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Year One - Cardiovascular System > Acute Coronary Syndrome > Flashcards

Acute Coronary Syndrome Flashcards

1
Q

What is acute coronary syndrome?

A

It is a term used to refer to conditions in which a thrombus from an atherosclerotic plaque blocking a coronary artery

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2
Q

What are the three types of acute coronary syndromes?

A

Unstable angina

ST elevation myocardial infarction (STEMI)

Non-ST elevation myocardial infarction (NSTEMI)

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3
Q

What is the pathological difference between a STEMI and NSTEMI?

A

STEMI - complete occlusion of the coronary artery

NSTEMI - partial occlusion of the coronary artery

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4
Q

Which is considered more severe - STEMI or NSTEMI?

A

STEMI

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5
Q

What two arteries does the left coronary artery divide into?

A

Circumflex

Left anterior descending (LAD)

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6
Q

What is the route of the circumflex artery?

A

It curves around the top, left and back of the heart

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7
Q

What two areas does the circumflex artery supply?

A

Left atrium

Posterior aspect of the left ventricle

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8
Q

What is the route of the left anterior descending artery?

A

It travels down the middle of the heart

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9
Q

What two areas of the heart does the left anterior descending artery supply?

A

Anterior aspect of the left ventricle

Anterior aspect of the septum

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10
Q

What is the route of the right coronary artery?

A

It curves around the right side and under the heart

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11
Q

What four areas does the right coronary artery supply?

A

Right atrium

Right ventricle

Inferior aspect of the left ventricle

Posterior septal area

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12
Q

What is the main clinical feature of acute coronary syndromes?

A

Central, constricting chest pain

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13
Q

How long should the chest pain be present for before acute coronary syndromes can be diagnosed?

A

20 minutes

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14
Q

What six other clinical features are associated with acute coronary syndrome?

A

Nausea and vomiting

Sweating

Impending doom feeling

S.O.B

Palpitations

Pain radiating to the jaw/arm

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15
Q

Which group of patients tend not to experience chest pain during acute coronary syndromes? What is this known as?

A

Diabetic

Silent MI

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16
Q

What five investigations are used to diagnose acute coronary syndrome?

A

ECG scan

Blood tests

CXR

ECHO

CT coronary angiogram

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17
Q

What is the first line investigation used to diagnose acute coronary syndrome?

A

ECG scan

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18
Q

What two ECG scan features indicate a STEMI diagnosis?

A

ST elevation

Left bundle branch block

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19
Q

On an ECG, what ST elevation length is required in the chest leads for a diagnosis of STEMI?

A

> 2mm

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20
Q

On an ECG, what ST elevation length is required in the limb leads for a diagnosis of STEMI?

A

> 1mm

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21
Q

What three ECG scan features indicate a NSTEMI diagnosis?

A

ST depression

T wave inversion

Pathological Q waves

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22
Q

What do Q waves indicate on an ECG?

A

A deep infarct

It is a late sign and demonstrates that the infarct has been present for three days

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23
Q

What area of the heart does the left coronary artery supply?

A

Anterolateral

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24
Q

What ECG leads would show abnormalities when acute coronary syndrome affects the left coronary artery?

A

I

aVL

V1 - V6

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25
Q

What area of the heart does the left anterior descending artery supply?

A

Anterior

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26
Q

What ECG leads would show abnormalities when acute coronary syndrome affects the left anterior descending artery?

A

V1 - V4

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27
Q

What area of the heart does the circumflex artery supply?

A

Lateral

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28
Q

What ECG leads would show abnormalities when acute coronary syndrome affects the circumflex artery?

A

I

aVL

V5 - V6

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29
Q

What area of the heart does the right coronary artery supply?

A

Inferior

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30
Q

What ECG leads would show abnormalities when acute coronary syndrome affects the right coronary artery?

A

II

III

aVF

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31
Q

What investigation is conducted when no ST elevation is present on the ECG scan?

A

Troponin blood tests

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32
Q

What are troponins?

A

They are proteins which are released when cardiac muscle becomes damaged

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33
Q

How long following cardiac muscle damage are troponin released?

A

10-12 hrs

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34
Q

What diagnosis is indicated when troponin blood tests are normal?

A

Unstable angina

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35
Q

What diagnosis is indicated when troponin blood tests are elevated?

A

NSTEMI

STEMI

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36
Q

What is the main investigation used to differentiate between unstable angina and myocardial infarctions?

A

Troponin blood test

37
Q

What seven other conditions cause elevated troponin levels?

A

Sepsis

Myocarditis

Aortic dissection

Pulmonary embolism

Acute heart failure

Arrhythmias

Chronic kidney failure

38
Q

What seven other blood tests should be conducted to investigate acute coronary syndrome?

A

FBC

LFTs

U&Es

TFTs

ESR/CRP

Cholesterol

Glucose

39
Q

In which arm should we collect blood samples from in suspected acute coronary syndrome cases? Why?

A

Left

This is due to the fact that the right radial artery is used for PCI

40
Q

What are the four immediate management options of acute coronary syndrome?

A

MONA

Morphine

Oxygen

Nitrates

Aspirin

41
Q

What administration route is used to administer morphine to MI patients? Which dose is used? Which medication is administered with morphine?

A

IV

5-10mg

Metoclopramide 10mg IV

42
Q

When do we administer oxygen to patients suffering from acute coronary syndrome?

A

When the patient’s saturation levels are below 94%

43
Q

How do we maintain oxygen saturation levels in acute coronary syndrome patients?

A

High flow 10-15L via Hudson mask

44
Q

What nitrate is administered to acute coronary syndrome patients?

A

IV GTN

45
Q

What dose of aspirin is administered to manage acute coronary syndrome patients?

A

300mg

46
Q

How do we manage acute STEMIs that present within 12 hours of onset?

A

Primary PCI

OR

Thrombolysis

47
Q

How do we determine whether to conduct primary PCI or thrombolysis?

A

Primary PCI is the first line treatment option however can only be selected if it is available within 2 hours of presentation

48
Q

What is PCI?

A

It involves putting a catheter into the patient’s radial or femoral artery, feeding that up to the coronary arteries under x-ray guidance and injecting contrast to identify the area of blockage

This can then be treated using balloons to dilate the vessels or devices to remove the blockage

A stent is put in to keep the artery open

49
Q

Which artery is preferred for primary PCI insertion - femoral or radial?

A

Radial artery

50
Q

What are the two types of stents that can be used in PCIs?

A

Drug eluting

Bare metal

51
Q

What is the first line stent used in PCIs?

A

Drug eluting

52
Q

What is thrombolysis?

A

It involves injecting a fibrinolytic medication that rapidly dissolves the clots

53
Q

Name three fibronylitic medications

A

Streptokinase

Altepase

Teneteplase

54
Q

What is the treatment option selected in NSTEMI patients with a low risk GRACE score?

A

Percutaneous coronary intervention will be performed at a later date

55
Q

How do we determine the acute treatment option for stable NSTEMI’s?

A

We conduct the GRACE score

56
Q

What is the GRACE score?

A

This is a scoring system used to estimate the six month risk of death or repeat MI

57
Q

What are the seven poor prognostic factors of acute coronary syndrome?

A

Heart failure

Peripheral vascular disease

Reduced systolic blood pressure

Elevated initial cardiac markers

Cardiac arrest on admission

ST segment deviation

Cardiogenic shock

58
Q

What are the is the most significant poor prognostic factor of acute coronary syndrome?

A

Cardiogenic shock

59
Q

What is the treatment option selected in NSTEMI patients with a medium to high risk GRACE score?

A

Percutaneous coronary intervention will be performed within four days of admission

60
Q

What is the treatment option selected in unstable NSTEMI?

A

Immediate coronary angiography with PCI

61
Q

What lifestyle advice is used to prevent secondary acute coronary syndrome?

A

Stop smoking

Reduce alcohol consumption

Mediterranean diet

Cardiac rehabilitation

Optimise treatment of other conditions

62
Q

What is cardiac rehabilitation?

A

It is a specific exercise regime for patients post MI

63
Q

What are the six pharmacological management options used to prevent secondary acute coronary syndrome?

A

6As

Aspirin (75mg once daily)

Antiplatelet (clopidogrel, tricragrelor for 12 months)

Atorvastatin (80mg once daily)

ACEI (ramipril 10mg once daily)

Atenolol

Aldosterone antagonist (eplenerone 50mg once daily)

64
Q

What are the five complications of MI?

A

DREAD

Death

Rupture of the heart septum/papillary muscle

eOedema (heart failure)

Arrhythmias/Aneurysms

Dressler’s syndrome

65
Q

Which arrhythmia is associated with MI’s?

A

Ventricular fibrillation

66
Q

How do we manage ventricular fibrillation, which has resulted in cardiac arrest?

A

We deliver DC shock 150V

67
Q

In what two ways do we manage ventricular fibrillation, once spontaneous circulation has resumed?

A

Order ECG scan

Maintain saturations 94 - 96%

68
Q

What is another term for Dressler’s syndrome?

A

Post myocardial infarction syndrome

69
Q

When does Dressler’s syndrome occur?

A

2-3 weeks after an MI

70
Q

What is Dressler’s syndrome?

A

It is caused by a localised immune response leading to pericarditis

71
Q

What are the three clinical features of Dressler’s syndrome?

A

Pleuritic chest pain

Fever

Pericardial rub

72
Q

What three investigations are used to diagnose Dressler’s syndrome?

A

Blood tests

ECG scan

ECHO

73
Q

What blood tests are conducted to diagnose Dressler’s syndrome?

A

Inflammatory markers - such as CRP and ESR

74
Q

What inflammatory marker blood result indicates Dressler’s syndrome?

A

Increased

75
Q

What are the two features of Dressler’s syndrome on ECG?

A

Global ST elevation

T wave inversion

76
Q

What is the features of Dressler’s syndrome on ECHO?

A

Pericardial effusion

77
Q

What is the first line pharmacological management option for Dressler’s syndrome?

A

NSAIDs (aspirin/ibruprofen)

78
Q

What is the second line pharmacological management option for Dressler’s syndrome?

A

Steroids (prednisolone)

79
Q

What surgery is used to treat Dressler’s syndrome? What is the purpose of this procedure?

A

Pericardiocentesis

This is a procedure that removes fluid from around the heart

80
Q

What is another complication of myocardial infarction?

A

Acute mitral regurgitation

81
Q

How long after MIs does acute mitral regurgitation take to develop?

A

A few hours

82
Q

What are the three clinical features of acute mitral regurgitation?

A

Flash pulmonary oedema

Breathlessness

Coarse bilateral lung crackles

83
Q

What is flash pulmonary oedema?

A

It is when blood is directed back towards the pulmonary veins causing congestion in the lungs

84
Q

What is a clinical feature of flash pulmonary oedema?

A

White frothy sputum production

85
Q

What is another complication of myocardial infarction?

A

Ventricular septal defect

86
Q

When does ventricular septal defect tend to present following myocardial infarction?

A

Within the first week

87
Q

How does myocardial infarction lead to ventricular septal defects?

A

It can lead to ischaemic damage to the inter-ventricular septum

88
Q

What are the two clinical features of ventricular septal defects?

A

Acute heart failure

Pan-systolic murmur

89
Q

What investigation should be used to diagnose ventricular septal defects?

A

ECHO

Year One - Cardiovascular System (20 decks)

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