Acute Coronary Syndrome Flashcards
Why does acute coronary syndrome normally occur?
Result of a thrombus from an atherosclerotic plaque blocking a coronary artery.
What are thrombi made up of mostly?
Platelets
Why are antiplatelet drugs useful in ACS?
Thrombi are made up of platelets
What does he right coronary artery supply?
RA
RV
Inferior aspect of the LV
Posterior septal area
Where is the circumflex artery?
Curves around the top, left and back of heart
What does the circumflex artery supply?
LA
Posterior aspect of the LV
Where does the LAD travel?
The left anterior descending artery travels down the middle of the heart
What does the LAD supply?
Anterior aspect of LV
Anterior aspect of the septum
Three types of ACS?
Unstable angina
NSTEMI
STEMI
How you diagnose a STEMI?
ST elevation
New left bundle branch block
What do you do next if there is no ST elevation?
Investigate troponin blood levels
If there is increased troponin or other ECG changes (ST depression/T wave inversion/Path Q waves)?
NSTEMI
What would give the diagnosis of unstable angina?
Chest pain but normal troponin & no pathological changes
Symptoms of ACS?
Central constricting chest pain with
- Nausea/vomiting
- Sweating/clamminess
- Feeling of impending doom
- SOB
- Palpitations
- Pain radiating to jaw and arms
Should be concerned about ACS symptoms if?
They persist at rest for more than 20 mins
What is a silent MI?
Diabetic patients not experiencing typical chest pain for an MI
What would an ECG of a STEMI show?
ST elevation in leads consistent with ischaemia
New left bundle branch block
What would an ECG of -ST depression in specific regions -Deep T wave inversion -Pathological Q waves indicate?
NSTEMI
What part of the heart does the Left coronary artery relate to?
Anterolateral
Which leads does the left coronary artery show?
I, aVL, V3-6
What artery corresponds to the anterior part of the heart?
LAD
Which leads show the anterior part of the heart/LAD?
V1-4
What does the circumflex correspond to?
Lateral part of the heart
Leads 1, aVL, V5-6
What do leads 2,3, aVF correspond to? Part of the heart & artery?
Inferior
2,3, aVF
What is troponin?
Protein found in cardiac muscle
What does a diagnosis of ACS typically require?
Serial troponins 6 or 12 hours after onset
What is a rise in troponin consistent with?
Cardiac ischaemia
Alternative causes of raised troponin?
Chronic renal failure Sepsis Myocarditis Aortic dissection Pulmonary embolism
Investigations for ACS?
All the ones for stable angina: -Physical exam -ECG -FBC -U&Es -LFTs -Lipid profile -HbA1C & fasting glucose -Thyroid function \+ Chest x-ray (for pulm oedema) Echocardiogram (assesses heart damage) CT coronary angiogram (Assess c artery disease)
Treatment of a STEMI if presenting with 12 hours of onset?
Primary= PCI if available within 2 hours of presentation
If PCI not available= Thrombolysis
What is thrombolysis?
Injecting fibrinolytic medication which breaks down fibrin, that rapidly dissolves clot.
Cons of thrombolysis?
Significant risk of bleeding
Agents for thrombolysis?
Streptokinase
Alteplase
tenecteplase
Treatment for NSTEMI?
B- Beta blockers
A- Aspirin 300mg stat dose
T- Ticagrelor 180mg (or clopidogrel 300mg)
M- Morphine titrated for pain
A- Anticoags: Low molecular weight heparin @ treatment dose
N- Nitrates (GTN) to relieve coronary artery spasm
Thing for remembering how to treat an NSTEMI?
BATMAN
Risk assessment to assess if PCI is necessary for a NSTEMI?
GRACE score -gives the 6 month risk of death or repeat MI after NSTEMI <5%= low 5-10%= Medium >10%= High
Consider high and medium for a PCI
Complications of an MI?
D- Death R- Rupture of heart septum/papillary muscles E- oEdema (CHF) A- Arrhyhmia & aneurysm D- Dressler's syndrome
How to remember complications of an MI?
DREAD
Another term for Dressler’s syndrome?
Post MI syndrome
When does Dressler’s syndrome occur?
2-3 weeks after an MI
Why does dressler’s syndrome occur?
Caused by localized immune response & causes pericarditis
How does Dressler’s syndrome present?
Pleuritic pain, low grade fever, pericardial rub on auscultation
What can post MI syndrome cause?
Pericardial effusion
Pericardial tamponade
How to diagnose Dressler’s syndrome?
ECG (global ST elevation & T wave inversion)
Echocardiogram - pericardial effusion
Raised inflammatory markers (CRP/ESR)
Management of Post MI syndrome?
NSAIDS: aspirin/ibuprofen
Steroids: severe cases (prednis)
Pericardiocentesis: removes fluid from around the heart if necessary
Prevention of secondary medical management of ACS?
6 As
Aspirin - 75mg daily
Another anti-platelet- clopidogrel/tecagrelor up to 12 months
Atenolol- or other B blocker titrated as high as tolerated
ACE Inhibitor- Ramipril titrated as tolerated up to 10mg daily
Atorvastatin- 80mg daily
Aldosterone antagonist- for those with CHF
How many types of MI?
5
1: traditional MI due to AC event
2: Ischaemia secondary to increased demand/reduced supply
3: Sudden cardiac death/arrest suggestive of ischaemic event
4: MI associated with procedures such as PI, coronary stenting or CABG
