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Cardiovascular > Acute Coronary Syndrome ACS > Flashcards

Acute Coronary Syndrome ACS Flashcards

1
Q

What is Angina Pectoris?

A

Stable angina: fixed stenosis of coronary arteries due to atheromatous plaque.
Demand lead ischemia- occurs during exercise/stress
Predictable and safe

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2
Q

What advice is given to someone when they have an angina attack?

A

Stop, sit and spray
Stopping and sitting will reduce the oxygen demand of the heart and GTN spray will reduce the BP and afterload on the heart)

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3
Q

What is ACS?

A

Any acute presentation of coronary artery disease. Its a previsional diagnosis which covers a spectrum of diseases including STEMI, NSTEMI and unstable andgina

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4
Q

When do ACSs occur?

A

When there is plaque rupture and thrombosis => dynamic stenosis with sub total or total occlusion.
Supply lead ischemia. Unpredictable and dangerous

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5
Q

Coronary arteries are end arteries. What is meant by this term?

A

Any area is only supplied by one artery

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6
Q

What factors can increase the likelihood of plaque rupture?

A 
High lipid content of plaque
Thin fibrous cap
Sudden changes in intraluminal pressure 
Bending and twisting arteries including heart contraction
Mechanical injury and plaque shape
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7
Q

What causes platelets to adhere to the site of endothilial injury?

A

Exposed subendothilial collagen, tissue factor and von Willebrands Factor

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8
Q

How are platelets activated and what substances are released from activated platelets?

A

Activated by a conformational change and begin to extend pseudopodia.
ADP is released through platelet degranulation
TXA2 is generated by by COX enzyme

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9
Q

Why does ST elevation happen?

A

The death of monocytes leads to the failure of the Na+/K+ pump meaning that resting potential is not well established

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10
Q

What would you discover in an ACS history?

A

Acute, severe, central crushing chest pain radiating to the arm and jaw (esp left)
Similar to angina but prolonged and not relieved by GTN
Associated with sweating, nausea and vomiting

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11
Q

Signs of an STEMI on ECG

1) Acutely?
2) After 24 hours?
3) Any previous MI?

A

1) ST elevation within first few hours
2) Pathological Q wave formation and T wave inversion
3) Pathological Q waves +/- inverted T waves

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12
Q

What are the parameters for ST elevation in a STEMI?

A

> 1mm ST elevation in 2 adjacent limb leads
2mm ST elevation is 2 or more adjacent precordial leads
New onset bundle branch block

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13
Q

ST elevation in Leads 2, 3 and aVF. Where is the MI and which artery is effected?

A

Inferior MI affecting the Right coronary artery

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14
Q

ST elevation in Leads 2, aVL and V5-6. Where is the MI and which artery is effected?

A

Lateral MI effecting the Left circumflex artery

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15
Q

ST elevation in V1-4. Where is the MI and which artery is effected?

A

Anterioseptal MI effecting the left anterior descending artery

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16
Q

ST elevation in Leads 2, aVL, V3-6. Where is the MI and which artery is effected?

A

Anteriolateral MI effecting the Left circumflex or LAD

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17
Q

Which cardiac enzyme is no longer used in ACS diagnosis?

A

Creatinine Kinase (peaks within 24 hours)

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18
Q

Which protein marker is used in ACS diagnosis?

A

Troponin- highly specific for cardiac muscle cells

TnI will be the most sesitive but TnT can be used also. Will peak in about 6 hours

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19
Q

How is a STEMI treated immediately?

A 
Morphine and antiemitic
Oxygen if hypoxic
Nitrates (GTN if BP > 90mmHg)
Asprin- 300mg tablet (chew it)
\+Ticagrelor 180mg (Clopidogrel 300mg can be used)
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20
Q

What is the pharmacological action of asprin?

A

COX 1 antagonist so prevents production of TXA2

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21
Q

What is the pharmacological action of ticagrelor?

A

P2Y12 antagonist so prevents ADP binding to platelets to activate them

22
Q

What is the pharmacological action of clopidegrel?

A

P2Y12 antagonist so prevents ADP binding to platelets to activate them

23
Q

What can be used to thrombolyse a patient?

A

Streptokinae or tissue plasminogen activator (tPA)

24
Q

Can paramedics give thrombolysis pre-hospital?

A

Yes but often they don’t for fear of haemorrhage

25
Q

What are some of the contra- indications for thrombolysis?

A

Prior intra-cranial haemorrhage, Ischemic stroke within 3 months, recent surgery, suspected aortic dissection, active PUD

26
Q

In what percentage of cases is thrombolysis effective?

A

50% of cases- long term mortality doubled in 50% of cases

27
Q

Within what time frame should you be taken straight to a PCI centre and what should be done if the transfer time is greater than this?

A

Within 2 hours go straigh to PCI centre

If transfer greater than 2 hours, thrombolyse in the community and bring to PCI centre.

28
Q

If thrombolysis fails, what is done next?

A

Rescue PCI is performed

29
Q

What are good IV anti-emitics to use in ACS?

A

Cyclazine or metoclopramide

30
Q

What are the complications of a STEMI?

A

Death
Arrhythmia
Structural complications
Functional complications

31
Q

What does ST elevation and ST depression imply?

A

ST elevation = infarction

ST depression = ischemia

32
Q

What are the common arrhythmia complications of STEMI?

A

Ventricular fibrilation/tachycardia

33
Q

What are the structural complications of STEMI?

A

1) Cardiac rupture- rupture of the free wall of the ventricle => blood in the pericardium
2) Ventricular Septal Defect- blood moving from left to right ventricle => heart failure and pulmonary oedema
3) Mitral valve regurgitation- fluid overload and pulmonary oedema
4) Left ventricualr anneurysm fomation
5) Mural thrombosis +/- systemic emboli
6) Inflammation
7) Acute pericarditis
8) Dressler’s syndrome

34
Q

What are some of the functional complications of STEMI?

A

1) Acute ventricular failure
2) Chronic cardiac failure
3) Cardiogenic shock (inadequate circulation generated)

35
Q

What is Dresslers syndrome?

A

Auto immune disease following an MI

36
Q

What classifiation is used to grade heart failure post MI?

A

Killip classification. Grades 1-4. Effects mortality

1) No signs of heart failure
2) Crepitations <50% of lung fields
3) Crepitations >50% of lung fields
4) Cardiogenic shock

37
Q

What are the routine observations post STEMI?

A 
Cardiac monitor 
Pulse and BP
Heartsounds 
Pulmonary crepitations 
New murmours 
Fluid balance/urine output
38
Q

What is pink frothy sputum a sign of?

A

Pulmonary oedema

39
Q

What is unstable angina?

A

New onset or deterioration of present angina

Unpridictable pain at rest => dynamic changes and dangerous.

40
Q

Pathophysiology of unstable angina?

A

Plaque rupture and haemorrhage into the plaque and smooth muscle contraction
Instability implies the clot is being built up and then broken down in a cycle involving tPA

41
Q

ECG changes in NSTEMI?

A

The ECG may be normal

ST depression implies ischemia (high predictor of a bad outcome within 30 days

42
Q

Which troponins are unique to the heart?

A

Troponin T and I

Troponin C is found in cardiac and skeletal muscle

43
Q

What does troponin release imply?

A

Myocyte necrosis- measuring platelets breaking of thrombus and blocking the microcirculation of the heart

44
Q

What are the advantages and disadvantages of troponin?

A

+ Helps to distinguish acute from chronic events
- Can also be elevated in CCF, Hypertensive crisis, Renal Failure, PE, Sepsis, stroke/TIA, peri/myocarditis and post arrhythmia

45
Q

What is the treatment for an NSTEMI?

A

Immediate = Asprin 300mg + Ticagrelor 180mg
Anticoagulants = LMWH or Fondaparinux
GPIIb/IIIa inhibators = Tirofiban or Abciximab
PCI = people at medium to high risk of recurrent cardiac events

46
Q

What is the pharmacological action of GPIIb/IIIa inhibators?

A

Prevent fibrinogen binding to platelets

47
Q

How is risk of recurrent cardiac events and mortality assessed?

A

GRACE score

48
Q

How long is a hospital stay for unclompicated STEMI/NSTEMI?

A

3 days

49
Q

What are the 4 phases of cardiac rehab?

A

1) In patient- cardiac rehab nurses
2) Early post discharge- cardiac nurse home visit/telephone
3) Structured exercise programme- hospital based
4) Long term lifestyle change- community based

50
Q

Which healthcare professionals are in the cardiac rehab team?

A

Cardiac rehab nurses, Physios, Smoking cessation specialists, Pharmacists, nutritionists and clinical psychologists, cardiologists

51
Q

What are the common drugs on discharge?

A

Antiplatelet
Beta blocker
ACE inhibitor
Statin

52
Q

What is the cholesterol and BP target post MI?

A

Cholesterol <4mmol/L

BP < 140/90mmHg or <130/80mmHg if diabetic, renal disease or target organ damage

Cardiovascular (24 decks)

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