Acute coronary syndrome Flashcards
Thrombus mostly made up of
Platelets
Anti-platelet examples
Aspirin
Clopidogrel
Ticagrelor
Left coronary artery becomes
Circumflex
Left anterior descending
Right coronary artery supplies
Right atrium
Right ventricle
Inferior aspect of left ventricle
Posterior septal area
Circumflex artery supplies
Left atrium
Posterior aspect of left ventricle
Left anterior descending supplies
Anterior aspect of left ventricle
Anterior aspect of septum
Symptoms of ACS
Central crushing chest pain
Nausea and vomiting
Sweating and clamminess
Feeling of impending doom
SOB
Palpitations
Pain radiation to jaw or arms
STEMI ECG changes
ST segment elevation in leads consistent with area of ischaemia
New LBBB
NSTEMI ECG changes
ST segment depression
Deep T wave inversion
Pathological Q waves (suggesting a deep infarct- late sign)
Left coronary artery ECG leads
I
aVL
v3-6
LAD ECG leads
V1-4
Circumflex ECG leads
I
aVL
v5-6
Right coronary artery ECG leads
II
III
aVF
Alternative causes of raised troponins
Chronic renal failure
Sepsis
Myocarditis
Aortic dissection
PE
Acute STEMI treatment
Primary PCI (if available within 2 hours presentation)
Thrombolysis (if PCI not available)
PCI
Catheter through brachial/ femoral artery
Under xray guidance and inject contrast to identify area of blockage
Thrombolysis
Inject fibrinilytic medication to dissolve clot
Streptokinase, alteplase, tenecteplase
Acute NSTEMI treatment
Beta blockers
Aspirin (300mg stat)
Ticagrelor (180mg stat)
Morphine tirate to control pain (only if severe pain)
Anticoagulant- fondaparinux
Nitrates
Oxygen if sats dropping
GRACE score
6 month risk of death or repeat MI after NSTEMI
<5% low risk
5-10% medium risk
>10% high risk
Medium or high considered for early PCI
Complications of MI
Death
Rupture of heart septum or papillary muscles
Edema (heart failure)
Arrythmias and aneurysm
Dressler’s syndrome
Dressler’s syndrome
Occurs 2-3 weeks after MI
Caused by immune response and causes pericarditis
Dressler’s syndrome presentation
Pleuritic chest pain
Low grade fever
Pericardial rub
Can cause pericardial effusion and pericardial tamponade
Dressler’s syndrome management
NSAIDs (aspirin/ ibuprofen)
Steroids in more severe cases
May need pericardiocentesis
Secondary prevention medical management
Aspirin 75mg OD
Another antiplatelet e.g. clopidogrel or ticargreol for up to 12 months
Atorvastatin 80mg OD
ACEi
Atenolol
Aldosterone antagonist for those with clinical heart failure
Secondary prevention lifestyle
Stop smoking
Reduce alcohol consumption
Mediterranean diet
Cardiac rehabilitation
Optimise treatment of other medical conditions
Killip class
System used to stratify risk post MI
Killip class I
No clinical signs of HF
6% 30 day mortality
Killip class II
Lung crackles
S3
17% 30 day mortality
Killip class III
Frank pulmonary oedema
38% 30 day mortality
Killip class IV
Cardiogenic shock
81% 30 day mortality
STEMI ECG criteria
Clinical symptoms of ACS >20 mins with >20 mins ECG feature in >2 continuous leads:
2.5mm ST elevation in v2-3 in men under 40
2.0mm ST elevation in v2-3 in men over 40
1.5mm ST elevation in v2-3 in women
1mm ST elevation in other leads
New LBBB
Drug therapy during PCI
Radial access:
- unfractionated heparin with bailout glycopriten IIb.IIIA inhibitor
Femoral access:
- bivalirudin with bailout GPI
GRACE calculated using
Age
HR/ BP
Killip class and renal function (serum creatinine)
Cardiac arrest on presentation
ECG findings
Troponin levels
