Acute Coronary Syndrome Flashcards
what is the usual cause of ACS
thrombus from an atherosclerotic plaque blocking a coronary artery
when a thrombus is formed in a fast flowing artery what is it mostly made up of
platelets
in what case is a thrombus mostly made up of platelets
when formed in a fast flowing artery
what type of medication is the main treatment for ACS
anti platelet medication
give 3 examples of anti platelet medication
- aspirin
- clopidogrel
- ticagrelor
which artery is most commonly affected by ACS as a result of a thrombus
Left anterior descending
what 2 vessels branch off the left coronary artery
- circumflex
- left anterior descending
what areas (4) of the heart are supplied by the right coronary artery
- right atrium
- right ventricle
- inferior aspect of left ventricle
- posterior septal area
what areas of the heart (2) does the circumflex artery supply
- left atrium
- posterior aspect of left ventricle
what areas of the heart (2) does the left anterior descending artery supply
- anterior aspect of left ventricle
- anterior aspect of septum
name the 3 types of ACS
- unstable angina
- STEMI
- NSTEMI
what is the first step when a patient presents w/ ACS symptoms
perform ECG
how is STEMI diagnosed (2)
- ST elevation on ECG
- new left bundle branch block
what is the next step if no ST elevation is shown on the ECG
perform troponin blood tests
how is NSTEMI diagnosed (2-4)
- raised troponin levels and/or - other ECG changes --> ST depression --> T wave inversion --> pathological Q waves
diagnosis if troponin levels are normal and no pathological changes shown on ECG
unstable angina
differential diagnosis if troponin levels are normal and no pathological changes shown on ECG
musculoskeletal chest pain
what is the main symptom of ACS
central constricting chest pain
what other ACS symptoms can be assc. w/ chest pain (6)
- nausea and vomiting
- sweating and clamminess
- feeling of impending doom
- SoB
- palpitations
- pain radiating to jaw or arms
where might chest pain radiate to in ACS (2)
- jaw
- arms
changes in what ECG leads would indicate pathology in LCA (3)
- i
- aVL
- V3-6
changes in what ECG leads would indicate pathology in LAD artery
- V1-4
changes in what ECG leads would indicate pathology in circumflex artery (3)
- i
- aVL
- V5-6
changes in what ECG leads would indicate pathology in RCA
- ii
- iii
- aVF
what are troponins
proteins found in cardiac muscle
presence of what SPECIFIC troponins is used for diagnosis of ACS
serial troponins
what is the time period of measuring troponins (2)
- baseline
- 6 or 12 hours after onset of symptoms
what pathological condition is a rise in troponin levels consistent with and why (2)
- myocardial ischaemia
- troponin released from ischaemic muscle
what does it mean that troponins are non-specific
raised troponin doesn’t automatically mean ACS
give some alternative causes of raised troponins (5)
- chronic renal failure
- sepsis
- myocarditis
- aortic dissection
- pulmonary embolism
what other investigations might you perform when investigating Px presenting w/ ACS (8)
- physical exam
- ECG
- FBC
- U&E
- LFTs
- Lipid profile
- Thyroid function test
- HbA1c and fasting glucose
what radiographic investigations might you do for Px presenting w/ ACS (3) and why (3)
- chest Xray
- -> other causes of chest pain and pulmonary oedema
- echocardiogram
- -> after event to assess functional damage
- CT coronary angiogram
- -> assess for coronary artery disease
what is the treatment for acute STEMI (2) and the time period of treatment (2)
- primary PCI
- -> if available within 2hrs of presentation
- thrombolysis
- -> if PCI not available within 2hrs
describe Percutaneous Coronary Intervention (PCI)
catheter inserted into Px brachial/femoral artery, fed up to coronary arteries under X-ray guidance, contrast injected and used to identify area of blockage, balloon used to widen gap, stent put in place to keep artery open
describe thrombolysis treatment
fibrinolytic medication injected to breakdown fibrin and rapidly dissolve clots
what is the risk with thrombolysis treatment
significant risk of bleeding
give examples of thrombolytic agents (3)
- streptokinase
- alteplase
- tenecteplase
list the treatment options for acute NSTEMI (6)
BATMAN
B - beta blockers
A - aspirin 300mg stat dose
T - ticagrelor 180mg stat dose (clopidogrel if ^ bleeding risk)
M - morphine (pain control)
A - anticoagulant (unless ^ bleeding risk)
N - nitrates (GTN) (relieve coronary spasm)
what is the GRACE score
scoring system that gives 6 month risk of death/ repeat MI after having an NSTEMI
what are the 3 limits in GRACE score and what limits would Px be considered for PCI
- <5% low risk
- 5-10% med risk
- > 10% high risk
med and high risk considered for early PCI
give the complications of MI (5)
DREAD
D - death R - rupture of heart septum or papillary muscles E - 'edema' (heart failure) A - arrhythmia and aneurysm D - Dressler's syndrome
what is Dressler’s syndrome (post-myocardial infarction syndrome), how does it present (3), what can it cause (2), how is it diagnosed (3), and how is it managed (3)
- localised immune response that causes pericarditis
symptoms
- pleuritic chest pain
- low grade fever
- pericardial rub on auscultation
causes
- pericardial effusion
- pericardial tamponade
diagnosis
- ECG (global ST ^ and T wave inversion)
- echocardiogram (pericardial effusion)
- ^ inflammatory markers (CRP and ESR)
Managed
- NSAIDs
- steroids (severe) (prednisolone)
- pericardiocentesis (remove fluid)
outline secondary prevention medical management (6)
6As
- Aspirin (75mg x1 a day)
- Another antiplatelet
- Atorvastatin (80mg x1 a day)
- ACEi
- Atenolol
- Aldosterone antagonists (Px w/ clinical heart failure)
outline secondary prevention lifestyle changes (5)
- stop smoking
- reduce alcohol consumption
- mediterranean diet
- cardiac rehabilitation
- optimise treatment of other medical conditions
