Acute Coronary Syndrome Flashcards
What is ACS
Includes unstable angina or
MI:
STEMI (ACS with ST elevation or new-onset LBBB) or
NSTEMI (Trop +ve ACS with no ST elevation)
ACS diagnosis
Increase in cardiac biomarkers (troponin) and either:
Symptoms of ischaemia
ECG changes of new ischaemia
Development of pathological Q waves
New loss of myocardium
Regional wall motion abnormalities on imaging
Silent ACS patients
Most common in diabetics and elderly
ACS investigations
Troponin
ECG shows ST elevation/ new LBBB within hours, NSTEMI may show ST depression or nothing
CXR may show cardiomegaly, pulmonary oedema or widened mediastinum but don’t delay treatment for it
Echo shows regional wall abnormalities
Troponin limitations
Prolonged elevation in myo/pericarditis so watch change in troponin
SAH, burns, sepsis cause artificial elevation, as does renal failure
ACS longer-term management
Symptom control: GTN for pain Control RFs Cardioprotective medications Revascularisation Driving advice
ACS cardioprotective medications
Fondaparinux until discharge
Aspirin 75mg OD + clopidogrel for 12mths ± PPI
beta-blockade, if CI then verapamil
ACE-i for LV dysfunction, diabetes, HT
Atorvastatin 80mg
Eplerenone in MI pt with heart failure (ejection fraction <40%)
ACS driving guidelines
Normal licenses can drive 1wk after successful angioplasty, 4wks after ACS without successful angioplasty
For lorries/buses must inform DVLA and after functional test results, may be able to work after 6wks
ACS with ST-elevation emergency management
Attach 12 lead ECG
IV access and bloods for trop
Aspirin 300mg + 180mg ticagrelor
Morphine 5-10mg IV + metoclopramide 10mg IV
If STEMI on ECG and PCI available <2h of medical contact, Primary PCI
If not then fibrinolysis + transfer to 1˚ PCI centre for rescue PCI/angioplasty if unsuccessful
Pt without reperfusion treatment should receive fondaparinux
1˚ PCI indications
STEMI pt within 12h of symptoms
Use after 12h if ongoing ischaemia or with specialist advice in stable pt at 12-24h
Thrombolysis indications
Target time <30 mins from admission
>12h post symptoms requires specialist advice
Thrombolysis CI
Previous intracranial haemorrhage Ischaemic stroke <6mths Recent head injury <3wks GI bleeding <1mth Aortic dissection Bleeding disorder
NSTEMI emergency management initial
Sats <90% or breathless then low flow O2
Morphine 5-10mg + Metoclopramide 10mg IV
GTN spray PRN
Aspirin 300mg PO
Measure troponin and risk assess with GRACE score
NSTEMI emergency management high-risk pt
Fondaparinux 2.5mg OD SC
Ticagrelor 180mg PO
IV nitrate if pain continues, maintain systolic BP >100
Oral beta-blocker (bisoprolol 2.5mg OD)
Cardiologist review for angiography
NSTEMI emergency management low risk pt
Repeat troponin
May be discharged with 2˚ prevention
Arrange outpt investigations e.g. stress test
