Acute coronary syndrome Flashcards
What does acute coronary syndrome cover?
- ST elevation myocardial infarction (STEMI)
- non-ST elevation myocardial infarction (NSTEMI)
- unstable angina
How is chest pain in ACS usually described?
Chest pain:
- typically central/left-sided
- may radiate to the jaw or the left arm
- ‘heavy’ or constricting, ‘like an elephant on my chest’
- in real clinical practice patients present with variety of types of chest pain :. confuse ischaemic pain for other causes e.g. dyspepsia
- diabetics/elderly may not experience any chest pain
What are other symptoms of ACS?
- dyspnoea
- sweating
- nausea and vomiting
What are signs of ACS?
- pulse, blood pressure, temperature and oxygen saturations are often normal or only mildly altered e.g. tachycardia
- if complications of the ACS have developed e.g. cardiac failure then clearly there may a number of findings
- the patient may appear pale and clammy
What are the two most important investiogations in ACS?
- ECG
- cardiac markers e.g. troponin
Which leads correlate to the arteries of the heart plus view?
Anterior: V1-V4 = Left anterior descending
Inferior: II, III, avF = Right coronary
Lateral: I, V5-6 = Left circumflex
How do you manage ACS?
- prevent worsening of presentation (i.e. further occlusion of coronary vessel)
- revascularise (i.e. ‘unblock’) the vessel if occluded (patients presenting with a STEMI)
- treat pain
Morphine
Oxygen (if sats <94%)
Nitrates
Aspirin
How do you manage a STEMI?
How do you manage NSTEMI?
What is the secondary prevention of ACS?
- aspirin
- a second antiplatelet if appropriate (e.g. clopidogrel)
- a beta-blocker
- an ACE inhibitor
- a statin
When would you not give fondaparinux in NSTEMI?
- If angiography likely within 24 hours
- Patients creatinine is > 265 µmol/l
Unfractionated heparin should be given instead
When is prasugrel preferred? How long do you continue antiplatelet therapy?
- If the patient is going to have a percutaneous coronary intervention
- Generally given to all patients and continued for 12 months
- vary according to bleeding/ischaemic risk.
When are Intravenous glycoprotein IIb/IIIa receptor antagonists(eptifibatide or tirofiban) given in NSTEMI?
- scheduled to undergo angiography within 96 hours of hospital admission
- intermediate or high risk of adverse cardiovascular events
What is the mechanism of aspirin?
Antiplatelet - inhibits the production of thromboxane A2
What is the mechanism of clopidogrel?
Antiplatelet - inhibits ADP binding to its platelet receptor