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Acute Care > Acute coronary Syndrome > Flashcards

Acute coronary Syndrome Flashcards

1
Q

What is ACS?

A

Acute coronary syndrome: a syndrome in which there is reduced blood flow in the coronary arteries causing cardiac muscle dysfunction/ischaemia

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2
Q

What is the most common presentation of ACS?

A

Central crushing chest pain, radiating up to the jaw

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3
Q

How is ACS classified?

A

STEMI
NSTEMI
Unstable angina

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4
Q

What are the features of STEMI?

A
  • 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
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5
Q

What are the features of NSTEMI?

A

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

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6
Q

What are the features of unstable angina?

A

Chest pain at rest lasting >10 minutes

Crescendo angina

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7
Q

What is crescendo angina?

A

Decrease in the distance the patient is able to walk before symptoms occur

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8
Q

What is the pathophysiology of STEMI?

A

Transmural myocardial ischaemia resulting in myocardial injury or necrosis

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9
Q

What may cause a STEMI?

A

Coronary plaque eruption
Erosion
Fissuring or dissection causing sudden obstructive thrombus

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10
Q

What is the definitive treatment for STEMI?

A

Percutaneous coronary intervention (PCI)

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11
Q

What is the initial treatment for STEMI?

A

ABCDE approach

IV access, cardiac monitor

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12
Q

What are the target stats in STEMI?

A

94-98%

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13
Q

Why is it important not to over oxygenate in STEMI?

A

Over oxygenation can cause free radical formation and worsen myocardial damage

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14
Q

What is the timeframe for PCI?

A

<90 minutes if in PCI capable hospital

<120 minutes if transfer required

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15
Q

What medication is required in treatment of STEMI?

A

Morphine and GTN for pain

Load with dual antiplatelet (aspirin and Ticagrelol)

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16
Q

What are the immediate complications of STEMI?

A

Death
Ventricular arrhythmias
Pulmonary oedema
Cardiogenic shock

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17
Q

What ventricular arrhythmias are ischaemic driven?

A

Ventricular fibrillation

Ventricular tachycardia

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18
Q

What are the sub acute complications of STEMI?

A

Interventricular wall rupture
Acute mitral regurgitation
Ventricular free wall rupture

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19
Q

What are the long term complications of STEMI?

A

Heart failure
Cardiac arrhythmias
Psychological morbidity (anxiety)

20
Q

What is NSTEMI?

A

Mismatch of myocardial oxygen demand and myocardial oxygen consumption
Often caused by artery plaque rupture

21
Q

What is the pathogenic difference between STEMI and NSTEMI?

A

NSTEMI does not have complete blockage of coronary artery blood flow
Some myocardial damage but not complete transmural damage as STEMI

22
Q

What is required to make NSTEMI diagnosis?

A

Clinical history suggestive of ACS
ECG: normal or subtle ST abnormalities, ST depression, T wave inversion
Troponin - positive

23
Q

What are the management steps for NSTEMI?

A 
ABCDE approach
Cardiac monitor
Serial ECGs
Blood test: highly sensitive troponin
Involve cardiology
Admit for treatment +/- angiography
24
Q

What is the immediate medical treatment for ACS?

A

Load with dual antiplatelets

300mg Aspirin + 300mg Clopidogrel/Ticagrelol 180mg

25
Q

What medical treatment for ACS is required when in hospital?

A

Anticoagulation

Fundaparinox 2.5mg SC OD for 2-8 days until discharge or revascularisation

26
Q

What long term treatment is required after ACS?

A

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

27
Q

What are the features of unstable angina?

A

Cardiac sounding chest pain at rest
Crescendo angina
No acute ECG findings
Normal troponin

28
Q

Give some key features of classic cardiac chest pain history

A 
Retrosternal heaviness/pressure
Radiation to jaw or arm
Intermittent or persistent
Exertion exacerbates symptoms
GTN will improve symptoms
29
Q

Give some examples of possible associated symptoms with chest pain

A 
Autonomic features:
Chest pain
Sweating
Dyspnoea
Syncope
30
Q

Give some atypical presentation of chest pain

A

Epigastric pain

Isolated SoB and indigestion like symptoms - more common in elderly, diabetes, CKD and dementia

31
Q

Give some risk factors for ACS

A 
Older age
Male
Smoking
Family history of CAD
Diabetes
Hyperlipidaemia
HTN
CKD
Peripheral vascular disease
Known coronary artery disease
Cocaine use
32
Q

What other conditions is it important to recognise cause associated raised troponin?

A

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

33
Q

What other conditions may cause elevated troponin?

A
  • 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
34
Q

What scoring systems are used for NSTEMI/unstable angina?

A

Grace ACS Risk and Mortality scoring system
TIMI risk scoring
HEART

35
Q

What are the features of Grace ACS Risk and Mortality scoring system?

A 
Age
HR
Systolic BP
Creatinine
Cardiac arrest at admission
ST segment deviation of ECG
Abnormal cardiac enzymes
Evidence of heart failure
36
Q

What are the features of TIMI risk scoring?

A

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

37
Q

What are the features of HEART scoring?

A 
History
ECG
Age
Risk factors
Troponin (initial)
38
Q

What secondary prevention is used after STEMI/NSTEMI?

A

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

39
Q

Give cardiac DDx of chest pain

A 
ACS
Myopericarditis/cardiomyopathies
Tachyarrythmias
Acute heart failure
Hypertensive emergencies
Aortic stenosis
Tako-Tsubo cardiomyopathy
Coronary spasm
Cardiac trauma
40
Q

Give some pulmonary DDx for chest pain

A

PE
Pneumothorax
Bronchitis/pneumonia
Pleurisy

41
Q

Give vascular DDx for chest pain

A

Aortic dissection

Symptomatic AAA

42
Q

Give GI DDx for chest pain

A

Oesophagitis, reflux or spasm
Peptic ulcer/gastritis
Pancreatitis
Cholecystitis

43
Q

Give orthopaedic DDx for chest pain

A 
MSK disorders
Chest trauma
Muscle injury/inflammation
Chostocondritis
Cervical spine pathology
44
Q

Give some other DDx for chest pain

A

Anxiety disorders
Herpes zoster
Anaemia

45
Q

What categories may include DDx for chest pain?

A 
Cardiac
Pulmonary
Vascular
GI
MSK

Acute Care (2 decks)

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