Acute Coronary Syndrome Flashcards
ESSENCE
Usually result of thrombus from atherosclerotic plaque blocking a coronary artery, this thrombus is is mostly made of platelets
3 types of acute coronary syndrome
- Unstable angina
- ST elevation myocardial infarction (STEMI)
- Non-ST elevated myocardial infarction (NSTEMI)
INVESTIGATIONS
First line
- 1) ECG - if ST elevation diagnosis is STEMI
- 2) Tropnonin blood tests - if raised or ECG changed diagnosis is NSTEMI, if normal and ECG unchanged then unstable angina
INVESTIGATIONS
Other investigations
- Chest x-ray - investigate other causes of pain
- ECHO - assess functional damage
- CT coronary angiogram - assess for coronary artery disease
- FBC
- U&Es
- LFT
- Lipid profile
- TFT
- HbA1c and fasting glucose
CLINICAL FEATURES
Symptoms
- Central, constricting chest pain associated with
- Nausea and vomiting
- Sweating and clamminess
- Feeling of impending doom
- Shortness of breath
- Palpitations
- Pain radiating to jaw or arms
- Lasts for 20 minutes after rest
AETIOLOGY
Risk factors
- Diabetes
- Hyperlipidaemia
- Hypertension
- Metabolic syndrome
- Renal impairment
- Peripheral arterial disease
- History of ischaemic heart disease
- Obesity
- Age
- Smoking
- Cocaine use
- Physical inactivity
- Family history
INVESTIGATION
ECG changes in STEMI
- ST segment elevation
- New left bundle branch block
INVESTIGATION
ECG changes in NSTEMI
- ST segment depression
- Deep T wave inversion
- Pathological Q waves
Left coronary artery - heart area and ECG leads
Area - anterolateral
ECG leads - I, aVL, V3-6
Left anterior descending - heart area and ECG leads
Area - anterior
ECG leads - V1-4
Circumflex - heart area and leads
Area - lateral
Leads - I, aVL, V5-6
Right coronary artery - heart area and ECG leads
Area - inferior
Leads - II, III, aVF
Other causes of raised troponins
- Chronic renal failure
- Sepsis
- Myocarditis
- Aortic dissection
- Pulmonary embolism
What are troponins
Proteins found in cardiac muscle, released when muscle is ischaemic
MANAGEMENT
Acute STEMI treatment
- Primary PCI (if within 2 hours presentation)
- Thrombolysis (if PCI not available within 2 hours presentation)
Thrombolysis mechanism
Injecting a fibrinolytic medication breaks down fibrin and dissolves clots, significant risk of bleeding
MANAGEMENT
Acute NSTEMI treatment
- Remember BATMAN
- Beta-blockers unless contraindicated
- Aspirin 300mg stat dose
- Ticagrelor 180mg stat dose (or clipidogrel if higher bleed risk)
- Morphine titrated to control pain
- Anticoagulant (Fondaparinux)
- Nitrates (GTN)
- Give oxygen only if saturations dropping <95%
Score used to assess for PCI in NSTEMI
- GRACE score
- Gives 6 month risk of death or repeat MI after having NSTEMI
- <5% low risk
- 5-10% medium risk
- >10% high risk
- If medium or high then considered for early PCI to treat underlying artery disease
COMPLICATIONS
Of MI
- Remember DREAD
- Death
- Rupture of heart septum or papillary muscles
- Edema (heart failure)
- Arrhythmia and aneurysm
- Dressler’s syndrome
MANAGEMENT
Secondary prevention
- Medical (6As)
- Aspirin 75mg once daily
- Another antiplatelet (clopidogrel or ticagrelor for 12 months)
- Atorvastatin 80mg
- ACE inhibitor (ramipril)
- Atenolol (or other beta blocker)
- Aldosterone antagonist for those with heart failure
- Lifestyle
- Stop smoking
- Reduce alcohol
- Exercise
- Diet
Types of MI
- Traditional due to acute coronary event
- Ischaemia secondary to increased deman or supply of oxygen (such as anaemia, tachycardia or hypotension)
- Sudden cardiac death or arrest suggestive of ischaemic event
- Associated with PCI/coronary stunting/CABG
