Acute Coronary Syndrome Flashcards
When does ACS occur
When a thrombus blocks a Coronary artery
What are the three types of ACS
Unstable Angina
NSTEMI
STEMI
What is the difference between MI and Angina
MI is referred to the death of myocardium whereas angina is the underperfusion
What are the non modifiable risk factors for ACS
Age
Male
Family history
South Asian
What are the modifiable risk factors for ACS
Smoking HTN Hyperlipidaemia Obesity Diabetes Sedentary Lifestyle
What is the difference between STEMI and NSTEMI
STEMI= complete occlusion NSTEMI = Severe occlusion
When can NSTEMIs occur n a non occlusive setting
Severe sepsis
Hypotension
Hypovolemia
Coronary Artery Spasm
What is the presentation of ACS
Central CRUSHING Chest pain
Radiates to neck jaw and arms
Present with N+V, sweating, SOB or syncope
What are some non MI causes of Chest pain
C- Myocarditis/Pericarditis C- Cardiomyopathy C -Valvular disease C- Aortic Dissection P- PE P- Pneumonia P- Pneumothorax R- Costochondritis R- Herpes G- Oesophageal spasm G- Cholecystitis G-Pancreatitis
Describe Troponin levels in unstable angina, STEMI and NSTEMI
Unstable= normal troponin NSTEMI= Raised troponin STEMI= Raised troponin
Describe the ECG Changes for Unstable, STEMI and NSTEMI
UNSTABLE =NORMAL/ST DEPRESSION
NSTEMI = NORMAL/ST DEPRESSION
STEMI = ST ELEVATION/LBBB
How would you diagnose a STEMI
ST elevation
->2mm in chest lead
->1mm in limb leads
LBBB with chest pain
How would you diagnose NSTEMI
Raised troponin
Chest pain
Abnormal ECG
What is the initial investigation of ACS
ECG
STEMI= urgent referral
After ECG what should you investigate
Bloods Troponin (3hrs after pain starts) FBC and CRP (Infection?) D-Dimer (PE?) Chest X ray (pulmonary oedema?)
An RCA STEMI would be present on what leads and myocardium area
II, III and aVF
Inferior myocardium
A LAD STEMI would be found on what leads and area
V1-V6
(V1-V2 = Poximal LAD at septal)
(V3-V4 = LAD at Anterior)
V5-V6 =Distal LAD at Apex)
An LCx STEMI would be found on what leads and area
I, aVL
Lateral Myocardium
An RCA/LCx STEMI would be found on what leads and area
V7-V9 with ST depression at V1-V3
Posterolateral myocardium
What is Troponin
A protein marker of dead cardiomyocytes which raise 3hrs after MI
What are some non ACS causes of raised Troponin
Myocarditis and Pericarditis Arrythmia Heart Fail Type A Aortic Dissection Sepsis Strenuous Exercise
What is the managment for ACS
"What's HAPON" H- Hospital (PCI IMMEDIATE if STEMI) A- Aspirin w/ Clopidogrel P- Pain relief (morphine) O- Oxygen N- NItrates
What is the management for STEMI
ACS Management then ...... Before PCI -Prasugrel (not on anti-coag) -Clopidogrel (on anti coag) PCI (<2hr of medical contact) Thrombolysis (>12hr of symptoms)
Why may you choose clopidogrel over prasugrel
Clopidogrel should be used if the patient is on anticoagulation already
What is the management of NSTEMI
Oxygen >90 Aspirin with GRACE score if low risk = prasugrel/ticragelor if high risk = clopidogrel GTN for symptom relief IV morphine (decrease preload) Start LMWH or Fondaparinux
What is the Post MI management
Aspirin 75mg with clopidogrel 75 mg (Anti Platelet) Bisoprolol (BB) Ramipril (CCB) Atorvastatin -do ECHO = heart fail? -do cardiac rehab
What are the main complications of MI
Heart fail -Ventricular fibrillation -Mitral Incompetence -LV rupture -Cardio shock Dressler's
How does ECG change after an MI
Hyperacute T wave
Deep Q wave
LBBB
What is the difference between T1 and T2 MI
T1- IHD
T2 - Demand / Vasospasm
How does occlusion change between unstable, NSTEMI and STEMI
Unstable = Minor NSTEMI = Major STEMI = Total
How does infarction change between unstable, NSTEMI and STEMI
Unstable = Only ISCHEMIA NSTEMI = Sub endo infarction STEMI = Transmural infarction
What investigation shows the extent of occlusion
CT Coronary Angiogram
Why is alteplase used in thrmobolysis of a STEMI
Clot buster
-Activates plasmin which decreases fibrin
What is the long term prevention of ACS
Beat Blocker
Aspirin (300mg load then 75mg) w/ Clopidogrel
Atorvastatin
ACE inhibitor
