ACS & AMI - Presentation & Investigation Flashcards
What are the four main acute coronary syndromes (ACS)?
STEMI
NSTEMI
unstable angina
sudden cardiac death (SCD)
An ACS causes problems due to the effects of ________ _________.
myocardial ischaemia
Myocardial infarction (MI) implies cell death due to _________ _________.
prolonged ischaemia
What is cardiac arrest?
What are features of a cardiac arrest? (3)
Abnormal heart rhythm not compatible with life.
Ventricular fibrillation
Ventricular tachycardia
Asystole
Is a cardiac arrest the same as an MI?
Not necessarily, a cardiac arrest can occur during the acute phase of MI, in the late stage or be unrelated at all.
What are the three main coronary arteries affected in MI?
- left anterior descending (LAD) artery
- right coronary artery (RCA)
- circumflex artery
What stage of atherosclerosis results in stable angina?
3
- there is a stable fixed plaque, some occlusion but not completely blocked.
- fibrous cap acts as protection.
- no rupture or thrombus production.
What ACS’s are the diagnosis when there is thrombus present in the coronary artery?
STEMI
NSTEMI
Is stable angina is not considered an ACS, what is it?
chronic ischaemic heart disease
What would be picked up on an initial ECG where there is complete coronary occlusion?
What type of ACS is this?
ST elevation
STEMI
What would be picked up on an initial ECG where there is partial coronary occlusion?
What type of ACS is this?
No ST elevation
(ST depression)
NSTEMI
What has likely been the ACS if no pathological Q waves are picked up on an ECG 3 days following initial ECG?
NSTEMI
If an ECG is showing pathological Q waves, what is the likely cause?
There has been a STEMI (transmural MI)
What are the other clinical terms for STEMI/NSTEMI?
STEMI: transmural MI
NSTEMI: subendocardial MI
What main investigations are used to diagnose a MI?
2
- bloods
- ECG
What blood result would indicate a recent/ongoing MI?
be specific
- increased troponin
Troponin I, Troponin T
Which troponin is indicative of STEMI?
B1/Troponin I
Which troponin is indicative of NSTEMI?
B2/Troponin T
What are other causes of increased troponin levels, other than coronary artery disease?
(5)
- arrhythmia
- cardiac contusion
- renal failure
- sepsis
- pulmonary embolism
Briefly, what defines a type I MI?
2
- spontaneous MI
- associate with ischaemia due to thrombus, rupture, fissuring or dissection.
Briefly, what defines a type II MI?
2
- imbalance in O2 supply and demand
- ischaemia, but not due to thrombosis.
Briefly, what defines a type III MI?
2
- sudden cardiac death
- confirmed iscahemia, thrombus on angiogram or autopsy.
What are causes of type I MI other than atherosclerosis?
4
- vasospasm
- coronary dissection
- embolism (air, fat)
- vasculitis (inflammation)
What information can be gathered from the history which points to MI?
(4/5)
- chest pain (more like a discomfort)
- pain radiation (jaw, arm)
- severe, but not agony
associated symptoms: SOB, sweating, nausea
What are the common cardiac risk factors?
8
- Male
- Age
- Known heart disease
- High BP
- High cholesterol
- Diabetes
- Smoker
- FHx of premature heart disease
What should be included in the examination of a patient with suspected MI?
(2)
- BP, HR (both arms)
- auscultation
What should you listen for on auscultation of the heart?
2
murmurs or crackles
What findings on an ECG may be indicative of a STEMI?
2
ST elevation
pathological Q waves
What findings on an ECG may be indicative of a NSTEMI?
4
ST depression
inverted T waves
No Q waves
May be normal
An inferior MI indicates occlusion of which coronary artery?
RCA
A posterior MI indicates occlusion of which coronary artery?
circumflex branch
An anterior MI indicates occlusion of which coronary artery?
LAD artery
Which MI can be easy to miss on an ECG?
posterior MI/circumflex branch
Which ECG leads are used to detect anterior MI?
V1, V2, V3, V4
Which ECG leads are used to detect inferior MI?
SLL 2, SLL 3, aVF
Which ECG leads are used to detect a lateral MI?
V5, V6
Which ECG leads are used to detect a high lateral MI?
SLL 1, aVL
What could be changed in order to detect a posterior MI more easily?
- Position leads on back
- see opposite results on opposite leads (i.e. V1, V2)
What is the surgical treatment options for MI?
Would this be used in STEMI or NSTEMI?
PCI (percutaneous coronary intervention)
STEMI mainly, NSTEMI possibly but not immediately important.
If a NSTEMI patient was not having immediate PCI, how would they be treated?
(2)
- fondaparinux
- LMWH s/c
What treatment option would be required if a patient was not near a cath lab for PCI?
Which drug might be used for this?
thrombolysis
tenecteplase (TNK)
What risks are associated with thrombolysis?
When should it not be given to patients? (3)
- bleeding
- recent stroke or previous intercranial bleeding
- on warfarin
- recent surgery
- severe hypertension
What are classical symptoms of unstable angina?
How will an ECG appear?
How will troponin be affected?
- chest pain at rest
- rapidly worsening
normal or abnormal
unchanged - no cell death
As well as checking troponin blood levels, what other blood tests should be investigated?
(3)
- Hb
- cholesterol
- kidney function
What is the pharmacological treatment for MI?
MONA B
- Morphine
- Oxygen (if hypoxic)
- Nitrate (GTN)
- Anticoagulants/antiplatelett
- Beta-blockers
What antiplatelet might be prescribed?
What other medicine might be given along with this? (hint: it begins with a)
aspirin
antiemetic
What are other antiplatelet drugs that may be prescribed?
(hint: __grel)
(3)
Clopidogrel
Ticagrelor Prasugrel
What anticoagulant drugs are used in treating MI?
hint: to treat NSTEMI before PCI
- heparin
- LMWH
- fondaparinux
What drugs are prescribed to MI patients on discharge?
4
- aspirin
- ACE inhibitor
- beta-blocker (or CCB)
- statin
What risks are associated with coronary angiogram and PCI?
6
- Bleeding from access site
- Blood vessel damage
- MI
- Coronary perforation
- Stroke
- Contrast nephropathy
If PCI was an unsuitable surgical option, what else may be considered?
CABG
What are post-MI complications?
C PEAR DROP
Cardiac arrhythmia/shock
Pericarditis
Emboli
Aneurysm
Rupture of ventricle
Dressler’s syndrome
Rupture of free wall
Papillary muscle rupture
How does AF present? (2)
What does it increase patient risk of?
- irregularly irregular pulse
- ECG no P waves, narrow QRS complex
Stroke
What can myocardial rupture lead to (rupture of free wall)?
cardiac tamponade
What can papillary muscle rupture lead to?
mitral regurgitation
Elevated troponin indicates what?
myocardial cell death, MI
What is the most important investigation in MI?
ECG
