acute coronary syndrome Flashcards by James Keenlyside

where is heart disease in the causes of death in Scotland

the second most common cause of death in Scotland

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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

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what causes a major MI

due to a complete coronary artery occlusion

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what causes a minor MI

due to a partial (or transient complete) coronary artery occlusion

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on a ECG what are the sings of complete coronary occlusion

initially - ST elevation

at 3 days - Q waves

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on a ECG what are the signs of partial coronary occlusion

initially - no ST elevation

3 days - NO Q waves

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what is classed under acute coronary syndrome

unstable angina

STEMI
NSTEMI

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why is STEMI seen as worse than NSTEMI

it damages the full thickness of the heart (transmural vs subendocardial)

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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

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how can you detect cardiac cell death

troponin - +ve cardiac biomarkers

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what are some non cardiac causes of troponin rise

pulmonary embolism

sepsis

renal failure

sub-arachnoid haemorrhage

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what are the type of MI

type 1
2
3
4a
4b
5

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what is type 1

spontaneous MI - with ischemia - due to primary coronary event ie thrombosis

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what is a type 2 MI

due to imbalance of supply and demand of O2

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what is type 3 MI

sudden cardiac death

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what is type 4a/b MI

associated with coronary intervention(a) or angiogram (b)

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what is type 5 MI

MI associated with CABG

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what can cause type 1 MIs

coronary atherosclerosis
coronary vasospasm
coronary dissection
inflammation of CAs

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what can cause coronary vasospasms

cocaine, triptans (anti-migraine meds)

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what can cause coronary dissection

spontaneous - often young healthy females

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what causes inflammation of the coronary arteries

vasculitis

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what coronary artery occlusion can be easily missed why

LCx (left circumflex coronary artery) as there can be little change on the ECG

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what might be needed to detect a posterior

ECG leads V7, V8, V9

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when are hyperacute T waves seen

at the early stages of complete coronary occlusion

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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