Acute Coronary Syndrome Flashcards
What clinical features are seen?
- chest pain
- central / left-side
- heavy in nature “elephant sitting on chest”
- radiates to jaw / left arm
- wide variety e.g. diabetics/elderly might not get any chest pain
- dyspnoea
- sweating
- palpitations
- N+V
- pale + clammy
What investigations should be done?
- ECG
- cardiac markers: troponin
What artery is blocked in the following MIs:
- anterior
- inferior
- lateral
- left anterior descending
- right coronary
- left circumflex
What secondary prevention medication is given lifelong to everybody who has had a MI?
- aspirin
- second antiplatelet e.g. clopidogrel
- ACE inhibitor
- beta-blocker
- statin
- What factors indicate poor prognosis for death in hospital or after discharge following ACS?
- State the Killip class which is used to identify risk post MI.
- age
- medical conditions: HF (history or development of), PVD
- exam findings: ST deviation, reduced systolic BP
- bloods: raised troponin, raised creatinine
- cardiac arrest on admission
- Killip class
1. Killip class I: no clinical signs of HF Killip class II: lung crackles, S3 Killip class III: frank pulmonary oedema Killip class IV: cardiogenic shock
What drug therapy should be given to all patients presenting with ACS?
- morphine (if severe pain)
- oxygen (if sats <94%)
- nitrates (can be given sublingually or IV, avoid if hypotensive)
- aspirin 300mg
mnemonic: MONA
NOTE: give either opiate or paracetamol for pain management - NSAIDs can interfere with anti-platelet drugs
STEMI management
State and describe the two routes of management.
Percutaneous Coronary Intervention (PCI)
- given if within 12 hrs of onset of symptoms AND PCI can be delivered within 2 hrs
- BEFORE PCI give a further anti-platelet (e.g. prasgurel, ticagrelor, clopidogrel)
- DURING PCI:
- via radial access: unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor
- via femoral access: bivalirudin with bailout glycoprotein IIb/IIIa inhibitor
Fibrinolysis
- given if PCI criteria not met
- give antithrombin drug (anything ending in ban / dabigatran)
- repeat ECG 60-90 mins after: if persistent myocardial ischaemia consider PCI (2 and 12 hour rules no longer apply)
NSTEMI / unstable angina
- What additional drug therapy is given following diagnosis on top of MONA?
- What risk assessment tool is used to guide further management?
- When is coronary angiography indicated?
- If PCI is decided as management, what would be given prior to the procedure?
- If PCI is not planned what should be given?
- not high risk of bleeding and not having angiography: fondaparinux
if planned angiography or creatinine >265: unfractionated heparin - GRACE
- immediate: if clinically unstable (e.g. hypotensive)
- within 72 hrs: intermediate risk or above (GRACE >3%)
- ischaemia after admission
- unfractioned heparin
- a further anticoagulant
- a further anticoagulant
If both anti platelets and anticoagulants are indicated. When would mono therapy with ONLY anticoagulants be indicated?
stable CV disease
so keep dual for:
- ACS
- stroke
- PAD
In what type of MI is AV node block most common?
inferior MI
MI complications
NOTE: LV aneurysm elsewhere
What should you suspect in the following clinical presentations:
- acute heart failure with raised JVP, pulsus paradoxus and diminished heart sounds
- acute heart failure + pan systolic murmur
- following posterior/inferior infarction patient develops acute heart failure and early / mid systolic murmur
- LV wall rupture (symptoms seen due to tamponade)
- VSD
- mitral regurgitation secondary to papillary muscle rupture
NOTE: management for each of these is urgent surgical repair
What lifestyle advice should be given post MI?
20-30 mins exercise a day until slightly breathless
change fat and cheese for plant il based products
sex can continue 4 weeks after MI, after this sex will not increase their likelihood of another MI
What should be considered regarding thrombolysis?
tissue plasmonigen activitor (tPA) shows mortality benefit over streptokinase
tenecteplase very similar efficacy + side effects to alteplase but easier to administer
How should type 2 diabetics be managed during and immediately after ACS?
stop drugs and aim for tight glycemic control with IV insulin
