Acute Coronary Syndrome Flashcards
What are the symptoms of myocardial infarction
- Chest pain
- Back pain
- Jaw pain
- Indigestion
- Sweatiness, clamminess
- Shortness of breath
- May have no symptoms
- Death
What are the signs of myocardial infarction?
- Tachycardia
- Distressed patient
- Heart failure
- Shock (cardiogenic)
- Arrhythmia
- None
What are the investigations for acute myocardial infarction?
- ECG - evidence of ST segment deviation
- Bloods - cardiac troponin
- Chest X ray and Echocardiogram to look for evidence of acute heart failure/left ventricular systolic dysfunction
- Coronary angiogram: coronary artery anatomy
What is troponin?
- Integral part of the myocyte
- 3 types: Tn1, TnT, TnC
- Release into blood stream and is a maker of myocyte necrosis
What causes an increase in troponin?
In order from largest increase to low •STEMI •NSTEMI •Myocarditis •Marathon •PE (right ventricle struggling)
What is the universal definition of MI?
•Any elevation in troponin in clinical setting consistent with myocardial ischaemia
type 1 MI
Spontaneous MI due to a primary coronary event (coronary artery plaque rupture and formation of thrombus
i.e. coronary artery is the problem
Type 2 MI
Increased oxygen demand or reduced oxygen supply •Heart failure •Sepsis •Arrhythmia •Hyper or hypotension
i.e. coronary artery is not the problem
Type 3 MI
Sudden cardiac death
Type 4a MI
MI associated with percutaneous coronary intervention
Type 4b
MI stent thrombosis documented by angiography or PM
Type 5 MI
MI associated with CABG
What will patients with a type 1 MI always have that those with a type 2 MI may or may not have?
Atherosclerosis
Drugs immediately given for STEMI
- Aspirin - 300mg
- Ticagrelor - 180mg
- IV heparin -5000u (if not already anti coagulated)
Drugs given immediately for ACS (NSTEMI)
Aspirin - 300mg
What is the name of the score for chest pain patients
HEART
Explain the HEART score
•History
- highly suspicious - 2
- moderately - 1
- slightly - 0
•ECG
- Significant ST deviation - 2
- Non specific repolarisation disturbance/LBBB/PM - 1
- Normal - 0
•Age
- ≥65 - 2
- 45-65 - 1
- ≤45 - 0
•Risk factors
- ≥ 3 or atherosclerotic disease - 2
- 1 or 2
- none known - 0
•Troponin
- ≥3 times normal limit - 2
- ≥ 1-3 times normal limit
According to the HEART score what are the risk factors of atherosclerotic disease?
- Hypertension
- hypercholesterolaemia
- Diabetes mellitus
- Cigarette smoking
- Positive family history
- Obesity (BMI > 30)
What are the proposed policies based on the HEART scores?
- 0-3 = discharge
- 4-6 = observation and risk management
- 7-10 = observation, treatment, CAG
Management of ACS once confirmed troponin ≥16ng/L in women or >34 for men
- Full medical review: bloods, ECG, Chest X ray
- Consider other causes of raised troponin (PTE, LVF, arrhythmia, sepsis)
- Ensure not on any anticoagulants
- Ticagrelor 180mg then 90mg
- Fondapaeinux 2.5mg subcut
- PRN sublingual GTN spray
What are the non coronary causes of elevated troponin?
Causes of Type 2 MI: •Sepsis •Congestive heart failure (acute) •Tahcy-arrhythmia •Pulmonary embolism •Apical ballooning syndrome •Anything that stresses the heart i.e. critically unwell patient
Chronic elevation of troponin:
•Renal failure
•Chronic heart failure
•Infiltrative cardiomyopathies e.g. sarcoidosis, amyloidosis, haemochromatosis
What is unstable angina?
An acute coronary event without a rise in troponin
Explain glagovian remodelling
- Normal vessel
- Minimal CAD - atheroma starts to form in wall but lumen is maintained due to compesnsatory expansion
- Advanced CAD - expansion limit and lumen narrows
What does ST elevation represent?
Occlusion of a coronary artery
In which location of a STEMI would you not be able to see ST elevation?
Posterior
What can obscure ST elevation on a ECG?
An old left bundle branch block
Which arteries are affected in an inferior infarction?
- Mostly Right Coronary Artery
* Or left circumflex
Which arteries are responsible for a posterior infarct?
- Mostly circumflex
* Can be Right coronary artery
Which arteries are responsible for lateral infarct?
Left circumflex
Which arteries are repsonsible for an anteroseptal infarct?
Left anterior descending
What are the anterior ECG leads?
V1- V3
What are the inferior ECG leads?
2, 3, avF
What are the Lateral ECG leads?
V5, V6
What are the septal leads?
V3, V4
What would a posterior STEMI look like on ECG?
- Anterior lead ST depression - V1-V3
* May see inferior or lateral ST elevation
What is the immediate management of a STEMI?
•ABC •Put in ambulance attached to defibrillator •Aspirin 300mg PO •Unfractionated heparin 5000u IV •Morphine •Anti-emetics •Clopidogrel - 600mg if PPCI - 300mg if for thrombolysis (75mg if >75) •Ticagrelor •Activate PPCI team
What is the subsequent management for MI?
- Monitor in coronary care unity for complications
- Drugs for secondary prevention
- Echocardiogram
- Cardiac rehabilitation
- if LVSD at >9 months, consider primary prevention ICD
What are the drugs for secondary prevention of MI?
- ACEi
- Beta blockers
- Statins
- Epelerone - only for diabetes and LVSD or clinical HF
What are the complications of MI?
- Arrhythmia
- Heart failure
- Cardiogenic shock
- Myocardial rupture
- Psychological: anxiety/depression
