Acute coronary syndrome Flashcards
Right coronary artery (RCA) supplies which parts of the heart?
(4)
- R atrium
- R ventricle
- Inferior aspect of the L ventricle
- Posterior septal area
The left coronary artery becomes the?
(2)
- Circumflex artery
- Left anterior descending (LAD)
Which parts of the heart does the circumflex artery supply?
- Left atrium
- Posterior aspect of left ventricle
Which part of the heart does the LAD supply?
Anterior aspect of the L ventricle
Anterior aspect of the septum
Suspect ACS if pain is in the and lasts for how long?
Chest, arms, back or jaw and lasts longer than 15 mins
In ACS the chest pain will be described as?
- Dull, central and/or crushing
- Will occur with little or no excergion and often lasts longer than 15 mins
In ACS what is teh chest pain associated with?
- Nausea, vomitting, sweating, breathlessness, palpitations
- Associated with haemodynamic instabiity ( systolic PB less than 90)
What test can be done to differntiate unstable angina from MI?
Serum troponin- remains elevated for up to 2 weeks after an MI
It is realsed from ischaemic heart muscle tissue
What is a silent MI and who is at risk of these?
Someone whp does not experince typical chest pain during acute conoary syndrome
* Patienst with diabetes are at risk of these
ECG changes in STEMI?
ST elevation
LEft bundle branch block
ECG chnages in NSTEMI?
ST depression
T wave inversion
Difference between an NSTEMI and STEMI?
NSTEMI- partial blockage of artery- can be diagnosed with troponin levels- high or rising= NSTEMI
STEMI- complete blockage- diagnosed on clinical findings and ECG
Alternative causes of raised troponin levels? (5)
- Chronic kidney disease
- Sepsis
- Myocarditis
- Aortic dissection
- Pulmonary embolism
STEMI is diagnosed when investigations show?
ECG shows either ST elevatio or new left bundle branch block
NSTEMI is diagnosed when investigations show?
Raised troponin with
* A normal ECG
* Other ECG chnages (ST depression or T wave inversion)
Unstable angina is diagnosed when investigations show?
Symptoms suggest ACS
Troponin is normal and either
* Normal ECG
* ECG chnages (ST depression or T wave inversion)
Initial management of chest pain? “CPAIN”
Call an ambulance
Perform an ECG
Aspirin 300mg
Intravenous morphine for the pain if required
Nitrate (GTN)
Management of STEMI presenting witin 12 hours of onset?
- Percutaneous coronary intervention (PCI)- within 2 hours of presentation
- Thrombolysis
What is percutaneous coronary intervention (PCI)?
Catheter into the patients radial or femoral artery undr x-ray guidance and injecting contrast to identify the blockage (angiography)
Blocakges can be treated with an angioplasty- balloon to widen the lumen of the artery and then stent inserted to keep the artery open
What is thrombolysis?
Injecting fibriolytic agent which breaks down fibrin in blood clots
Managment of NSTEMI? (BATMAN)
B- base the decsion about angiography or PCI on the GRACE score
A- Aspirin 300mg stat
T- Ticagrelor 180mg stat
M- morphine to control pain
A- Antithrombinn therapy with fondaparinux
N- Nitrate
What does the GRACE score predict in NSTEMI management?
Gives a 6 month probability of death after having an NSTEMI
* 3% or less is considered low risk
* Above 3 % is considered medium to high risk
What is Dressler’s syndrome and how does it present? Diagnosed and managed?
Also called post-myocardial infarction syndrome- usually occurs 2-3 weeks after MI- immune response causes inflammation to the pericardium
Presents:
* Pleuritic chest pain
* Low grade fever
* Pericardial rub on auscultation
Diagnosis:
* Made with an ECG- global ST elevation and T wave inversion
* echocardiogram
* Raised inflammatory markers (CRP and ESR)
Managment:
* NSAIDs
* Severe cases- steroids
Name the condition:
Sudden onset pleuritic pain either left sided or right sided, with associated dyspnoea and syncope
Pneumothorax
Name the cause:
Pain typically persistent (typically days or longer), worsened with passive and active motion and sometimes reproducible chest tenderness.
Musculoskeltal
Name the cause:
Exertional pain/discomfort in the centre or left side of chest, throat, neck or jaw relieved by rest or GTN within a few minutes. May radiate to neck, jaw or left arm. Sometimes there may not be any pain but breathlessness (angina equivalent).
Angina
Name the condition:
Constant or intermittent central pleuritic sharp pain often aggravated by position (classically worse on lying down and relieved by sitting or leaning forward)
Pericarditis
Name the condition:
Recurrent, vague epigastric discomfort, that is relieved by food, antacids, or both
Peptic ulcer disease
Name the conditon:
Sudden onset pleuritic pain with associated dyspnoea and tachycardia. Sometimes mild fever, haemoptysis and syncope
Pulmonary embolism
Name of the tool used in GP to determine a patients cardiovascular risk?
QRISK3- established a patients 10 year risk of cardiovascular events
Drugs used in secondary prevention in people who have had an MI?
ACE inhbitor
Antiplatelet therapy
Beta-blocker
Statin
What is angina and difernce between stable and unstable angina?
Angina= chest pain caused by an insufficient blood supply to myocardium.
Stable- occurs predictably with physical exertion or emotional stress and relived within minutes of rest or GTN spray
Unstable angina- new onset, often occuring at rest- requires immediate admission to hopsital
Key side effects of GTN spray?
Headaches and dizziness caused by vasodilation
Medications for secondary prevention of angina? 4 A’s
A- Aspirin 75mg once daily
A- Atorvostatin 80mg once daily
A- ACE inhibitor
A- already on a beta blocker for symptomatic relief
What is a Coronary artery bypass graft (CABG)?
Offered to patients with severe stenosis
Opens chest along sternum and attch graft vessel to the affected coronary artery, bypassing the stenoitc area
3 main options for graft vessel are:
* Saphenous vein
* Internal thoracic artery
* Radial artery
In patient with angina where beta blocker is contraindicated e.g. asthma. What else can be given alongside GTN and verapamil?
Long acting nitrate e.g. isosorbide mononitrate
Prior to percutaneous coronary intervention (PCI) what are patients given?
Dual antiplatelet therapy
* Aspirin and Clopidogrel (if on anticoag already)
* Aspirin and prasugrel (if not on anticoag already)
Patients undergoing fibrinolysis for a STEMI should also be given?
Antithrombin drug- Fondaparinux
