Acute Coronary Syndrome Flashcards by amo x

What is acute coronary syndrome?

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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What are the three types of acute coronary syndromes?

Unstable angina

ST elevation myocardial infarction (STEMI)

Non-ST elevation myocardial infarction (NSTEMI)

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What is the pathological difference between a STEMI and NSTEMI?

STEMI - complete occlusion of the coronary artery

NSTEMI - partial occlusion of the coronary artery

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Which is considered more severe - STEMI or NSTEMI?

STEMI

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What two arteries does the left coronary artery divide into?

Circumflex

Left anterior descending (LAD)

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What is the route of the circumflex artery?

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

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What two areas does the circumflex artery supply?

Left atrium

Posterior aspect of the left ventricle

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What is the route of the left anterior descending artery?

It travels down the middle of the heart

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

Anterior aspect of the left ventricle

Anterior aspect of the septum

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What is the route of the right coronary artery?

It curves around the right side and under the heart

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What four areas does the right coronary artery supply?

Right atrium

Right ventricle

Inferior aspect of the left ventricle

Posterior septal area

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What is the main clinical feature of acute coronary syndromes?

Central, constricting chest pain

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

20 minutes

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

Nausea and vomiting

Sweating

Impending doom feeling

S.O.B

Palpitations

Pain radiating to the jaw/arm

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

Diabetic

Silent MI

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What five investigations are used to diagnose acute coronary syndrome?

ECG scan

Blood tests

CXR

ECHO

CT coronary angiogram

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

ECG scan

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What two ECG scan features indicate a STEMI diagnosis?

ST elevation

Left bundle branch block

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

> 2mm

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

> 1mm

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What three ECG scan features indicate a NSTEMI diagnosis?

ST depression

T wave inversion

Pathological Q waves

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What do Q waves indicate on an ECG?

A deep infarct

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

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

Anterolateral

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

aVL

V1 - V6

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

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

V1 - V4

What area of the heart does the circumflex artery supply?

Lateral

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

I aVL V5 - V6

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

Inferior

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

II III aVF

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

Troponin blood tests

What are troponins?

They are proteins which are released when cardiac muscle becomes damaged

How long following cardiac muscle damage are troponin released?

10-12 hrs

What diagnosis is indicated when troponin blood tests are normal?

Unstable angina

What diagnosis is indicated when troponin blood tests are elevated?

NSTEMI STEMI

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

Troponin blood test

What seven other conditions cause elevated troponin levels?

Sepsis Myocarditis Aortic dissection Pulmonary embolism Acute heart failure Arrhythmias Chronic kidney failure

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

FBC LFTs U&Es TFTs ESR/CRP Cholesterol Glucose

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

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

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

MONA Morphine Oxygen Nitrates Aspirin

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

IV 5-10mg Metoclopramide 10mg IV

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

When the patient's saturation levels are below 94%

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

High flow 10-15L via Hudson mask

What nitrate is administered to acute coronary syndrome patients?

IV GTN

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

300mg

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

Primary PCI OR Thrombolysis

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

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

What is PCI?

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

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

Radial artery

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

Drug eluting Bare metal

What is the first line stent used in PCIs?

Drug eluting

What is thrombolysis?

It involves injecting a fibrinolytic medication that rapidly dissolves the clots

Name three fibronylitic medications

Streptokinase Altepase Teneteplase

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

Percutaneous coronary intervention will be performed at a later date

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

We conduct the GRACE score

What is the GRACE score?

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

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

Heart failure Peripheral vascular disease Reduced systolic blood pressure Elevated initial cardiac markers Cardiac arrest on admission ST segment deviation Cardiogenic shock

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

Cardiogenic shock

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

Percutaneous coronary intervention will be performed within four days of admission

What is the treatment option selected in unstable NSTEMI?

Immediate coronary angiography with PCI

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

Stop smoking Reduce alcohol consumption Mediterranean diet Cardiac rehabilitation Optimise treatment of other conditions

What is cardiac rehabilitation?

It is a specific exercise regime for patients post MI

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

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)

What are the five complications of MI?

DREAD Death Rupture of the heart septum/papillary muscle eOedema (heart failure) Arrhythmias/Aneurysms Dressler's syndrome

Which arrhythmia is associated with MI's?

Ventricular fibrillation

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

We deliver DC shock 150V

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

Order ECG scan Maintain saturations 94 - 96%

What is another term for Dressler's syndrome?

Post myocardial infarction syndrome

When does Dressler's syndrome occur?

2-3 weeks after an MI

What is Dressler's syndrome?

It is caused by a localised immune response leading to pericarditis

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

Pleuritic chest pain Fever Pericardial rub

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

Blood tests ECG scan ECHO

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

Inflammatory markers - such as CRP and ESR

What inflammatory marker blood result indicates Dressler's syndrome?

Increased

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

Global ST elevation T wave inversion

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

Pericardial effusion

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

NSAIDs (aspirin/ibruprofen)

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

Steroids (prednisolone)

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

Pericardiocentesis This is a procedure that removes fluid from around the heart

What is another complication of myocardial infarction?

Acute mitral regurgitation

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

A few hours

What are the three clinical features of acute mitral regurgitation?

Flash pulmonary oedema Breathlessness Coarse bilateral lung crackles

What is flash pulmonary oedema?

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

What is a clinical feature of flash pulmonary oedema?

White frothy sputum production

What is another complication of myocardial infarction?

Ventricular septal defect

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

Within the first week

How does myocardial infarction lead to ventricular septal defects?

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

What are the two clinical features of ventricular septal defects?

Acute heart failure Pan-systolic murmur

What investigation should be used to diagnose ventricular septal defects?

ECHO