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Acute coronary syndrome (ACS) Flashcards

1
Q

What is acute coronary syndrome (ACS)? What are the three types of ACS?

A

Refers to a set of symptoms and signs that occur due to decreased (coronary) blood flow to the heart (cardiac ischaemia) at rest.

Cardiac ischaemia can occur due to athrombus (blood clot) formationfrom anatherosclerotic plaqueblocking acoronary artery.

ACS is a term for a group of conditions such as:
- STEMI
- NSTEMI
- Unstable angina

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2
Q

How does acute coronary syndrome (ACS) present?

A

Chest pain
- sudden, severe
- constant (timing)
- dull
- central or left-sided
- +/- crushing

Pain radiates to the left arm, neck, and jaw.

Pain lasts longer than 15 minutes.

Associated symptoms:
- n+v
- sweating
- clamminess
- SOB
- palpitations
- syncope
- haemodynamically unstable (e.g. systolic BP <90mmHg)

Worsened by exercise/exertion.

May be improved by GTN spray.

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3
Q

Risk factors for acute coronary syndrome (ACS)? Distinguish them as modifiable and non-modifiable.

A

Non-modifiable:
Age
Male sex
Family history
Ethnicity (particularly South Asians)

Modifiable:
Smoking
Hypertension
Hyperlipidaemia
Hypercholesterolaemia
Obesity
Diabetes
Stress
High fat diets
Physical inactivity

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4
Q

What atypical presentations may there be in acute coronary syndrome (ACS)?

A

Epigastric pain
No pain (common in elderly and pts with diabetes)
Acute breathlessness
Palpitations
Acute confusion
Diabetic hyperglycaemic crises
Syncope

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5
Q

What is STEMI (ST-Elevation Myocardial infarction)?

A

Refers to completely occluded coronary artery.

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6
Q

What are the key features to identify STEMI?

A

Chest pain at rest or minimal exertion, lasting >15 minutes

ECG changes (new ST-elevation or left bundle branch block)

Troponin raised (indicates myocardial necrosis)

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7
Q

How do you diagnose STEMI?

A

Clinical diagnosis + ECG + Biochemical findings

Cardiac chest pain at rest
+
ECG
- new persistent ST-segment elevation in 2 or more contiguous leads or LBBB

ST elevation should be:
- ≥2mm in the precordial (V1-V6) leads OR ≥1mm in the limb leads.

(note that there is no need for a troponin in this case).

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8
Q

How is STEMI managed?

A

For emergencies, always follow A-E structure.

Morphine
Metoclopramide
Oxygen (if sats <94%)
Nitrates (GTN spray)
Aspirin 300 mg
Clopidogrel 300 mg

Presenting STEMI within 12hrs of onset:
- PCI (Percutaneous coronary intervention if available within 2 hrs) + Aspirin & Prasugrel (prepare for PCI) (must be haemodynamically stable)

  • if PCI not available in 2hrs →do thrombolysis
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9
Q

What is PCI (Percutaneous coronary intervention)?

A

Involves putting a catheter into the patient’s radial or femoral artery (radial is preferred), feeding it up to the coronary arteries under x-ray guidance and injecting contrast to identify the area of blockage (angiography).

Blockages can be treated using balloons to widen the lumen (angioplasty) or devices to remove or aspirate the blockage.

Usually, a stent is inserted to keep the artery open.

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10
Q

What is thrombolysis?

A

Involves injecting afibrinolyticagent.

Fibrinolytic agents work by breaking down fibrin in blood clots.

There is a significant risk of bleeding, which can make thrombolysis dangerous.

Some examples of thrombolytic agents arestreptokinase,alteplaseandtenecteplase.

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11
Q

What are the contraindications for thrombolysis?

A

AGAINST

Aortic Dissection
GI bleed
Allergic reaction
Iatrogenic: recent surgery
Neurological disease: recent stroke (within 3 months), malignancy
Severe HTN (>200/120)
Trauma, including recent CPR

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12
Q

What is NSTEMI (non-ST elevation myocardial infarction)?

A

Refers to severe but incomplete occluded coronary artery.

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13
Q

What are the key features to identify NSTEMI?

A

Chest pain at rest or minimal exertion lasting >15 minutes

Normal or abnormal ECG
If abnormal:
- new ST-depression of T wave inversion

Troponin raised (due to myocardial necrosis)

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14
Q

How do you distinguish NSTEMI and unstable angina?

A

Troponin level is raised in NSTEMI.

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15
Q

How is NSTEMI diagnosed?

A

Requires two of the following:
- Cardiac chest pain
- Newly abnormal ECG which shows ST depression, T wave inversion or non-specific changes.
- Raised troponin (with no other reasonable explanation)

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16
Q

How is NSTEMI managed?

A

For emergencies, always follow A-E structure.

  1. Offer Aspirin300mg
  2. Offer antithrombin therapy (e.g. fondaparinux, low molecular weight heparin; unless high bleeding risk or immediate angiography)
  3. Calculate GRACE score (predicts 6-month mortality and risk of CVS events)
    - intermediate or higher risk = angiography (with PCI if indicated) AND Ticagrelor (clopidogrel or prasugrel if high bleeding risk)
  • low risk = Ticagrelor (clopidogrel if high bleeding risk) + aspirin and test for ischaemia and assess left ventricular function
    →consider angiography (with PCI if indicated) if ischaemia develops or shown on testing
  1. GTN spray (symptom relief)
  2. IV morphine/diamorphine
17
Q

What is unstable angina?

A

Refers to partial occlusion of a coronary artery.

18
Q

What are the key features to identify unstable angina?

A

Chest pain at rest or minimal exertion lasting >15 minutes

ECG changes
- new ST-depression or T wave inversion

NO rise in troponin (normal): no myocardial necrosis

19
Q

Management for unstable angina?

A

For emergencies, always follow A-E structure.

  1. Offer Aspirin300mg
  2. Offer antithrombin therapy (e.g. fondaparinux, low molecular weight heparin; unless high bleeding risk or immediate angiography)
  3. Calculate GRACE score (predicts 6-month mortality and risk of CVS events)
    - intermediate or higher risk = angiography (with PCI if indicated) AND Ticagrelor (clopidogrel or prasugrel if high bleeding risk)
  • low risk = Ticagrelor (clopidogrel if high bleeding risk) + aspirin and test for ischaemia and assess left ventricular function
    →consider angiography (with PCI if indicated) if ischaemia develops or shown on testing
  1. GTN spray (symptom relief)
  2. IV morphine/diamorphine
20
Q

Is the treatment for NSTEMI and unstable angina the same?

A

Yes

21
Q

What management plan should post-MI patients be started on?

A

Medications:
- Aspirin 75mg OM + second anti-platelet (clopidogrel 75mg OD or ticagrelor 90mg OD)

  • Beta blocker (bisoprolol)
  • ACEi (ramipril)
  • High dose statin (e.g. Atorvastatin 80mg ON -every night)

ECHO (assess systolic function, evidence of heart failure)

Cardiac rehabilitation

Ischaemia testing (if pt had no angiography)

22
Q

Complications of ACE?

A

Ventricular arrhythmia
Recurrent ischaemia/infarction/angina
Acute mitral regurgitation
Congestive heart failure
2nd, 3rd degree heart block
Cardiogenic shock
Cardiac tamponade
Ventricular septal defects
Left ventricular thrombus/aneurysm
Left/right ventricular free wall rupture
Dressler’s Syndrome
Acute pericarditis

23
Q

How is unstable angina diagnosed?

A

Cardiac chest pain at rest

Abnormal/normal ECG

Normal troponin

24
Q

What is GRACE score?

A

GRACE score gives a6-monthprobability ofdeath (mortality)after having an NSTEMI.
- 3% or less is considered low risk
- Above 3%is consideredmediumtohigh risk

Patients at medium or high risk are considered for early angiography with PCI (within 72 hours).

25
Q

What investigations would you do for ACS?

A

ECG

Bloods:
- HbA1c
- FBC
- CRP
- Renal function (U&Es, creatinine, eGFR)
- troponin
- D-dimer
- lipid profile

CXR (pulmonary oedema, pneumothorax)

CVS (10 decks)

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