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Medicine & Surgery: Cardiovascular > Acute Coronary Syndrome > Flashcards

Acute Coronary Syndrome Flashcards

1
Q

What is an acute coronary syndrome?

A

Spectrum of clinical conditions which occur when there is a sudden severe reduction in myocardial perfusion leading to ischemia and/or infarction.

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2
Q

What conditions are included in acute coronary syndrome and what is their common underlying pathology?

A
  1. Unstable angina and myocardial infarction.

2. Plaque rupture, thrombosis and inflammation.

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3
Q

What is a STEMI?

A
  1. Abrupt and catastrophic destruction of a cholesterol ridden plaque.
  2. Resulting exposure of substances promoting platelet activation and aggregation, thrombus formation, interruption of blood flow.
  3. If severe and persistent, myocardial cell necrosis can occur.
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4
Q

What is an NSTEMI?

A
  1. Imbalance between oxygen demand and supply, due to a non-occlusive thrombus.
  2. The lack of ST elevation is because the infarct does not involve the full thickness of the myocardium.
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5
Q

What is unstable angina?

A
  1. Non-occlusive thrombus but the myocardium could be richly collateralised.
  2. Fever, tachycardia, thyrotoxicosis, anaemia and hypoxaemia may precipitate.
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6
Q

How can you distinguish between STEMI, NSTEMI and unstable angina?

A
  1. STEMI - ST elevation/new LBBB and troponin rise
  2. NSTEMI - no ST elevation, may have T wave inversion and will have troponin rise
  3. Unstable angina - no ST elevation or troponin rise
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7
Q

What are the modifiable risk factors for acute coronary syndrome?

A

Smoking, hypertension, type 2 diabetes, hyperlipidaemia, obesity, sedentary lifestyle, cocaine use.

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8
Q

What are the non-modifiable risk factors for acute coronary syndrome?

A

Age, male gender, family history of ischaemic heart disease, type 1 diabetes.

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9
Q

What is this a presentation of?

Acute central crushing chest pain radiating to left arm, jaw, or abdomen. Nausea, sweating, dyspnoea, palpitations.

A

Acute coronary syndrome

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10
Q

What are the signs present in acute coronary syndrome?

A

Pallor, tachycardia or bradycardia, hyper or hypotension, low fever.

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11
Q

What does this ECG indicate?

Hyperacute tall T waves, ST elevation, new LBBB. T wave inversion and pathological Q waves follow over hours-days.

A

STEMI

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12
Q

What does this ECG indicate?

ST depression/T wave inversion/non-specific changes/normal.

A

NSTEMI

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13
Q

How do you investigate a suspected acute coronary syndrome?

A
  1. ECG
  2. Troponin
  3. CXR - cardiomegaly, pulmonary oedema, why mediastinum.
  4. Bloods - FBC, U&Es, glucose, lipids, cardiac enzymes
  5. Echo - regional wall abnormalities
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14
Q

Which leads will be affected in a lateral myocardial infarction?

A

I, aVL, V5, V6

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15
Q

Which leads will be affected in an inferior myocardial infarction?

A

II, III, aVF (bottom left leads on trace)

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16
Q

Which leads will be affected in a septal myocardial infarction?

A

V1 and V2

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17
Q

Which leads will be affected in an anterior myocardial infarction?

A

V3 and V4

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18
Q

Which artery is affected in a lateral myocardial infarction?

A

Left circumflex or left anterior descending

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19
Q

Which artery is affected in an inferior myocardial infarction?

A

Right coronary artery

20
Q

Which artery is affected in a septal myocardial infarction?

A

Left anterior descending

21
Q

Which artery is affected in an anterior myocardial infarction?

A

Left anterior descending

22
Q

What is the timeline of troponin rise in acute coronary syndrome?

A

Risers in hours following insult, Peaks at 24 hours and may stay elevated for 14 days. Measure at 3 and 6 hours.

23
Q

What can cause a rise in troponin?

A
  1. Myocardial damage - MI, myocarditis, pericarditis, ventricular strain, arrhythmias, dissection, chronic heart failure.
  2. CRP, DC cardioversion
  3. Non-cardiac - massive pulmonary embolism, subarachnoid haemorrhage, burns, sepsis, renal failure.
24
Q

What is the immediate management for a STEMI?

A
  1. Brief history, quick examination, 12 lead ECG.
  2. Bloods - U&Es, troponin, glucose, cholesterol, FBC
  3. Aspirin 300mg
  4. Ticagrelor 180mg
  5. Morphine 5-10mg IV and antiemetic (metoclopramide 10mg IV)
  6. Oxygen if sats <94%
  7. Beta blocker
  8. Reperfusion therapy, PCI within 2 hours, or thrombolysis.
  9. Anticoagulation in PCI (bivalirudin/enoxaparin)
  10. IV nitrate if pain persists provided systolic BP >90mmHg.
25
Q

What is the immediate management for an NSTEMI/unstable angina?

A
  1. Brief history, quick examination, 12 lead ECG.
  2. Bloods - U&Es, troponin, glucose, cholesterol, FBC
  3. Aspirin 300mg
  4. Ticagrelor 180mg
  5. Morphine 5-10mg IV and antiemetic (metoclopramide 10mg IV)
  6. Oxygen if sats <94%
  7. Beta blockers
  8. Fondaparinux 2.5mg SC
  9. IV nitrate if pain persists provided systolic BP >90mmHg.
26
Q

When is primary percutaneous coronary intervention indicated?

A

Within 12 hours of onset of symptoms and transferred within 2 hours of first medical contact, if not possible then for thrombolysis (alteplase/reteplase).

27
Q

What are the contraindications for thrombolysis?

A

Previous intracranial haemorrhage, ischaemic stroke in the last 6-months, recent major trauma or surgery in the last 3-weeks, bleeding disorder, aortic dissection.

28
Q

What should you do for patients with a STEMI who do not receive reperfusion therapy because they have presented more than 12 hours after symptoms?

A

Fondaparinux or enoxaparin

29
Q

What is a reperfusion injury?

A

Process of reperfusion damages some myocytes that were not already dead, mediated by toxic oxygen species over-produced on restoration of blood supply, can cause fatal arrhythmias.

30
Q

What is the GRACE score?

A

Prediction of 6-month mortality in NSTEMI/unstable angina and patient offered PCI.

31
Q

What risk does this patient have of mortality and within what time should they be offered reperfusion or CABG?
Haemodynamically unstable, recurrent chest pain refractory to medical treatment, life-threatening arrhythmias, acute heart failure, intermittent ST elevation.

A
  1. Very high risk

2. Within 2 hours

32
Q

What risk does this patient have of mortality and within what time should they be offered reperfusion or CABG?
GRACE score >140, high troponin >250.

A
  1. High risk

2. Within 24 hours

33
Q

What risk does this patient have of mortality and within what time should they be offered reperfusion or CABG?
GRACE score 109-140

A
  1. Intermediate risk

2. Within 3 days

34
Q

What are the indications for a CABG?

A
  1. Left main stem disease
  2. Angina unresponsive to drugs
  3. Angioplasty unsuccessful
35
Q

Which medications should be offered for a follow-up to acute coronary syndrome?

A

ACEi, beta blocker, clopidogrel, aspirin, statin, gastroprotection, aldosterone antagonist.

36
Q

After an acute coronary event, what dose of this medication should be given, who should receive it, and what are the contraindications?
ACEi

A
  1. Ramipril 1.25mg OD titrated up to 10mg OD.
  2. All patients
  3. Renal failure, systolic BP <90mmHg
37
Q

After an acute coronary event, what dose of this medication should be given, who should receive it, and what are the contraindications?
Beta blocker

A
  1. Bisoprolol 2.5mg OD titrated up to 5-10mg OD
  2. All patients
  3. Bradycardia, 2nd/3rd degree heart block, cardiogenic shock.
38
Q

After an acute coronary event, what dose of this medication should be given, and who should receive it?
Aspirin

A
  1. 75mg OD

2. All patients for one year

39
Q

After an acute coronary event, what dose of this medication should be given, and who should receive it?
Statin

A
  1. Atorvastatin 80mg OD

2. All patients regardless of lipid status

40
Q

After an acute coronary event, what dose of this medication should be given?
Gastroprotection

A

Lansoprazole 30mg OD

41
Q

After an acute coronary event, what dose of this medication should be given, who should receive it, and what are the contraindications?
Aldosterone antagonist

A
  1. Eplerenone 25mg OD
  2. Arrange Echo within 24 hours, give if clinical signs of heart failure and EF <40%.
  3. Not if eGFR <30 or K+ >5mmol/L
42
Q

What are the short term complications of acute coronary syndrome?

A
  1. Ventricular fibrillation
  2. Other arrhythmias - bradycardia, VT, SVT
  3. Acute cardiac failure/cardiogenic shock - key difference is BP
  4. Myocardial rupture - haemopericardium and cardiac tamponade
  5. Pericarditis - transmural infarct
  6. Mural thrombus - can embolise
43
Q

What is this a presentation of?

Post-myocardial infarction, acute mitral regurgitation, pulmonary oedema and acute left heart failure.

A

Rupture of the papillary muscle of the mitral valve

44
Q

What are the long-term complications of acute coronary syndrome?

A
  1. Recurrent MI - due to coronary artery atherosclerosis
  2. Chronic congestive cardiac failure - due to loss of contractile myocardium
  3. Dressler’s syndrome - autoimmune pericarditis 2-10 months post-transmural MI
  4. Ventricular aneurysm formation - can cause heart failure, arrhythmias, thrombus
45
Q

What is the primary care management after an acute coronary syndrome?

A
  1. Smoking cessation
  2. Treat diabetes, hypertension, hyperlipidaemia
  3. Diet - oily fish, fruit, vegetables, fibre, low saturated fats
  4. Daily exercise, cardiac rehab programme
  5. Flag depression/anxiety to GP
  6. Avoid work if manual labourer for some time
  7. Don’t need anticoagulation after hospital stay
46
Q

What advice do the DVLA give for these situations?

  1. Car/motorbike driver after successful angioplasty
  2. Car/motorbike driver without successful angioplasty
  3. Lorry drivers
A
  1. Resume driving after 1 week
  2. Resume driving after 4 weeks
  3. Resume driving after 6 weeks depending on results of functional tests.
47
Q

What can be identified on an ECG in the days following a myocardial infarction

A

Pathological Q waves and inverted T waves.

Medicine & Surgery: Cardiovascular (30 decks)

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