Acute coronary syndrome Flashcards
What is acute coronary syndrome (ACS)?
ACS is usually caused by a thrombus from an atherosclerotic plaque blocking a coronary artery. The thrombus is mainly composed of platelets, which is why antiplatelet medications (e.g., aspirin, clopidogrel, ticagrelor) are essential for treatment.
What are the types of acute coronary syndrome (ACS)?
The three types of ACS are:
* Unstable angina
* ST-elevation myocardial infarction (STEMI)
* Non-ST-elevation myocardial infarction (NSTEMI)
What are the two coronary arteries branching from the aorta?
The two coronary arteries are:
* Right coronary artery (RCA)
* Left coronary artery (LCA)
What does the right coronary artery (RCA) supply?
The RCA supplies the:
* Right atrium
* Right ventricle
* Inferior aspect of the left ventricle
* Posterior septal area
What does the left coronary artery (LCA) branch into?
The LCA branches into:
* Circumflex artery
* Left anterior descending (LAD)
What does the circumflex artery supply?
The circumflex artery supplies the:
* Left atrium
* Posterior aspect of the left ventricle
What does the left anterior descending (LAD) artery supply?
The LAD artery supplies the:
* Anterior aspect of the left ventricle
* Anterior aspect of the septum
What are common symptoms of acute coronary syndrome?
Symptoms include:
* Central, constricting chest pain
* Pain radiating to the jaw or arms
* Nausea, vomiting, sweating
* Shortness of breath, palpitations
* A feeling of impending doom
* Symptoms lasting more than 15 minutes
What is a silent myocardial infarction (MI)?
A silent MI occurs without typical chest pain, and patients with diabetes are at higher risk of experiencing it.
What are ECG changes in STEMI?
In STEMI, the ECG shows:
* ST-segment elevation
* New left bundle branch block
What are ECG changes in NSTEMI?
In NSTEMI, the ECG shows:
* ST segment depression
* T wave inversion
What do pathological Q waves suggest?
Pathological Q waves suggest a deep infarction (transmural) involving the full thickness of the heart muscle and appear 6+ hours after symptom onset.
What is troponin and its significance in ACS?
Troponin is a protein released from damaged myocardial tissue. Elevated troponin levels help diagnose NSTEMI. They are not required for diagnosing STEMI (which is based on clinical presentation and ECG).
What are the causes of elevated troponin levels apart from ACS?
Alternative causes include:
* Chronic kidney disease
* Sepsis
* Myocarditis
* Aortic dissection
* Pulmonary embolism
What investigations are performed for ACS?
Investigations include:
* Baseline bloods (FBC, U&E, LFT, lipids, glucose)
* Chest x-ray for pulmonary oedema and other causes
* Echocardiogram to assess heart damage once stable
How is ACS classified based on ECG and troponin?
STEMI: Diagnosed with ST elevation or new left bundle branch block.
NSTEMI: Diagnosed with raised troponin and either a normal ECG or changes (ST depression or T wave inversion).
Unstable Angina: Diagnosed with symptoms of ACS, normal troponin, and either normal or abnormal ECG.
What is the ‘CPAIN’ mnemonic for the initial management of ACS?
‘CPAIN’ mnemonic:
* C: Call an ambulance
* P: Perform an ECG
* A: Aspirin 300mg
* I: Intravenous morphine for pain
* N: Nitrate (GTN)
How should STEMI be managed within 12 hours of onset?
STEMI should be urgently discussed with a cardiac center for:
* PCI (if available within 2 hours)
* Thrombolysis (if PCI is not available within 2 hours)
What are the options for thrombolysis in STEMI?
Fibrinolytic agents used in thrombolysis include:
* Streptokinase
* Alteplase
* Tenecteplase
What is the ‘BATMAN’ mnemonic for managing NSTEMI?
‘BATMAN’ mnemonic:
* B: Base decision on the GRACE score
* A: Aspirin 300mg
* T: Ticagrelor 180mg (or clopidogrel if high bleeding risk)
* M: Morphine for pain relief
* A: Antithrombin therapy (fondaparinux)
* N: Nitrate (GTN)
How is angiography used in NSTEMI?
Angiography is used to assess medium or high-risk patients, based on the GRACE score, for PCI within 72 hours.
What is the ‘6 A’s’ mnemonic for secondary prevention after ACS?
‘6 A’s’ mnemonic:
* A: Aspirin 75mg daily
* A: Another Antiplatelet (ticagrelor or clopidogrel) for 12 months
* A: Atorvastatin 80mg daily
* A: ACE inhibitors (e.g., ramipril)
* A: Atenolol (or other beta-blocker like bisoprolol)
* A: Aldosterone antagonist (e.g., eplerenone) if heart failure present
What complications can occur after a myocardial infarction (MI)?
The ‘DREAD’ complications are:
* D: Death
* R: Rupture (heart septum or papillary muscles)
* E: Heart failure (oEdema)
* A: Arrhythmia and aneurysm
* D: Dressler’s syndrome
What is Dressler’s syndrome?
Dressler’s syndrome is post-MI pericarditis, causing pleuritic chest pain, fever, and pericardial rub. It may lead to pericardial effusion or tamponade and is treated with NSAIDs or steroids.
