Acute coronary Syndrome Flashcards
What is ACS?
Acute coronary syndrome: a syndrome in which there is reduced blood flow in the coronary arteries causing cardiac muscle dysfunction/ischaemia
What is the most common presentation of ACS?
Central crushing chest pain, radiating up to the jaw
How is ACS classified?
STEMI
NSTEMI
Unstable angina
What are the features of STEMI?
- Anyone with new LBBB
- ST elevation in 2 consecutive inferior leads of more than 1mm
- ST elevation in 2 consecutive chest leads of more than 2 mm
What are the features of NSTEMI?
Wide range of ECG changes that don’t fit criteria for STEMI: T wave inversion, ST depression etc
Associated with positive troponin and convincing chest pain history
What are the features of unstable angina?
Chest pain at rest lasting >10 minutes
Crescendo angina
What is crescendo angina?
Decrease in the distance the patient is able to walk before symptoms occur
What is the pathophysiology of STEMI?
Transmural myocardial ischaemia resulting in myocardial injury or necrosis
What may cause a STEMI?
Coronary plaque eruption
Erosion
Fissuring or dissection causing sudden obstructive thrombus
What is the definitive treatment for STEMI?
Percutaneous coronary intervention (PCI)
What is the initial treatment for STEMI?
ABCDE approach
IV access, cardiac monitor
What are the target stats in STEMI?
94-98%
Why is it important not to over oxygenate in STEMI?
Over oxygenation can cause free radical formation and worsen myocardial damage
What is the timeframe for PCI?
<90 minutes if in PCI capable hospital
<120 minutes if transfer required
What medication is required in treatment of STEMI?
Morphine and GTN for pain
Load with dual antiplatelet (aspirin and Ticagrelol)
What are the immediate complications of STEMI?
Death
Ventricular arrhythmias
Pulmonary oedema
Cardiogenic shock
What ventricular arrhythmias are ischaemic driven?
Ventricular fibrillation
Ventricular tachycardia
What are the sub acute complications of STEMI?
Interventricular wall rupture
Acute mitral regurgitation
Ventricular free wall rupture
What are the long term complications of STEMI?
Heart failure
Cardiac arrhythmias
Psychological morbidity (anxiety)
What is NSTEMI?
Mismatch of myocardial oxygen demand and myocardial oxygen consumption
Often caused by artery plaque rupture
What is the pathogenic difference between STEMI and NSTEMI?
NSTEMI does not have complete blockage of coronary artery blood flow
Some myocardial damage but not complete transmural damage as STEMI
What is required to make NSTEMI diagnosis?
Clinical history suggestive of ACS
ECG: normal or subtle ST abnormalities, ST depression, T wave inversion
Troponin - positive
What are the management steps for NSTEMI?
ABCDE approach Cardiac monitor Serial ECGs Blood test: highly sensitive troponin Involve cardiology Admit for treatment +/- angiography
What is the immediate medical treatment for ACS?
Load with dual antiplatelets
300mg Aspirin + 300mg Clopidogrel/Ticagrelol 180mg
What medical treatment for ACS is required when in hospital?
Anticoagulation
Fundaparinox 2.5mg SC OD for 2-8 days until discharge or revascularisation
What long term treatment is required after ACS?
Long term dual antiplatelet therapy
(75mg OD Aspirin + 75mg Clopidogrel OD/Ticagrelol 90mg BD)
For 1 year after STEMI or PCI
If PCI then lifelong antiplatelet therapy
What are the features of unstable angina?
Cardiac sounding chest pain at rest
Crescendo angina
No acute ECG findings
Normal troponin
Give some key features of classic cardiac chest pain history
Retrosternal heaviness/pressure Radiation to jaw or arm Intermittent or persistent Exertion exacerbates symptoms GTN will improve symptoms
Give some examples of possible associated symptoms with chest pain
Autonomic features: Chest pain Sweating Dyspnoea Syncope
Give some atypical presentation of chest pain
Epigastric pain
Isolated SoB and indigestion like symptoms - more common in elderly, diabetes, CKD and dementia
Give some risk factors for ACS
Older age Male Smoking Family history of CAD Diabetes Hyperlipidaemia HTN CKD Peripheral vascular disease Known coronary artery disease Cocaine use
What other conditions is it important to recognise cause associated raised troponin?
Tachyarrythmias
Heart failure
Hypertensive emergencies
Critical illness (shock, sepsis, burns)
Myocarditis
Tako-Tsubo cardiomyopathy
Structural heart disease (e.g. aortic stenosis)
Aortic dissection
Pulmonary embolism, pulmonary hypertension
Renal dysfunction and associated cardiac disease
What other conditions may cause elevated troponin?
- Coronary spasm
- Acute neurological event (e.g. stroke or subarachnoid haemorrhage)
- Cardiac contusion or cardiac procedures (CABG, PCI, ablation, pacing, cardioversion or endomyocardial biopsy
- Hyper- and hypothyroidism
- Infiltrative diseases (e.g. amyloidosis, haemochromatosis, sarcoidosis, scleroderma)
- Myocardial drug toxicity or poisoning (e.g. doxorubicin, 5-fluorouracil, herceptin, snake venoms)
- Extreme endurance efforts
- Rhabdomyolysis
What scoring systems are used for NSTEMI/unstable angina?
Grace ACS Risk and Mortality scoring system
TIMI risk scoring
HEART
What are the features of Grace ACS Risk and Mortality scoring system?
Age HR Systolic BP Creatinine Cardiac arrest at admission ST segment deviation of ECG Abnormal cardiac enzymes Evidence of heart failure
What are the features of TIMI risk scoring?
Age >65
>3 CAD risk factors (HTN, high cholesterol, diabetes, FH or CAD, current smoker)
Known CAD (stenosis >50%)
Aspirin use in past 7 days
Severe angina (> 2 episodes in past 24 hrs)
ECG ST changes >0/5mm
Positive cardiac markers
What are the features of HEART scoring?
History ECG Age Risk factors Troponin (initial)
What secondary prevention is used after STEMI/NSTEMI?
Dual antiplatelets for 1 year, then lifelong aspirin
ACEi
Statins
B blocker
Good BP control
Good diabetic control
Lifestyle advice: smoking cessation, exercise, healthy diet
Give cardiac DDx of chest pain
ACS Myopericarditis/cardiomyopathies Tachyarrythmias Acute heart failure Hypertensive emergencies Aortic stenosis Tako-Tsubo cardiomyopathy Coronary spasm Cardiac trauma
Give some pulmonary DDx for chest pain
PE
Pneumothorax
Bronchitis/pneumonia
Pleurisy
Give vascular DDx for chest pain
Aortic dissection
Symptomatic AAA
Give GI DDx for chest pain
Oesophagitis, reflux or spasm
Peptic ulcer/gastritis
Pancreatitis
Cholecystitis
Give orthopaedic DDx for chest pain
MSK disorders Chest trauma Muscle injury/inflammation Chostocondritis Cervical spine pathology
Give some other DDx for chest pain
Anxiety disorders
Herpes zoster
Anaemia
What categories may include DDx for chest pain?
Cardiac Pulmonary Vascular GI MSK
