Acute Coronary Syndrome and Acute MI Flashcards
Definition of acute coronary syndrome
Any sudden cardiac event suspected or proven to be related to a problem with the coronary arteries
How do the problems of an ACS arise?
Due to myocardial ischaemia
Definition of myocardial ischaemia
Reduction of blood supply of heart muscle
Definition of MI
Cell death due to ischaemia
Major vs minor MI
Major - complete coronary artery occlusion
Minor - partial (or transient complete) coronary artery occlusion
ECG initially then at 3 days in a complete coronary artery occlusion
Initially - ST elevation
3 days - Q waves
ECG initially then at 3 days in a partial coronary artery occlusion
Initially - No ST elevation
3 days - no Q waves
What are the ACS?
Unstable angina
MI (STEMI / NSTEMI)
Sudden cardiac death
What part of the heart is affected in a STEMI?
Q wave MI
Transmural MI
What part of the heart is affected in NSTEMI?
Non Q wave MI
Subendocardial MI
What does STEMI stand for?
ST elevation MI
What does NSTEMI stand for?
Non ST elevation MI
What does a completely occluded artery cause?
Ongoing myocyte death
Non cardiac causes of troponin rise
Pulmonary embolism
Sepsis
Renal failure
SAH
What is troponin?
A group of proteins that help regulate the contractions of the heart and the skeletal muscles
When does the heart release troponin into the blood?
Heart injury e.g. MI
Causes of MI
Coronary atherosclerosis
Coronary vasospasm
Coronary dissection
Embolism of material down coronary artery
Vasculitis of coronary arteries
Radiotherapy to chest causing fibrosis and stenosis of coronary arteries
Who often gets coronary dissection?
Younger, healthier females
Causes of coronary vasospasm
Cocaine
Triptans
5-FU (chemo)
Cardiac risk factors
Male Age Known heart disease High BP High cholesterol DM Smoker FH of premature heart disease
Diagnostic criteria for MI
- Detection of cardiac cell death by +ve cardiac biomarkers
- AND ONE OF
- symptoms of ischaemia
- new ECG changes
- evidence of coronary problem on coronary angioplasm or autopsy
- evidence of new cardiac damage on another test
Presentation of MI
Chest pain - radiating to neck / arm / jaw - may be described as a discomfort - severe pain Nausea Sweating SOB
Causes of chest pain
Cardiac - coronary artery disease - aortic valvular disease - pulmonary HTN - mitral valve prolapse - Pericarditis - idiopathic hypertrophic subaortic stenosis Pulmonary - PE - Pneumonia - Pleuritis - Pneumothorax Emotional - Anxiety - depression Vascular - aortic dissection Neural - herpes zoster MSK - costochondritis - Arthritis - muscular spasm - bone tumour GI - ulcer - bowel disease - hiatus hernia - pancreatitis - cholecystitis
How long do the symptoms of typical angina last of an ACS?
> 20 mins
What would you do if someone presented with ACS chest pain?
- ECG
- ST elevation = STEMI
- No ST elevation……. - After 3 - 4 hours
- Troponin
- if NO - unstable angina, if YES - NSETMI - After 1 - 2 days
- From NSTEMI if Q waves - Qw MI, if no Q waves the NQMI
Treatment for STEMI
Reperfusion - Primary PCI - Pharmacological Angioplasty Thrombolysis
How does angioplasty work?
Expanded balloon in between plaque and the artery
Stent is deployed compressing the plaque
How does thrombolysis work?
Tenecteplase (TNK) given as a bolus
What is the risks of thrombolysis?
Bleeding
Who should thrombolysis not be given to?
Recent stroke Previous intracranial bleeding Caution if - recent surgery - on warfarin - severe HTN
In STEMI, what should be done if can get to cath lab in 2 hours and what if not?
Within 2 hours - Primary PCI
After 2 hours - Thrombolysis then transfer for PCI
Compared to STEMI, NSTEMI patients tend to be…..
Older
More likely to have had previous MI
More likely to have had previous CABG/PCI
May not have clear obvious coronary presentation
Investigations of suspected ACS
Serial ECGs
Bloods
What should be given if admitted with suspected ACS?
GTN
Opiates (e.g. morphine)
What are the antithrombotic drugs?
Heparin
LWMH
Fondaparinux
Example of ACEI
Ramipril