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Acute coronary syndrome Flashcards

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1
Q

what is Acute coronary syndrome

A

clinical manifestation of myocardial infarct and commonly the default working diagnosis in patients with new onset chest pain suspected to be of cardiac ischaemic origin
divided into unstable angina, NSTEMI and STEMI

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2
Q

define unstable angina

A

acute myocardial ischemia that is not severe enough to cause detectable quantities of myocardial injury biomarkers or ST segment elevations on ECG

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3
Q

define NSTEMI

A

acute myocardial ischaemia that is severe enough to cause detectable quantities of myocardial injury biomarkers without ST segment elevations on ECG

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4
Q

define STEMI

A

acute myocardial ischaemia that is severe enoiugh to cause ST segment elevations

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5
Q

cardinal sympotms of MI

A

diaphoresis
sense of impending doom
nausea and vomiting
dyspnoea
restrosternal pain radiating to the left side of the body (arm, shoulder, neck and epigastrium)

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6
Q

non specific signs of MI esp. in women

A

dizziness
lightheadedness, syncope
fatigue, exhaustion
jaw, neck, upper back pain
palpitations
epigastric discomfort or pressure

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7
Q

clinical presentation of angina type pain

A

occuring at rest with minimal exertion, not relieved by rest or nitroglycerin
new onset
severe, persistant, worsening (crescendo angina)

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8
Q

autonomic symptoms

A

diaphoresis, syncope, palpitations, nausea and/or vomiting

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9
Q

pathophysiology of unstable angina

A

partial occlusion of coronary vessel
decreased blood supply
ischaemic symptoms without infarction

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10
Q

pathophysiology of NSTEMI

A

classicially due to partial occlusion of a coronary artery
affects the inner layer of the heart (subendocardial infarction)

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11
Q

pathophysiology of STEMI

A

classically due to complete occlusion of coronary artery
affects the full thickness of the myocardium (transmural infarction)

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12
Q

cardaic troponins

A

elevated in NSTEMI and STEMI within 1-6 hours
may initially be undetectable in patients who present early after symptom onset, especially if conventional rather than high sensitivity troponin assays are used

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13
Q

ECG findings for unstable angina and NSTEMI

A

no ST elevations
normal or non-specific eg. ST depression, loss of R wave, T wave inversion

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14
Q

ECG findings for STEMI

A

ST elevations in two contiguous leads or new LBBB with strong clinical suspicion of myocardial ischaemia
ST elevations can be masked by LBBB. however the presence of a new of presumably new LBBB in a patient with ACS is not always an ndication for PCI

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15
Q

initial management for the patient presenting with acute coronary syndrome

A

direct to resus
monitor ECG and O2
take obs (bilateral BP if dissectionn is being considered)
takes bloods - FBC, UEC, BSL, trops (senior doctor may add d-dimer if indicated)
CXR
aspirin unless already given or contrindicated
oxygen only if hypoxic <93%
take ECG for urgent review by senior
GTN (SL and then IV if required)
other analgesia eg. titrated morphine

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16
Q

Management for unstable angina and NSTEMI

A

invasive management depends on risk stratification
aspirin 300mg and tiicagrelor load 180mg plus 90mg bd
statins
beta blockers
ACEIs
pain management (opoiods, nitrates, titratd morphine)
do an EDACS score

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17
Q

Management for STEMI

A

immidiate revascularisation
adjunctive therapy similar to NSTEMI

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18
Q

can subtypes of ACS be differentaited based on clinical presentation

A

no

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19
Q

the type of MI is determined based on

A

ECG findings

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20
Q

unstable angina is differentiated from MI by

A

positive troponins

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21
Q

clinical triad for right ventricular infarction

A

hypotension
elevated JVP
clear lung feilds

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22
Q

initial triage based on ECG findings

Study These Flashcards
A

ST elevations present: start management of STEMI with immediate revascularisation therapy, preferably PCI

23
Q

transthoracic echocardography

Study These Flashcards
A

generally not necessary
should not delay reperfusion therapy
may be helpful study in patients with atypical symptoms or if the diagnosis is unclear

24
Q

findings in transthoracic echcardioraphy

Study These Flashcards
A

wall motion abnormalities
decreased LV function
signs of different conditions that cause chest pain

25
reperfusion therapy
PCI or thrombinolysis
26
STEMI treatment of choice
PCI vs. fibrinolysis aim for PCI within 90 minutes of first medical contact consider IV fibrinolytics if: - PCI cant be performed within 120 minutes - there are no contraindications to fibrinolytics for STEMI
27
ECG changes in STEMI
significant ST elevation in two contiguous leads findings may change over time hyperacute T waves can present without ST elevations in the very early stages of ischaemia If inferior MI is suspected, investigate for signs of right ventricular involvement
28
when are Q waves pathological
duration >0.04 seconds amplitude >1/4 of the R waves any Q wave in leads V1-3
29
ECG changes in chronic stage
permanent scarring persistent, broad deep Q waves often incomplete recovery of R waves permanent T-wave inversion is possible
30
the EDACS score
risk assessment for patients presenting to the ED with chest pain
31
procedure for PCI
coronary angiography with PCI ie. baloon dilatation with stent implantation
32
Fibrinolytic therapy is indicated if
PCI cannot be performed within 120 minutes of FMC no contraindications to fibrinolysis are present
33
regimens for fibrinolysis
Tenecteplase Alteplase Reteplase Streptokinase
34
absolute contraindications for fibrinolysis in STEMI
weigh risks and benefits carefully in individual patients active bleeding (not including menses) bleeding diathesis/known coagulopathy any prior intracranial bleeding intracranial or intraspinal surgery within the past 2 months serious head trauma within the past 3 months severe hypertension unresponsive to emergency therapy intracranial conditions increasing risk of bleeding eg. AV malformation suspected aortic dissection intracranial malignancy for streptokinase: previous exposure within the last 6 months (highly antigenic)
35
streptokinase is contraindicated when
there has been previous exposure to streptokinase within the last 6 months
36
antiplatelet therapy and anticoagulation in STEMI if undergoing PCI
DAPT: Aspirin and ADP receptor inhibitor (Prasugral or ticagrelor is preferred, otherwise clopidogrel) anticoagulation: unfractionated heparin, bivalirudin consider adjunctive use of glycoprotein inhibitor
37
antiplatelet therapy and anticoagulation in STEMI if NOT undergoing PCI
aspirin and clopidogrel (DAPT) one of: unfractionated heparin, enoxaparin, fondaparinux (anticogulant) glycoprotein not routinely recommended
38
for patients presenting more than 12 hours after symptom onset
myocardial infarction may already be complete, but still consider PCI/thrombolytic therapy if - ongoing ischaema (persistant pain, dynamic changes on ECG) - viable myocaardium (preservation of R waves) - major complications ( cardiogenic shock, heart failure, malignant arrythmia)
39
when is PCI preferred over thrombolytic therapy
PCI is mor beneficial over thrombolytic therapy in reducing mortality, recurrent MI and stoke. the benefit of PCI over thrombinolysis increases aas time between symptom onset and patient presentation increases
40
if thrombolytic therapy fails
if the patient is at a centre where PCI is not available and thrombolytic therapy is either contraindicated or has failed, promptly transfer the patient to a centre where PCI is availble
41
how do you know if thrombolytic therapy has failed
50% or less ST resolution after 60 to 90 minutes or continued haemodynamic instability
41
what to do if thrombolytic therapy succeeds
arrange transfer to a centre where percutaneous coronary intervention is available with a plan for coronary angiography within 24 hours
42
long term medication for STEMI
antiplatelet statin ACEI/ARB beta blocker
43
are fibrinolytics indicated in NSTEMI
no
44
how to risk stratify NSTEMIs
use EDACS score / GRACE score ECG changes? ongoing ischaemic-like chest pain syncope, systolic BP<90 not due to GTN, haemodynamic instability, signs and symptoms of heart failure, signs and symptoms of heart failure/pulomnnary oedema, recent PCI pr prior CABG, sustainedarrythmia
45
invasive strategy for NSTEMI for very high to intermediate risk patients
within 2 hours for very high risk within 24 hours for high risk
46
ischaemia guided strategy for NSTEMI
for stable, low risk patients non invasive cardiac stress testing eg. exercise ECG, stress echo) to evaluate need for coronary angiography
47
antiplatelet therapy and anticoagulation for NSTEMI
DAPT: aspirin and either Ticagralor or clopidogrel (ADP receptor inhibitors) anticoagulation: enoxaparin, unfractionated heparin, fondaparinux or bilivardin only in invasive strategy consider glyoprotein inhibitor for intermediate/high risk patients with early invasive strategy
48
monitoring during ACS
continuous cardiac monitoring serial 12 lead ECG every 15-30 minutes serial serum troponin measurement every 1-6 hours
49
adjunct medical therapy in ACS
nitrates beta blockers opioids ACE inhibitors/ARBs aldosterone agonists high intensity statin
50
acronym for MI management
MONA BASH Morphine Oxygen Nitroglycerin Antiplatelets (aspirin + ADP receptor inhibitor) beta blockers ACE inhibitors Statins Heparin
51
oxygen therapy should be used for patients with
cyanosis severe dyspnoea SpO2 <93%
52
fluid management
IV fluids: consider for inferior MI causing RV dysfunction, because increasing preload optimises left and right ventricular filling and reduces haemodynamic instaability loop diuretic eg. furosemide: consider for patients with pulmonary oedema, acute heart failure
53

int med 2024 (47 decks)

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