Acute Coronary Syndrome

Question 1

What is ACS due to?

Answer 1

Acute coronary syndrome is due to thrombus formation following the breakage of atherosclerotic plaques.
The thrombus then blocks of the coronary artery resulting in symptoms associated with ACS.

Question 2

What symptoms are associated with ACS?

Answer 2

Central, constricting chest pain associated with:

• Dyspnea
• n+v
• palpitations
• feeling of impending doom
• pain radiating to the arms or jaw
• sweating and clamminess

Note that diabetics or very elderly may not present with a central chest pain –> silent MI

Question 3

What are the different types of ACS?

Answer 3

• Unstable angina
• STEMI
• NSTEMI

Question 4

What are the 2 most important investigations when investigating a patient with a potential ACS?

What other investigations are important?

Answer 4

ECG and troponin levels

If an ECG shows a ST elevation or a new left bundle branch block, then diagnose patient with a STEMI.

If a patient does not show an ST elevation, then check the patient’s troponin levels across multiple time periods.

If there is a raise in troponin levels and/or there are other pathological ECG changes (e.g. ST segment depression, T wave inversion and pathological Q waves), then diagnose patient with an NSTEMI.

If a patient does not have raised troponin levels or pathological ECG changes, then diagnose unstable angina or the pain is due to a musculoskeletal cause.

Other investigations that can be carried out

• Cardio examination to look at heart sounds, BMI (waist circumference, measure weight), signs of heart failure (e.g. oedema) etc.
• FBCs (anaemia)
• U&Es (important when initiating ACEi and other meds)
• LFTs (important before starting statins)
• TFTs (hypo/hyperthyroidis are associated with atherosclerosis and atrial fibrillation)
• Hb1AC (to check for diabetes status)
• Lipids (to check for non-HDL lipid status to see if its a cardiovascular risk factor).

Along side these blood tests also do:

• Chest x ray to rule out any other causes of chest pain and see if there is evidence of pulmonary oedema which would indicate heart failure
• Echo to assess the extent of heart damage following the cardiovascular event
• CT coronary angiography to see if there is a blockage in the blood vessels.

Question 5

What does raised troponin indicated?

Answer 5

Raised troponin is typically associated with heart failure as troponin is only released by ischaemic heart tissue.
But raised troponin is non-specific because there are other causes fo raised troponin.

C - CKD
A - Aortic dissection 
M - Myocarditis 
P - PE 
S - Sepsis

Question 6

How do you manage an acute STEMI?

What are the long term management of a STEMI?

Answer 6

Acute Management

Common management of all patients with ACS (MONA)

• Morphine (should only be given in patients with severe pain)
• Oxygen- only given if patients O2 levels < 94%
• Nitrates - can be given sublingually or IV. Useful if patient has ongoing chest pain or hypertension. Be careful if patient is hypotensive
• Aspirin- 300mg

If patient has a STEMI diagnosed.

• If presentation is within 12 hours and PCI is available within 2 hours, then perform PCI.
  > Alongside the 300mg of aspirin that was already given, give the patient another anticoagulant prior to starting PCI - this is known as dual antiplatelet therapy. If the patient is taking an oral anticoagulant, then give prasugrel. If the patient is not taking an anticoagulant, then give the patient clopidogrel.
  When doing the PCI, if the catheter is being inserted via the radial artery, then give the patient unfractionated herapin with bailout glycoprotein IIb/IIa inhibitors (e.g. tizrofabin or eptifabtide or roxifabin). If the access if via the femoral artery, during PCI, give the bivalirudin with bailout glycoprotein inhibitors.
• If presentation is within 12 hours but PCI isn’t available within 2 hours, then perform thrombolysis with anti-flibronyltics (e.g. tenecteplase, alteplase or streptokinase). Once you do the the thrombolysis, make sure to do an ECG of the patient 60-90 minutes after to see if the ECG changes (ST elevation) has resolved. If not, then reconsider PCI.

Secondary prevention 
- Medical (6As) 
 > Atenolol or other beta blockers
> Aspirin - 75mg OD 
> Atorvastatin - 80mg 
> ACEi --> e.g. ramipril 
> Another anti platelet e.g. ticagrelor or clopidogrel for up to 12 months 
> Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)

- Lifestyle management 
> Stopping smoking 
> Reducing alcohol consumption 
> Following a mediteranian diet 
> Cardiac Rehab 
> Optimising treatment for other conditions e.g. diabetes or hypertension.

Question 7

How do you manage an acute NSTEMI/stable angina?

What are the long-term management of an NSTEMI/stable angina?

Answer 7

Acute Management

Common management of all ACS patients

• Morphine - in patients with severe pain
• Oxygen - if sats < 94%
• N - nitrates
• A- aspirin 300mg

Once you have given the patient aspirin 300mg, you must also give them additional anti-thrombin therapy. Fondaparinux should be offered if the patient isn’t at a high risk of bleeding and who do not have angiography immediately. If coronary angiography is immediately available or creatinine is > 265, then unfractionated heparin should be given.

You should then assess the patient’s risk of developing future cardiovascular events and death by using GRACE. If a patient has a percentage risk less than 3%, they are low risk. If their risk is between 3-6%, they are moderate risk and high risk is >6%.

If patients have a moderate or high risk, they should offered a PCI within 3 days. If they are clinically unstable e.g. they are hypotensive, then it should be considered immediately.

If patients have a low risk, then treat the patient conservative by giving them an extra anti-platelet drug.
- if the patient does not have a high risk of bleeding, give ticagrelor. If they do have a high risk, then give clopidogrel.

Secondary Preventatuve Mangement
- Medical (6As)
> Aspirin 75mg OD
> Another anti platelet e.g. clopidogrel or ticagrelor for up to 12 months
> Atorvastatin 80mg OD
> Atenolol or another beta blocker titrated to as high dose as possible.
> ACE inhibitors e..g ramipril
> Aldosterone antagonist for those who have clinical heart failure e.g. eplerenone - titrated 50mg OD

- Lifestyle 
 > Stopping smoking 
> Reducing alcohol consumption 
> Following a mediteranian diet 
> Cardiac rehab 
> Optimising treatment for other medical conditions e.g. hypertension and diabetes

Question 8

What are potential complications of MI?

Answer 8

DREAD
D- death 
R- rupture of the septum or the papillary muscles 
E- edema (HF)
A - arrythmias or aneurysms 
D- Dressler's syndrome

Question 9

What is Dressler’s syndrome?

How do patients typically present?

What investigations would indicate this condition?

How do you manage these patients?

Answer 9

> Also regarded as post-MI syndrome

> Presentation would be:

• Pleuritic chest pain
• low grade fever
• pericardial rub on auscultation

Pericardial effusion and potential pericardial tamponade.

Ix

• ECG - global ST elevation, T waves inversion
• Echo - pericardial effusion
• Blood tests- raised CRP and ESR

Management

• NSAIDs (aspirin/ibuprofen)
• Steroids in more severe cases
• May need pericardiocentesis.

Question 10

What is the Mediterranean diet composed of?

Answer 10

Eat
> Eat: Vegetables, fruits, nuts, seeds, legumes, potatoes, whole grains, breads, herbs, spices, fish, seafood and extra virgin olive oil.

> Eat in moderation: Poultry, eggs, cheese and yogurt.

> Eat only rarely: Red meat.

> Don’t eat: Sugar-sweetened beverages, added sugars, processed meat, refined grains, refined oils and other highly processed foods.