ACS Flashcards
Conditions
Unstable angina
STEMI
NSTEMI
Pathophysiology of STEMI
Atheromatous plaque that ruptures causing a thrombus which completely occludes coronary artery causing transmural ischaemia and necrosis
Types of STEMI
Type I - atherosclerotic plaque rupture with intraluminal thrombus
Type II - imbalance between myocardial oxygen supply and demand - respiratory failure
Type III - MI causing death when biomarkers aren’t available
Type IV - MI due to PCI
Type V - MI due to coronary artery bypass
Risk factors
Age Male FHx < 55yo Hypercholesterolaemia Previous MI Diabetes HF Bypass surgery Smoking Obesity AF HTN
HEART SCORE
Predicts 6 week risk of major adverse cardiac event
Q risk
Calculates probability of a MI or stroke in the next 10 years
GRACE score
Estimates the in hospital and 6 month to 3 year risk of mortality of patients with ACS
TIMI score
Estimates mortality for patients with unstable angina and NSTEMI
If high score - coronary angiography within 72hrs
Symptoms
Central dull crushing chest pain Radiates to arm and jaw Nausea and vomiting Sweating Gradual onset
STEMI investigations
Obs Bloods - Trop I, FBC, U+Es, LFTs Lipid profile Diabetic screen ECG - ST elevation Transthoracic echocardiogram CXR - pulmonary oedema Coronary angiogram - plaque rupture/ dissection CT aorta - query aortic dissection into RCA
ECG changes
Min - hours - tall T wave 0 - 12 hours - ST elevation 1 - 12 hours - pathological Q wave 2 - 5 days - T wave inversion Weeks - months - T wave recovery
Acute management of STEMI
Morphine - 5 - 10mg IV
Oxygen
Nitrates - GTN spray
Aspirin - 300mg
PCI
Prasugrel contraindications
Over 75 yo
TIA or stroke
What medication is also given if morphine is administered?
Metoclopramide 10mg - antiemetic
When would fibrinolysis be given
If PCI cannot be done within 120mins and pt presented within 12 hours of onset of symptoms
- ECG 60-90 mins after
Long term medication
Aspirin - life long Ticagrelor - 12 months ACEi/ARB Beta blocker Statin - atorvastatin 80mg Risk factor reduction - smoking cessation, alcohol reduction, diabetes control
NSTEMI pathophysiology
Rupture of the fibrous cap of the atheromatous plaque in a coronary artery, causing a thrombus which PARTIALLY occludes the artery causing ST elevation which leads to subendocardial ischaemia and necrosis
GRACE Low risk NSTEMI management
Low risk - predicted 6 month mortality less than 3% GRACE score
- consider conservative management without angiography
- angiography may be beneficial in younger people
- ticagrelor with aspirin or clopidogrel if high bleeding risk
GRACE high risk NSTEMI management
Predicted 6 month mortality - 3%+
- immediate angiography
- follow on PCI if indicated within 72 hours
- prasugrel or ticagrelor with aspirin
- clopidogrel if already has indication for anticoagulants
- LMWH - if having PCI
- echocardiogram - left ventricular necrosis
Cardiac rehabilitation
Diet modification - decreased salt and cholesterol Exercise Stress management Health education Alcohol reduction Smoking cessation
ST elevation in leads II,III, AVF
Inferior STEMI
Right coronary artery
ST elevation in leads V5,V6, AVL
Lateral STEMI
Left circumflex artery
ST elevation in leads V1 - V4
Anterior STEMI
Left anterior descending artery (LAD)
Complications
Another MI
HF
Ischaemic heart disease
Mitral regurgitation
What should be prescribed if statin in contraindicated
Ezetimibe
Which artery supplies the SAN and AVN
Right coronary artery
Contraindications for thrombolysis (AGAINST)
- Aortic dissection
- GI bleeding
- Allergic reaction previously
- Iatrogenic: recent surgery
- Neuro: cerebral neoplasm or CVA Hx
- Severe HTN (200/120)
- Trauma, inc. CPR
Thrombolysis agents
1st: streptokinase ( can only be given once)
2nd: alteplase
What else should be given with Fibrinolysis
Antithrombin drugs e.g. Fondaparinux
Repeat ECG should be given within 60 - 90 mins
