Acute coronary syndrome Flashcards
What are the signs of STEMI?
-Clinical sounding chest pain
-ST elevation on ECG in 2 or more leads from the same zone.
-Troponin I >100
-CK>400
- could also be the presence of left bundle branch block (M signs in v4,5,6- and RAD)
Clinical signs of a NSTEMI?
-cardiac sounding chest pain-
-ST depression and T wave inversion
-Troponin I will be >100
Clinical Signs of Unstable Angina?
-Cardiac sounding chest pain
-ST segment depression
- NORMAL TROPONIN
Describe the changes in TROPONIN after a MI?
- rise 3-4 hours after an MI- stay elevated for 2 weeks
How to test for TROPONIN?
Usually take two tests- one on admission and another an hour later. If however, the patients MI was 3+ hours ago the one TROPONIN rest is sufficient
Reference ranges for men and women for TROPONIN indicative of myocardial necrosis?
Men-34ng/l
Women-16ng/l
Which conditions also present with raised TROPONIN?
-aortic dissection
-Pulmonary Embolism
-Severe Congestive cardiac failure
-renal failure
-aortic stenosis
-tachyarrythmias
What indicates a posterior myocardial infarction?
ST depression in leads v1-v4. These patients should have their posterior leads checked as well v7-v9
What are the strange clinical signs associated with Inferior MI?
Abdominal, epigastric pain- often confused with acid reflux
What changes on the ECG can be confused for STEMI?
-Younger more athletic patients have upsloping of ST segment- more common in Afro-Carribean
-Pericarditis- saddle shaped ST elevation
-Brugada syndrome
-Takotsubo Cardiomyopathy
Management of STEMI
IV Access
Pain relief
Oxygenation
Aspirin-300mg loading dose- 75mg dose od for life
Prasugrel 1st line
Clopidogrel -12months 60mh od (2nd line)
Ticagrelor(2nd line)
Percutaneous coronary intervention
-lipid profile, random glucose and HB1AC
-FBC
-bisoprolol -1.25mg od
-ACEi-ramipril 2.5mg O.D (after checking renal function)
Or- Losartan-25mg of
-Statin to reduce LDL <1.8mmol
-ccontrol hypertension, diabetes and smoking
- patients with AF and STEMI- are on anticoagulants, do they are taking three anticoags- TRIPLE THERAPY- risk of bleeding very high
Management of NSTEMI
-Pain relief
-Aspirin 300mg loading and 75mg OD
-Low molecular weight heparin
-Repeat ECG
-Risk Assessment for patients with elevated Troponin I and if it’s > 3% Ticagrelor 180mg loading dose and 90mg BD
-Anti-anginals- Nitrates, Ranolazine
Symptoms of ANGINA
-Chest discomfort- usually brought on by exercise, emotion and relieved by rest
-Throat tightness and arm heaviness
-Fear
-Sweating
-Nausea
-pain is not constant
-Pain is not very prolonged
What is Angina?
chest pain usually associated with some kind of coronary artery disease - like Aortic stenosis, hypertensive heart
When is Angina not a concern?
when the heart is structurally normal and normal coronary arteries- some people experience recurrent angina
What physical examinations do you do in Angina?
-BMI - obesity is an indication of CVS disease
-Blood pressure- hypertensive heart
-Presence of murmurs- aortic stenosis
-hyperlipidaemia-
-Peripheral vascular disease- diabetes
Investigations for Angina?
-FBC- glucose/HbA1C
-Full lipid profile
-12 lead ECG’s
What is the medication used for ANGINA?
-Aspirin 75mg OD
(for those allergic give clopidogrel)
-Sublingual GTN spray
-B-blockers and Ca2+ channel blocker
-Long acting nitrates-Isosorbide Mononitrate OR potassium channel opening drugs - Nicoranadil- DON’T PRESCRIBE BOTH- BECAUSE PATIENT WILL DEVELOP NITRATE TOLERANCE
-Ivabradine- more useful where B-blocker is contraindicated.Never give with non-dihydropyridine Ca2+ channel blockers
-Ranolazine- be careful cannot give to patients with eGFR <30
Describe the three stages of hypertension
Stage 1 Hypertension 140/90mmHg, or average is 135/80 or higher
Stage 2- 160/100 or average 150/95
Severe- systolic 180 or diastolic is 110
When should ambulatory monitoring be offered?
if the BP is >140/90. however if the BP is severe hypertensive, start them on treatment without ABPM
What is Ambulatory Blood pressure monitoring?
-Monitoring BP over 24hrs
Symptoms of Hypertension
-Sometimes asymptomatic or headache
-Sweating, headache, palpitations and anxiety- all indicate Phaechromocytoma
-Muscle weakness/ tetany - HYPERALDOSTERINSM
What are the investigations we do for hypertension?
-examine for Cushings, polycystic kidney disease, coarctation of aorta.
-test for preteinuria, haematuria
-Measure plasma glucose,electrolytes, creatinine,eGFR, total cholesterol and HDL
-FBC- electrolytes
-Examine the fundi for hypertensive retinopathy
-12 lead ECG
Treatment for Hypertension
Non pharm- weight loss and reducing salt intake
Pharmacological- ACEi or Ca2+ channel blocker, then all three( ARBS) then consider B-blocker, for persistent Hypertension refer to specialist.
Difference between hypertensive urgency and emergency
Emergency is an elevation of BP with critical event -oedema, AKI
Whereas Urgency is elevated BP without critical event
What is the treatment for hypertensive emergency?
Sodium nitroprusside
Labetalol
GTN
Esmolol
The aim is to get diastolic BP around 110 mmHg
Hypertensive urgency treatment
Amlodipine
Diltiazem
Lisonopril
ACEi
calcium antagonist
Nifedipine and amlodipine (forever)
Aim for BP 100mmHg diastolic
What is the triadic symptom associated with Phaechromocytoma?
-headache
-sweating
-tachycardia
How do you test for Phaechromocytoma?
Urine metanephrines and a CT or MRI- often scans can’t detect it
Treatment for Phaechromocytoma
Usually surgical resection.
Awaiting surgery, patients should have BP control, alpha blocker
Phenoxybenzamine- if this is not tolerated by the patient try calcium channel blocker nicardine
After alpha blocker then give beta blocker NEVER give beta blocker first
