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Phase 4 - Cardiology > Acute Coronary Syndrome > Flashcards

Acute Coronary Syndrome Flashcards

1
Q

What is unstable angina?

A

An acute coronary event without a rise in troponin. So a clinical presentation of an MI with ECG changes or tight narrowing’s on a coronary angiography.
It is myocardial ischemia at rest/minimal exertion without cardiomyocyte necrosis

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2
Q

What are the signs and symptoms of ACS?

A
  • Central/left sided chest pain whcih may radiate to jaw/left arm. Heavy or constricting in nature.
  • Can present atypically with dyspepsia or epigastric pain
  • Dyspnoeea,
  • Sweating,
  • Nausea and vomiting
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3
Q

What is the pathophysiology of ischeamic heart disease/coronary artery disease?

A

Initial endothelial dysfunction triggered by smoking, hypertension or hypoglycaemia. This causes pro-inflammatory proliferation and reduced nitric oxide bioavailability.
LDL infiltrated subendothelial space.
Macrophages ingest oxidized LDL and become foam cells.
Smooth muscle proliferation causes formation of fibrous capsule.

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4
Q

|What are the complications of atherosclerosis?

A
  • Plaque forms physical blockage in the lumen of the coronary artery.
  • Plaque ruptures causing complete occlusion of coronary artery
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5
Q

What are the unmodifiable and modifiable risk factors for coronary artery disease?

A

Unmodifiable - Increasing age, male sex, family history.
Modifiable - smoking, diabetes mellitus, hypertension, hypercholesterolaemia, obesity

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6
Q

What are the investigations for a suspected MI?

A

ECG - Evidence of ST segment deviation
Bloods - Cardiac troponin
CXR and ECHO - evidence of acute heart failure/LV systolic dysfunction
Coronary angiogram

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7
Q

What are the ECG changes that are diagnostic of a STEMI?

A
  1. ST elevation in all leads except V2-V3 > 1mm in adjacent limb leads
  2. New LBBB with chest pain or suspicion of MI
  3. In leads V2-3 then elevation >2.5mm in men under 40y, >2mm in men over 40y and >1.5mm in women
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8
Q

What are the different types of myocardial infarctions?

A
  • Type 1: Spontaneous MI due to a primary coronary event.
  • Type 2: Increased oxygen demand or decreased oxygen supply (HF, sepsis, anaemia, arrhythmias, hypertension or hypotension) can have atherosclerotic coronaries or not.
  • Type 3: sudden cardiac death,
  • Type 4: alpha is MI associated with PCI, beta is MI stent thrombosis
  • Type 5: MI associated with CABG
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9
Q

What is required when a patient presents with cardiac chest pain?

A

ECG and troponin done within 15mins

HEART score preformed, if heart score is below threshold then do serial troponin at baseline, 3 hours and then 6 hours

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10
Q

What are some causes of type 2 MIs?

A

Acute presentation of heart failure,
Tachy-arrhythmias,
Pulmonary embolism,
Sepsis,
Apical ballooning syndrome,
Anything that stresses the heart (critically unwell patient)

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11
Q

What are some non-coronary causes of chronic elevated troponin?

A

Renal failure,
Chronic heart failure,
Infiltrative cardiomyopathies (amyloidosis, hemochromatosis or sarcoidosis)

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12
Q

What leads and artery represent the inferior myocardium?

A

Leads II, III and aVF.
Right coronary artery.

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13
Q

What leads and artery represent the septal myocardium?

A

Leads V1-2.
Proximal LAD artery

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14
Q

What leads and artery represent the anterior myocardium?

A

Leads V3-V4.
LAD artery

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15
Q

What leads and artery represent the lateral myocardium?

A

Leads I, aVL, V5-6.
Left circumflex artery

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16
Q

What leads and artery represent the posterior myocardium?

A

ST depression in leads V1-3/4.
Left circumflex or right coronary artery

17
Q

What is the time limit for a PCI?

A

120 mins

18
Q

What is the initial management of all patients with ACS?

A

MONA
- Morphine: Only if patient is in severe pain.
- Oxygen: Only if O2 says <94%
- Nitrates (caution if patient is hypotensive)
- Aspirin 300mg

19
Q

What are the two options of treatment for a STEMI?

A
  • Percutaneous coronary intervention: Should be offered if presentation is within 12 hours of onset and PCI can be delivered in 120mins
  • Fibrinolysis: If presentation is within 12 hours and PCI cannot be delivered in 120mins
20
Q

What should be given prior to PCI

A
  • Give anyone who will undergo PCI dual antiplatelet therapy.
    Either Prasugrel/ticagrelor and aspirin if not already taking an oral anticoagulant
    or
    Clopidogrel and aspirin if they are already taking anticoagulant
21
Q

What should be given during a PCI

A

With radial access: Unfractionated heparin with bailout glycoprotein IIB/IIIa inhibitor.

With femoral access: Bivalirudin with bailout GPI

22
Q

Describe features of fibrinolysis

A
  • Give antithrombin at the same time (LMWH, fondaparinux)
  • Give fibrinolysis eg, alteplase
  • Start ticagrelor following proceedure,
  • Do ECG 60-90mins after, if myocardial ischaemia continues then do PCI
23
Q

What are the absoloute contraindications to fibrinolytic therapy?

A
  • History of intracranial haemorrhage,
  • Ischaemic stroke in last 6 months,
  • CNS damage or arteriovenous malformation,
  • Major trauma in last 1 month,
  • GI bleeding within last month,
  • Bleeding disorder,
  • Aortic dissection,
  • Non compressible punctures in last 24hrs eg, liver biopsy or LP
24
Q

What is the management of NSTEMI/unstable angina if GRACE score >3%

A
  • Fondaparinux if no immediate PCI planned.
  • If unstable then Immediately do PCI.
  • If stable then do PCI within 72 hours.
  • Give prasugrel/ticagrelor
  • Give unfractionated heparin
  • Give dual antiplatelet therapy (low risk of bleeding then ticagrelor. High risk of bleeding then clopidogrel
25
Q

what medications should be given post ACS?

A

SAAB
Statin,
Aspirin,
Ace inhibitor
Beta blocker
Give Aldosterone antagonist in anyone with signs of heart failure

26
Q

What is the management of an NSTEMI with a GRACE score <3%

A
  • Give Fondaparinux as no immediate PCI will be planned
  • Continue with dual anti-platelet therapy. aspirin + another drug (ticagrelor is low risk of bleeding and clopidogrel if high risk of bleeding)

Phase 4 - Cardiology (15 decks)

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