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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
What are some of the contra- indications for thrombolysis?
Prior intra-cranial haemorrhage, Ischemic stroke within 3 months, recent surgery, suspected aortic dissection, active PUD
26
In what percentage of cases is thrombolysis effective?
50% of cases- long term mortality doubled in 50% of cases
27
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?
Within 2 hours go straigh to PCI centre | If transfer greater than 2 hours, thrombolyse in the community and bring to PCI centre.
28
If thrombolysis fails, what is done next?
Rescue PCI is performed
29
What are good IV anti-emitics to use in ACS?
Cyclazine or metoclopramide
30
What are the complications of a STEMI?
Death Arrhythmia Structural complications Functional complications
31
What does ST elevation and ST depression imply?
ST elevation = infarction | ST depression = ischemia
32
What are the common arrhythmia complications of STEMI?
Ventricular fibrilation/tachycardia
33
What are the structural complications of STEMI?
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
What are some of the functional complications of STEMI?
1) Acute ventricular failure 2) Chronic cardiac failure 3) Cardiogenic shock (inadequate circulation generated)
35
What is Dresslers syndrome?
Auto immune disease following an MI
36
What classifiation is used to grade heart failure post MI?
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
What are the routine observations post STEMI?
``` Cardiac monitor Pulse and BP Heartsounds Pulmonary crepitations New murmours Fluid balance/urine output ```
38
What is pink frothy sputum a sign of?
Pulmonary oedema
39
What is unstable angina?
New onset or deterioration of present angina | Unpridictable pain at rest => dynamic changes and dangerous.
40
Pathophysiology of unstable angina?
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
ECG changes in NSTEMI?
The ECG may be normal | ST depression implies ischemia (high predictor of a bad outcome within 30 days
42
Which troponins are unique to the heart?
Troponin T and I | Troponin C is found in cardiac and skeletal muscle
43
What does troponin release imply?
Myocyte necrosis- measuring platelets breaking of thrombus and blocking the microcirculation of the heart
44
What are the advantages and disadvantages of troponin?
+ 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
What is the treatment for an NSTEMI?
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
What is the pharmacological action of GPIIb/IIIa inhibators?
Prevent fibrinogen binding to platelets
47
How is risk of recurrent cardiac events and mortality assessed?
GRACE score
48
How long is a hospital stay for unclompicated STEMI/NSTEMI?
3 days
49
What are the 4 phases of cardiac rehab?
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
Which healthcare professionals are in the cardiac rehab team?
Cardiac rehab nurses, Physios, Smoking cessation specialists, Pharmacists, nutritionists and clinical psychologists, cardiologists
51
What are the common drugs on discharge?
Antiplatelet Beta blocker ACE inhibitor Statin
52
What is the cholesterol and BP target post MI?
Cholesterol <4mmol/L | BP < 140/90mmHg or <130/80mmHg if diabetic, renal disease or target organ damage

Cardiovascular (24 decks)

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