ACS Presentation & Management

Question 1

What is acute coronary syndromes defined as ?

Answer 1

New collection of symptoms related to acute coronary iscahemia with or without myocardial infacrtion

Question 2

What is the presentation of stable angina ?

Answer 2

Caused by a stable coronary lesion
Predictable symptoms due to narrowing
Symptoms relived by rest

Question 3

What is the presentation of ACS ?

Answer 3

Caused by unstable lesion
Unpredictable
May occur at rest
Includes MI and unstable angina

Question 4

What is the diagnosis of MI ?

Answer 4

Detection of cardiac cell death:
- +ve cardiac biomarker
And one of:
- Symptoms of ischaemia
- New ECG changes
- Evidence of coronary problem on coronary angiogram or autopsy
- Evidence of new cardiac damage on another test

Question 5

What is the specific marker for damage of myocardial cells ?

Answer 5

Troponin

Question 6

What else can cause a troponin rise ?

Answer 6

Arrhythmia
PE
Cardiac contusion
Sepsis 
Anaemia

Question 7

What is useful in the history of ACS ?

Answer 7

Ischamic sounding chest pain:

- May radiate to neck or arm 
- Often a discomfort or tightening in chest 
- May be associated with nausea, sweating, SOB

Question 8

What are the risk factors of ACS ?

Answer 8

Male
Age
Known heart disease
High BP
High cholesterol
Diabetes
Smoker
Family history of premature heart disease

Question 9

What is included in an examination of ACS ?

Answer 9

May look unwell if having a STEMI
May look fine
Often no specific exam features 
Ensure to check
	- HR
	- BP
	- Murmurs 
        - Crackles

Question 10

What are the investigations of ACS ?

Answer 10

Serial ECG:
	- Repeat if not sure if there is any change
	- Think about posterior leads
Blood test:
	- Troponin
	- Point of care test 
	- Hb
	- Kidney function
        - cholesterol

Question 11

What is the therapy of ACS ?

Answer 11

Mechanical:
	- In cath lab with balloons and stents 
	- = primary PCI
Pharmacological:
        - Strong blood thinner

Question 12

What is thrombolysis ?

Answer 12

Very strong blood thinning medication
Can be given in ambulance
Often will then arrange prompt transfer to cardiac centre

Question 13

What are the risks of thrombolysis ?

Answer 13

Bleeding
Dont give if recent stroke or previous intracranial bleed
Causation if had recent surgery, on warfarin, severe hypertension

Question 14

What is the management of ACS ?

Answer 14

Admit to hospital
ECG
Attach cardiac monitor
Gain IV access
Give O2 only if levels low

Question 15

What is the treatment of ACS ?

Answer 15

GTN:
	- Vasodilator 
	- Spray or IV infusion
Opiates e.g. Morphine:
	- Helps relieve pain
        - Helps venodilate

Question 16

What anti-thrombotic drugs can be used ?

Answer 16

Dual anti-platelet therapy: 
	- Aspirin 300mg the 75mg
Plus one of new P2Y12 receptor blocker:
	- Clopidogrel- 
	- Ticagrelor
        - Prasugrel

Question 17

What other drugs can be used for ACS ?

Answer 17

Beta-blockers:
	- Reduces work of heart 
Statins:
	- Lowers cholesterol
ACEI:
        - Helps heart muscle recover

Question 18

What are the complications of ACS ?

Answer 18

Arrhythmias 
LVF or RVF
Arterial hypertesnion
Cardiogenic shock 
Thrombus
Rupture
Aneurysm
Pericarditis 
Extension of infacrtion 
Death