Acute coronary syndrome Flashcards
Acute coronary syndrome consists of
Unstable angina
NSTEMI
STEMI
Pathophysio of ACS
Myocardial ischemia due to coronary obstruction
Main difference between unstable angina and stable angina
UA develops AT REST or with minimal exertion
How to differentiate between UA, NSTEMI & STEMI?
UA, NSTEMI vs STEMI: ECG will show ST-segment elevation in the part of the myocardial wall that is infarcted due to complete occlusion of the coronary artery supplying that area (for stemi)
UA vs NSTEMI: look at rising trend of cardiac enzymes for NSTEMI
- initial mx for both is same
Stable angina presentation
Exertional CP
Relieved by rest or nitrates
Stable angina:
ECG
Cardiac enzymes
Stable angina:
ECG - Normal or ST depression during CP
Cardiac enzymes - Normal
Unstable angina presentation
3 main presentations:
1. New onset angina
2. Crescendo/accelerated angina
Symptoms become
- more frequent
- more severe
- more prolonged
- less responsive to nitrates
3. Rest angina
Unstable angina:
ECG
Cardiac enzymes
Unstable angina:
ECG - Normal or ST depression
Cardiac enzymes - Normal
NSTEMI presentation
Crushing central chest pain
Radiates to left hand, jaw
Nausea, vomiting
Diaphoresis
NSTEMI:
ECG
Cardiac enzymes
NSTEMI:
ECG - Normal or ST depression
Cardiac enzymes - RAISED
STEMI presentation
Crushing central chest pain
Radiates to left hand, jaw
Nausea, vomiting
Diaphoresis
STEMI:
ECG
Cardiac enzymes
STEMI:
ECG - ST elevation (localise to corresponding coronary artery)
Cardiac enzymes - RAISED
In inferior STEMI or inferoposterior STEMI, what should you evaluate before administering pharmacotherapy?
Evaluate for hypotensive patient needing fluids
Evaluate for need for GTN for relieving the ischaemic pain
If yes -> do right sided ecg to look for RV infarct (ST ELEVATION IN V2-6 R)
Management for ACS
Manage at P1
1. Secure ABCs
2. Run POCTs: ECG, CBG, CXR
3. Run investigations:
Pre-op bloods - FBC, RP, LFT, coagulopathy panel
CARDIAC TROPS for serial trops trending
4. Continuous cardiac monitoring
- Start DAPT: PO aspirin 300mg + ticagrelor 180mg
- Sublingual GTN for ischemic pain -> if better patch GTN
-> persistent pain -> IV GTN - IMMEDIATE CATH LAB ACTIVATION FOR PCI
When is GTN contraindicated?
If there is a RV infarct
- consider in inferior/inferoposterior STEMI
- so must check first!!!! before giving GTN
Why are fluids contraindicated in ACS management?
Fluids can lead to overloaded left ventricles which can lead to CCF
Early ECG change suggestive of impending MI
Hyperacute T waves (super broad based like a cone)
‘Clinical picture’ pointing towards ‘underlying cause’
Chest pain/breathlessness = ischemia, infarct, pulmonary embolism
Weakness = calcium, magnesium
Syncope/palpitations = arrythmias
