ACS and AMI Flashcards
What does plaque disruption lead to
Atherothrombosis formation
What does a rupture of an atherothrombosis cause (4)
Unstable angina
NSTEMI
STEMI
Sudden cardiac death
Why do plaques rupture (2)
Inflammation
Shear stress
What symptoms will a rupture give
Symptoms at rest
How would you diagnose ACS
Site of pain
Character of pain
Radiation sites
Aggravation
Non-modifiable Risk Factors for ACS (6)
Age Gender Creed Family History Genetics
Modifiable Risk factors of ACS (5)
Smoking Diabetes Mellitus Hyperlipidaemia Hypertension Lifestyle-exercise & diet
Atypical ACS Presentation NSTEMI (3)
Women
Elderly
Diabetes
Symptoms of NSTEMI (3)
- Breathlessness alone +/- signs of heart failure
- Nausea & Vomiting +/- other autonomic symptoms
- Epigastric pain +/- recent onset indigestion
Diagnosis of NSTEMI- ECG (3)
May be normal
ST segment depression
T wave inversion
Diagnosis of NSTEMI-Biomarkers
Cardiac troponin
What does elevated cardiac troponin indicate
Myocyte damage
Immediate treatment form NSTEMI
ABCDE Morphine/Diamorphine Oxygen Nitroglycereine (GTN) Aspirin
Antiplatelet therapy
Aspirin
Clopidogrel
Prasugrel
Ticagrelor
Anti-thrombotic therapy (3)
IV unfractioned heparin
LMW heparin
Given subcutaneously
Other medical therapy for ACS
Beta blockers
Statins
ACEI
What type of patients are given coronary revascularisation
UA/NSTEMI
Treatment of STEMI
PCI
When PCI cannot be performed what is the other option
Fibrinolytic Therapy within 90 minutes of calling or 30 minutes of hospital arrival
What patients have increased risk of bleeding and intra-cranial haemorrhage in some patients (7)
- Age >75
- Female
- Previous stroke
- Low body weight
- SBP > 160 mmHg
- INR > 4 (blood clotting)
- Chronic disease and elevated creatine
When is thrombolysis best (2)
Door-balloon >90 minutes
<3 hour symptom onset
Primary PCI is best (5)
Door-ballon <90 minutes >3 hour symptom onset High Bleeding risk Cardiogenic shock Heart Failure
Secondary Prevention treatment for ST elevated MI (General measures) (3)
Stop smoking
Diet
Exercise
STEMI secondary prevention (co-morbidities) (2)
Control BP,
Glycaemic control
Other secondary treatment for STEMI
Aspirin Clopidogrel B-blockers Statins ACEI
Treatment- inpatient investigations
EChO
What are you looking for when using an ECHO
Size of wall motion abnormality and whether hypokinetic or akinetic (partial or complete loss of muscle movement) ; overall contractility and also presence and degree of mitral regurgitation (inferiors)
Presence of mural thrombus (antero-apical Mis)
What are the 2 life threatening MI complications
Mechanical
Ventricular arrhythmic
Mechanical Complications
Tearing or rupture of infarcted myocardium
3 main complications of mechanicalcoomplications
Free wall rupture
Papillary muscle rupture
Rupture of IVS
What are the consequences of free wall rupture
Edge ofinfarcted area
Haemopericardium
Acute tamponade
Free wall rupture is more common in (4)
Elderly
Female
HBP
Anterior MI
Papillary muscle rupture causes (2)
Inferior MI
Ant/Lat MI
Symptoms and features of IVS rupture (6)
Major haemodynamic compromise Sudden severe breathlessness Sweating Nausea Vomiting Chest pains
Signs of papillary muscle rupture (6)
- Shock
- Tachycardia
- Pulmonary oedema
- New harsh systolic murmur
- Right parasternal heave
- Palpable thrill, elevated JVP
Investigations for mechanical complications
ECHO
Cath Lab
Initial management of papillary muscle rupture (4)
IV nitrates
Inotropes
IABP- reduce afterload and augment DBP
Surgery for Papillary Muscle Rupture (2)
Mitral valves are usually replaced
Coronary artery bypass is needed and possible
Ventricular Arrhythmic Complications (3)
Ventricular Tachycardia
Ventricular Fibrillation
LV thrombus
Ventricular Tachycardia
May be driven by MI or ischaemia
Medical therapy for Ventricular Tachycardia
Implantable cardioverter defibrillator with anti-tachycardia pacing
Ventricular Fibrillation
Multiple waves of electrical activity
Deteriorates into asystole
What is the only effective treatment of VF
Defibrillation
Once Asystole is reached what is difficult to restore
Cardiac Output
Where is LV thrombus seen typically
aical/antero-apical MI
Treatment of LV thrombus (3)
Anticoagulants and repeat and repeat echo
Why does mechanical ruptures occur
Necrotic myocardial tissue is softest and most prone to rupture
What is the consequence of the rupture
Connection between the two ventricles Haemodynamic deterioration Hypotension Heart Failure Cardiogenic Shock
Rupture of the IVS causes a
left to right shunt
A left to right shunt leads to
an overload of the right ventricles which eventually leads to overload of left ventricle
During rupture of IVS the left ventricular function causes
Compensatory vasoconstriction
Systemic vascular resistance
