiac cause of dyspnoea - like COPD

ANP