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Cardiovascular Disease > ACS/MI > Flashcards

ACS/MI Flashcards

1
Q

What is a myocardial infarction (MI)?

A

Ischaemic necrosis to the myocardial tissue.

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2
Q

What is an Acute Coronary Syndrome (ACS)?

A

Clinical manifestation of myocardial infarction. It is a medical emergency and requires immediate hospital admission.

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3
Q

What are the 3 main types Acute Coronary Syndrome (ACS)?

How are the classified (2)?

A
  • Unstable Angina
  • Non-ST Elevated Myocardial Infarction (NSTEMI)
  • ST elevated Myocardial Infarction (STEMI)

They are classified by ECG and serial troponin levels.

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4
Q

ECG changes that are indicative of new ischaemia?

A
  • new ST-T changes (e.g. T wave inversion, flat T waves, ST depression)
  • new left bundle branch block (WiLLiaM on V1 and V6)
  • development of pathological Q waves

CAUTION: sometimes no ECG changes (in unstable angina and NSTEMI)

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5
Q

Non-modifiable risk factors of ACS/atherosclerosis? (5)

A
  • age
  • male sex
  • FHx of premature CHD
  • premature menopause
  • certain ethnicities
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6
Q

Modifiable risk factors of ACS/atherosclerosis? (6)

A
  • smoking
  • diabetes (impaired glucose tolerance)
  • metabolic syndrome
  • hypertension
  • hyperlipidaemia
  • obesity
  • physical inactivity
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7
Q

Non-atherosclerotic causes of ACS?

A
  • oxygen supply: oxygen demand mismatch (e.g. lack of supply in anaemia or increased demand in hyperthyroidism)
  • coronary emboli (from infected valve)
  • coronary occlusion secondary to vasculitis
  • cocaine use
  • congenital coronary abnormalities
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8
Q

What can an ACS present with? (5)

A
  • epigastric/central chest pain (dull, aching, crushing, pressure, squeezing pain that can radiate to the arms, shoulders, jaw or neck)
  • fevers
  • chills, clammy
  • nausea and vomiting
  • limiting daily activities
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9
Q

Atypical presentations of MI are common in (4)

A
  • women
  • older men
  • diabetic patients
  • ethnic minorities
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10
Q

Findings you may see on a cardiovascular examination after an MI?

A
  • low grade fever
  • pale, cool, clammy skin
  • hypo- OR hypertension (depending on the extent of MI)
  • 3rd and 4th heart sounds
  • murmurs caused by mitral regurgitation or VSD
  • pericardial rub (characteristic of acute pericarditis)
  • signs of congestive HF (e.g. raised JVP, peripheral oedema, pulmonary crackles)
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11
Q

What should patients with pre-existing angina be advised to do?

A
  1. Take your GTN spray/tablet
  2. If after 5 minutes the chest pain does not improve, take a 2nd GTN dose
  3. If after 5 minutes there is still no improvement, take a 3rd GTN dose
  4. If no improvement after the 3 doses and 15 minutes, call an ambulance immediately.
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12
Q

Cardiovascular differentials for MI (6)

A
  • pericarditis
  • myocarditis
  • aortic stenosis
  • aortic dissection
  • PE
  • stable angina
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13
Q

Respiratory differentials for MI (2)

A
  • pneumothorax

- pneumonia

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14
Q

Gastrointestinal differentials for MI (5)

A
  • acute gastritis
  • GORD
  • oesophageal spasms
  • cholecystitis
  • acute pancreatitis
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15
Q

Main investigations during a suspected MI? (2)

A
  • 12 lead ECG

- Cardiac enzymes (e.g. Troponin I or T)

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16
Q

Other than an ECG and cardiac enzymes (e.g. Troponin), what other investigations are useful in suspected MI? (5)

A
  • Blood tests: FBC, electrolytes, eGFR, lipid profile, CRP, blood glucose
  • CXR: for complications such as pulmonary oedema, or to rule out other complications
  • Cardiac Magnetic Resonance (CMR): assessing the heart’s function, perfusion and structure
  • Coronary angiogram* - GOLD STANDARD for coronary artery disease
  • Echocardiogram: check for wall motion abnormalities)
17
Q

Immediate management of suspected ACS (6)

A
  • urgent hospital admission
  • CPR in case of cardiac arrest
  • pain relief (GTN, morphine)
  • aspirin 300 mg
  • resting 12 lead ECG
  • supplementary oxygen (aim for 94-98% or 88-92%)
18
Q

Early management of STEMI (2)

A
  • offer 300mg aspirin loading dose

- medical management OR re-perfusion therapy (Primary PCI or Fibrinolysis)

19
Q

Early management of NSTEMI/unstable angina (2)

A
  • offer 300mg aspirin loading dose

- GRACE score to determine conservative management (low risk) or immediate angiogram (high risk)

20
Q

Types of reperfusion therapy in STEMI? (2)

A
  1. primary PCI - if presenting before 12 hours of symptoms and procedure can be done within 120 minutes.
  2. fibrinolytic therapy - thrombolytic drugs if cannot have primary PCI (e.g. streptokinase or alteplase)
21
Q

When is primary PCI not indicated?

A

If patient presents after 12 hours of symptom onset and the procedure cannot be done within 120 minutes.

22
Q

What is the drug therapy for PCI?

A

When patients undergo Primary PCI, they are offered Prasugrel with aspirin. If there is an increased bleeding risk, Ticagrelor or Clopidogrel should be considered instead.

23
Q

What is the medical management for ACI? (2 options)

TIP: depends on the bleeding risk

A

Low bleeding risk: Ticagrelor with aspirin

High bleeding risk: Clopidogrel with aspirin

24
Q

What is fibrinolysis?

A

For those patients who cannot be offered Primary PCI, a thrombolytic drug (e.g. Streptokinase or Alteplase) should be given along with an antithrombin (e.g. Unfractioned Heparin, LMWH or Fondaparinux)

25
Q

When is CABG indicated?

A
  • When PCI has failed
  • Occlusion not amenable for PCI
  • Refractive symptoms agter PCI
  • Cardiogenic shock/mechanical complications (e.g. mitral regurg, VSD)
  • multivessel disease (may need to treat the infarct related vessel)
26
Q

If a patient has a predicted mortality after 6 months of MORE THAN 3% according to the GRACE score, what should the management plan be?

A

Immediate angiogram and consider primary PCI. Offer Prasugrel/Aspirin or Ticagrelor/Aspirin and a drug-eluting stent.

27
Q

If a patient has a predicted mortality after 6 months of LESS THAN 3% according to the GRACE score, what should the management plan be?

A

Conservative management: treat with Ticagrelor and Aspirin (high bleeding risk) or Clopidogrel and Aspirin (low bleeding risk)

28
Q

Other than primary PCI and fibrinolytic therapy, what other initial management should be considered?

A

A - ACE inhibitor
B - Beta Blockers
C - Cholesterol-lowering agents (Statins)
D - Dual antiplatelet therapy
E - Eplenerone (an aldosterone antagonist if they have a reduced ejection fraction (<40%) and either Diabetes or clinical signs of HF).

29
Q

Which patients receive Eplenerone?

A

The aldosterone antagonist is given when the patient has a reduced ejection fraction (<40%) with Diabetes or clinical signs of HF.

30
Q

What are the main components of secondary prevention? (2)

A
  1. cardiac rehabilitation - lifestyle changes, stress management, health education, physical activity
  2. drug therapy - ABCDE
31
Q

What is involved in cardiac rehabilitation following an MI? (4)

A
  • lifestyle advice (driving, sex, flying)
  • stress management
  • physical activity
  • health education/lifestyle changes (healthy eating/Mediterranean diet, low risk drinking, no smoking, healthy weight management)
32
Q

How any people survive after an MI?

A

7 in 10 people

33
Q

What affects prognosis after an MI? (8)

A
  • rise in troponin levels
  • degree and extent of changes in the ECG
  • degree of LV dysfunction on echocardiogram
  • timing and nature of intervention
  • co-morbidities
  • site of infarction
  • depression
  • older age and females
34
Q

Complications following an MI? (5)

A

D - death
R - rupture of heart muscle or papillary muscles
E - edema (heart failure)
A - aneurysm, arrhythmia (AV node block, ventricular and supra-ventricular arrythmia)
D - Dressler’s syndrome (post-MI syndrome)/pericarditis

Cardiovascular Disease (5 decks)

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