acute coronary syndrome Flashcards
where is heart disease in the causes of death in Scotland
the second most common cause of death in Scotland
what is acute coronary syndrome
Any sudden cardiac event suspected or proven to be related to a problem with the coronary arteries
leading to myocardial ischemia
what causes a major MI
due to a complete coronary artery occlusion
what causes a minor MI
due to a partial (or transient complete) coronary artery occlusion
on a ECG what are the sings of complete coronary occlusion
initially - ST elevation
at 3 days - Q waves
on a ECG what are the signs of partial coronary occlusion
initially - no ST elevation
3 days - NO Q waves
what is classed under acute coronary syndrome
unstable angina
MI
STEMI
NSTEMI
why is STEMI seen as worse than NSTEMI
it damages the full thickness of the heart (transmural vs subendocardial)
how do you diagnose a MI
detection of cardiac cell death
and one of the following
symptoms of ischemia
new ECG changes
evidence of coronary problems
how can you detect cardiac cell death
troponin - +ve cardiac biomarkers
what are some non cardiac causes of troponin rise
pulmonary embolism
sepsis
renal failure
sub-arachnoid haemorrhage
what are the type of MI
type 1 2 3 4a 4b 5
what is type 1
spontaneous MI - with ischemia - due to primary coronary event ie thrombosis
what is a type 2 MI
due to imbalance of supply and demand of O2
what is type 3 MI
sudden cardiac death
what is type 4a/b MI
associated with coronary intervention(a) or angiogram (b)
what is type 5 MI
MI associated with CABG
what can cause type 1 MIs
coronary atherosclerosis
coronary vasospasm
coronary dissection
inflammation of CAs
what can cause coronary vasospasms
cocaine, triptans (anti-migraine meds)
what can cause coronary dissection
spontaneous - often young healthy females
what causes inflammation of the coronary arteries
vasculitis
what coronary artery occlusion can be easily missed why
LCx (left circumflex coronary artery) as there can be little change on the ECG
what might be needed to detect a posterior
ECG leads V7, V8, V9
when are hyperacute T waves seen
at the early stages of complete coronary occlusion
what are the cardiac risk factors
male old known Heart disease High BP high cholesterol diabetes smoker fam history
what is the treatment for STEMI
to get the coronary artery open ASAP
reperfusion therapy
what are the two types of reperfusion therapy
mechanical in the cath lab - primary PCI
pharmacological
what are the pharmacological treatments that can be used
thrombolysis - tenecteplase (TNK) given as a bolus
what are the risks of thrombolysis
bleeding
don’t give if recent stroke, previous intercranial bleed
caution if have had warfarin
what does PCI stand for
percutaneous coronary intervention
what does PCI do
treats coronary stenosis
expand a balloon and deploy a stent to press the plaque out and widen the artery
what is your preffered treatment for a STEMI
PCI if can get to a cath lab in under 2 hours
what are the pros and cons of thrombolysis
works if gioven early
more likely to cause bleeding
may not wotk - especially if there is delayed presentation
compared to STEMI what are NSTEMI patients more likely to be
older
more likely to have had previous MI
more likely to have had previous CABG/PCI
may not be as clear presentation
what pharmacological drugs can be given
antiplatelet drugs thrombolytic drugs beta blockers statin ACE inhibitors
what are exampels of anti platlet drugs
aspirin
ticagrelor
what are examples of anit-thrombotic drugs
heparin
low molecular weight heprin
FONDAPARINUX
what does CABG stand for
coronary artery bypass graft
what are the complications after a MI
arrhythmia
mechanical - cardiogenic shock, myocardial rupture
valve dysfunction - papillary muscle rupture
AV septal defect
what is the post operative care needed for PCI and stents
need dual anti platelet therapy
for up to 12 months
premature discontinuation of DAPT is fatal
how do thrombolytic agents work
by converting plasminogen to the natural fibrinolytic agent plasmin.
what does plasmin do
lyses clot by breaking down the fibrinogen and fibrin contained in a clot
what is a example of a thrombolytic agent
alteplase,
what are some contraindications for thrombolytic agents
active bleeding
prior intercranial haemorrhage
previous stroke in 3 months
what are the benefits of thrombolytic drugs
23% reduction in mortality
how does a 23% reduction in mortality
increase
when used with aspirin to 39%
what is the treatment for ACS with STEMI
thrombolytic agent with aspirin
what is the treatment for ACS with no STEMI (therefore NSTEMI)
aspirin
Tigagrelor/Clopidogrel
LMW heparin
Intravenous nitrate
Analgesia
Beta Blockers
what are the benefit of regular uses of antiplatelet therapy (aspirin)
reduction in MI mortality 20%
reduction of mortality in general for CV diseases
what is clopidgrel
a prodrug
stops platelet activation
what should you always do with clopidogrel
use it in combination with aspirin (DAP)
what are beta blockers used for
treatment of MI
secondary prevention of further MIs
what do beta blockers do
reduce myocardial O2 consumption
what are STEMIs likely to be
coronary thrombus
what is the problem with clopidigrel
14% of the population are resistant
if a patient is at risk of developing cardiogenic shock what should you do
NOT GIVE THEM BETA BLOCKERS
what is cardiogenic shock
severely damaged heart - often by MI - cant pump blood
what are some ECG sings for a NSTEMI and unstable angina
ST elevation
what are the symptoms of stable angina
central chest tightness, often radiating to the neck/ arms
aggravated by exertion and stress
when do ACS (acute coronary syndromes) occur compared to stable angina
ACS symptoms will always be at rest stable angina sometimes on exertion
when is cardiac troponin detected
when the myocyte integrity is compromised
what is the immediate treatment of unstable angina and NSTEMI
ABCDE
MONA
what does MONA stand for
morphine
oxygen
nitro-glycerine (GTN)
aspirin (DAPT)
what is asprin - what is it used with
antiplatelet therapy
clopidogrel
what is the pathophysiology of STEMI
necrosis of myocardial tissue caused by coronary occlusion
what is the primary treatment for STEMI
fibrinolysis or primary PCI (Percutaneous Coronary Intervention)
when is PCI most effective
within 90mins
what are the 2ndry treatments for STEMI
aspirin and clopidogrel
beta blockers
what is the main complication of MI
free wall rupture
