Acute coronary syndrome Flashcards
ACS mechanism
Thrombus from atherosclerotic plaque blocking a coronary artery - made up of mostly platelets
Types of ACS
Unstable angina
STEMI
NSTEMI
ACS diagnosis
ECG
ST elevation / new LBBB = STEMI
No ST elevation - check troponin (serial - at baseline and 6/12hrs after onset of symptoms)
High tropoinin + ST depression/ T wave inversion/ pathological Q waves = NSTEMI
If troponin and ECG normal - unstable angina / MSK etc
ACS sympotms
Central constricting chest pain
Continue at rest for more than 20 mins
Diabetics = silent MI
Right coronary artery (RCA) supplies the…
Right atrium
Right ventricle
Inferior aspect of left ventricle
Posterior septal area
Circumflex artery supplies the …
Left atrium
Posterior aspect of left ventricle
Left anterior descending (LAD) supplies the…
Anterior aspect of left ventricle
Anterior aspect of septum
Draw coronary arteries
(see zero to finals picture)
ECG area changes to artery affected
Leads I, aVL, V3-6 = anterolateral = LCA
Leads V1-4 = anterior = LAD
Leads I, aVL, V5-6 = lateral = circumflex
Leads II, III, aVF = inferior = RCA
What are troponins?
Proteins found in cardiac muscles
Causes of raised troponins
MI
Chronic renal failure
Sepsis
Myocarditis
Aortic dissection
PE
ACS investigations
Physical exam
ECG
FBC - anaemia
U&Es - prior to starting ACEi
LFTs - prior to statins
Lipid profile
Thyroid function tests
HbA1c
Fasting glucose
CXR - other causes of pain and pulmonary oedema
Echo - assess functional damage after event
CT coronary angiogram
Acute STEMI treatment
Within 12 hours of onset
Primary PCI (w/in 2 hours)
Thrombolysis (if PCI unavailable) - injecting fibrinolytic medication - streptokinase, altepase and tenecteplase
Acute NSTEMI treatment
BATMAN
B - beta blockers (check for contraindications)
A - aspirin 300mg stat
T - ticagrelor 180mg stat (clopidogrel if higher bleeding risk)
M - morphine titrated
A - anticoagulant - fondaparinux (unless high bleed risk)
N - nitrates - GTN
Oxygen if sats dropping
Grace score
Assess for PCI in NSTEMI
6 month risk of death or repeat MI
< 5% = low, 5-10% = medium, >10% = high
Medium/high = considered for early PCI (w/in 4 days of admission)
Complications of MI
DREAD
D- death
R - rupture of heart septum/papillary muscles
E - edema (heart failure)
A - arrhythmia and aneurysm
D - Dressler’s syndrome
Dressler’s syndrome definition
Post MI syndrome
2-3 weeks after MI
Dressler’s syndrome mechanism
Localised immune response
Causes pericarditis
Pericardial effusion (extra fluid)
Pericardial tamponade (rarely) (fluid constricts heart and prevents function)
Dressler’s syndrome symptoms
Pleuritic chest pain (when breathing)
Low grade fever
Pericardial rub
Dressler’s syndrome diagnosis
ECG - global ST elevation and T wave inversion)
Echocardiogram - pericardial effusion
Raised inflammatory markers - CRP and ESR
Dressler’s syndrome managmenet
NSAIDs
Steroids if severe
Pericardiocentesis to remove fluid
ACS secondary medical prevention
6As
Aspirin 75mg OD
Another antiplatelet (clopidogrel) for up to 12 months
Atorvastatin 80mg OD
ACE inhibitor (ramipril titrated to 10mg OD)
Atenolol
Aldosterone antagonist if clinical heart failure (eplerenone titrated to 50mg OD)
Dual anti-platelet therapy depends on PCI –> high risk of thrombus formation with different stents
ACS secondary prevention lifestyle
Stop smoking
Reduce alcohol consumption
Mediterranean diet
Cardiac rehabilitation
Optimise treatment of other conditions
