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Cardiovascular Medicine > Acute Coronary Syndrome > Flashcards

Acute Coronary Syndrome Flashcards

1
Q

What does ACS include?

A
  1. Unstable angina
  2. N-STEMI
  3. STEMI
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2
Q

What is a STEMI?

A
  • An ST elevation myocardial infarction

- A persistent ST segment elevation or new LBBB on their ECG.

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3
Q

What size must the ST elevation be?

How many leads must the ST elevation be in?

A
  • > 1mm in limb leads
  • > 2mm in chest leads
    The STEMI must be present in 2 contiguous leads.
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4
Q

What will hs-TnI level be in a STEMI?

A

> 100ng/L

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5
Q

What will CK level be in STEMI?

A

> 400

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6
Q

What is the pathophysiology of a STEMI?

A

A complete atherothrombotic occlusion of a coronary artery, causing myocardial cell death.

  1. Occurs after an abrupt and catastophic disruption of a cholesterol laden plaque.
  2. This promotes platelet activation and aggregration, thrombin generation and thrombus formation.
  3. This interrupts blood flow in the coronary arteries.
  4. The artherothrombotic occlusion causes myocardial cell necrosis.
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7
Q

What is the pathophysiology of athersclerotic plaques?

A
  1. They form gradually over years, beginning with the accumulation of LDL in the intima of blood vessels.
  2. Leukocytes (macrophages) adhere to the endothelium, then enter the intima and accumulate lipids and become foam cells.
  3. The lesion is called a fatty steak and is proinflammatory.
  4. Smooth muscle cells infiltrate from the media and proliferate.
  5. They deposit extracellular matrix (collagen and elastin) and form a plaque as they undergo apoptosis.
  6. The plaque enroaches on the arterial lumen and causes stenosis, limiting blood flow.
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8
Q

How does an MI cause heart failure?

A
  1. A significant portion of the myocardium undergoes ischaemic injury and cannot perform contractile work.
  2. LV pump volume becomes depressed: CO, SV, BP, compliance is reduce so ESV increases.
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9
Q

How does cardiogenic shock occur?

A

If 40% of the LV myocardium is lost.

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10
Q

After a 12 lead ECG shows ACS, what other ECG leads should you investigate and why?

A
  • V7, V8, V9 (posterior leads) as anterior leads may show ST depression as there is a posterior STEMI.
  • RV3, RV4, RV5, RV6 (right ventricular leads) as RV4 is very sensitive for RV MI.
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11
Q

How would you investigate a suspected MI?

A
  1. ECG
  2. CXR - Cardiomegaly, pulmonary oedema, widened mediastium
  3. FBC, U+E, LFT, glucose, lipids, cardiac enzymes, HbA1C
  4. Echocardiogram - Regional wall abnormalities
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12
Q

What should you keep in mind when interpreting troponin levels?

A
  1. Can rise with other causes of myocardial damage - myocarditis, pericarditis, ventricular strain (troponins likely to change little hour by hour)
  2. Iatrogenic causes of troponin rise - CPR, DC cardioversion, ablation therapy
  3. Non cardiac causes - massive PE causing RV strain, burns, sepsis, SA haemorrhage, renal failure
    - The CHANGE in troponin is more important than the troponin level itself
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13
Q

What are the ECG changes with a STEMI?

A
  1. Hyperacute T waves, ST elevation, new LBBB within hours

2. T wave inversion and pathological Q wave in days

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14
Q

What are some symptoms of an MI?

A

Acute central chest pain lasting over 20 minutes

Nausea, sweatiness, dyspnoea, palpitations

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15
Q

How does a silent MI present?

A

Syncope, pulmonary oedema, epigastric pain and vomiting, post operative hypotension, oliguria, acute confusion, stroke

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16
Q

What are some signs of an MI?

A
  1. Distress, anxiety, pallor, sweatiness
  2. Pulse and BP increased/decreased
  3. Signs of heart failure - Raised JVP, 3rd heart sound, basal crepitations
  4. Pansystolic murmur
  5. Later - pericardial rub and peripheral oedema
17
Q

A patient has had an ECG and is found to have a STEMI - how do you manage them?

A
  1. Get IV access
  2. Pain relief (morphine 2.5m-5mg IV and antiemetic metoclopramide 10mg IV)
  3. Oxygenation (if hypoxic, aim for 94%)
  4. Aspirin (300mg loading chew tablet, then 75mg od for life)
  5. Antiplatelets - Prasugrel 60mg loading, then 10mg OD for 12 months, clopidogrel 600mg loading, then 75mg OD for 12 months if prasugrel unsuitable. Ticagrelor is preferred to clopidogrel.
  6. Primary PCI if available within 120 minutes and within 12hrs of onset, if not consider fibrinolysis.
18
Q

When is prasugrel inappropriate to give as an antiplatelet?

A
  • Patients over 75
  • Previous TIA/stroke
  • Patient weighs under 60kg
19
Q

After immediate management, what can be given for pain relief in ACS?

A
  • GTN spray

- Opiates

20
Q

How can patient risk factors be modified?

A
  1. Stop smoking
  2. Identify and treat diabetes, hypertension and hyperlipidaemia
  3. Diet high in oily fish, fruit, veg and fibre. Low in saturated fat
  4. Encourage daily exercise
  5. Mental health referral
21
Q

What cardioprotective medication should be given after an MI?

A
  1. Antiplatelet - aspirin for life
  2. Second antiplatelet - clopidogrel for 12 months minimum
  3. Anticoagulate until discharge eg fondaparinux
  4. Beta blocker - bisoprolol (not in shock/hypotension) to reduce myocardial O2 demand
  5. Ace-i - If LV dysfunction, HTN, diabetes
  6. High dose statin eg atorvastatin
22
Q

What are risk factors for an ACS?

A

Non modifiable - Age, male, FH of IHD,

Modifiable - Smoking, hypertension, DM, hyperlipidaemia, obesity, sedentary lifestyle, cocaine use

23
Q

What is the management for a NSTEMI or unstable angina?

A
  1. Analgesia - morphine and metoclopramide
  2. Nitrates - GTN prn
  3. Aspirin 300mg loading, 75mg OD
  4. Repeat ECG at regular intervals
    Measure troponin and clinical parameters to risk assess (GRACE score)
    If high risk:
  5. LMWH - Enoxaparin for 48hr
  6. Ticagrelor 180mg loading and 80mg BD
  7. IV nitrates if pain continues
  8. Oral beta blockers eg bisoprolol
  9. Inpatient cardiologist review for angiography
    If low risk:
    - Outpatient investigations eg stress test
24
Q

What will an ECG show with unstable angina and STEMI?

A
  • ST segment depression

- T wave flattening or inversion

25
Q

Name some complications of MI?

A
  1. Cardiac arrest
  2. Cardiogenic shock
  3. Left ventricular failure/Right ventricular failure
  4. Arrythmia
  5. Pericarditis
  6. Systemic embolism
  7. Cardiac tamponade
  8. Mitral regurgitation
  9. Ventricular septal defect

Cardiovascular Medicine (14 decks)

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