Acute Coronary Syndrome And Angioplasty

Question 1

Name 3 conditions that ACS covers

Answer 1

Unstable angina

Non ST-segment-elevation myocardial infarction (NSTEMI) - doesn’t show up on an ECG

ST-segment-elevation myocardial infarction (STEMI) - shows on the ECG

Question 2

What are the signs and symptoms of myocardial ischaemia?

Answer 2

Central chest pain
Crushing or constricting in nature
Persists for more than 15 minutes
Pain may also be present in the shoulders, upper abdo or referred to the neck/jaw/arm

Question 3

What other signs and symptoms can feature in myocardial ischaemia?

Answer 3

Nausea and vomiting
Marked sweating
Breathlessness
Pallor
Combination of chest pain associated with haemodynamic instability (dropped blood pressure)
Feeling of impending doom
Clammy and cold to touch

Question 4

What patients are more prone to myocardial ischaemia?

Answer 4

Younger (25-40yrs) - Asian males
Older generation (over 75yrs)
Unwell diabetics
Unwell female patients

Question 5

Explain what Acute Coronary Syndrome (ACS) is?

Answer 5

ACS occurs when there is an abrupt reduction (narrowing) or cessation (stopping) in blood supply to the muscle of the heart, leading to myocardial ischaemia (lack of oxygen to tissue)

Question 6

What are the signs and symptoms of Unstable angina?

Answer 6

Angina of effort increasing frequency and provoked by less exertion
Angina occurring recurrently and unpredictably - not specific to exercise
Unprovoked and prolonged episode of chest pain - no ECG evidence of MI (myocardial infarction)
Woke up with pain

Question 7

What is Acute Myocardial Infarction?

Answer 7

Cardiac muscle is deprived of coronary blood flow enough to cause portions of the muscle to die.

Question 8

What can slow the blood flow through the coronary vessels?

Answer 8

Thrombus in coronary artery
Spasm in coronary artery
Reduced overall blood flow i.e PE (pulmonary embolism) arrhythmia (not normal heart rhythm)
Shock

Question 9

What are the aims in ACS?

Answer 9

Reduction of myocardial necrosis in patients with on going infarction - lost minutes = Lost heart muscle
Get the patient to hospital quickly
Prevention of major adverse cardiac events
Rapid defibrillation when ventricular fibrillation (V Fib) occurs

Question 10

What do all ACS’s have in common?

Answer 10

All have sudden ischaemia
Can not be differentiated in the first few hours
All have the same initiating signs and symptoms

Question 11

What are the factors that can increase infarction?

Answer 11

Plaque rupture
Myocardial oxygen demand
Coronary vasoconstriction
Thrombus formation
Collateral circulation

Question 12

Diagnosis of ACS

Answer 12

Clinical presentation - signs and symptoms
ECG
Imaging evidence of loss of viable myocardium (ultra sound)
Cardiac markers
Raised blood sugars if not diabetic (above 9)

Question 13

When would you take a patient to a Heart Attack Centre (cathlab)?

Answer 13

Patients with chest pain or tightness suggestive of ACS that is sustained for more than 20 mins and has occurred at any time within the last 9 minutes. This includes indigestion type pain.

Question 14

When would you take a patient into a Heart Attack Centre?

Answer 14

When 12 lead ECG showing clear ST segment elevation
ROSC (return of spontaneous circulation) in whom the post arrest 12 lead ECG shows clear ST elevation regardless of GCS (consciousness level)
New LBBB (left bundle branch block)
Silent MI or MI with atypical presentation
High risk ACS

Question 15

What is the ACS Care Bundle

Answer 15

Aspirin
GTN
2 pain scores (pre and post intervention)
Analgesia (entonox)
Don't forget a BM!

Question 16

What are the therapeutic effects of Aspirin?

Answer 16

Anti-platelet action (like Teflon) which reduces clot formation
Analgesic (pain killer), anti-pyretic (brings temperature down) and anti-inflammatory

Question 17

What are the indications for giving Aspirin?

Answer 17

Clinical or ECG evidence suggestive of MI or ischaemia

Question 18

What are the contraindications for giving Aspirin?

Answer 18

Known aspirin allergy or sensitivity
Children under 16 years
Active gastrointestinal (GI) bleeding (ulcer)
Haemophilia or other known clotting disorders
Severe hepatic disease

Question 19

What is the dose and how do you administer aspirin?

Answer 19

300mg tablet

Chew it

Question 20

What are the side effects of Aspirin?

Answer 20

Gastric bleeding

Wheezing in some asthmatics

Question 21

What patients can you still give Aspirin to, as the benefits outweigh the potential risks?

Answer 21

Asthma 
Pregnancy
Kidney or liver failure
Gastric or duodenal ulcer
Current treatment with anticoagulants

Question 22

What are the therapeutic effects of Glyceryl Trinitrate (GTN)?

Answer 22

Dilation of coronary arteries/relief of coronary spasm
Dilation of systemic veins resulting in lower preload
Reduced blood pressure

Question 23

What are the indications of GTN?

Answer 23

Cardiac chest pain due to angina or MI

Acute cardio genie pulmonary oedema

Question 24

What are the contraindications of GTN?

Answer 24

Hypotension
Hypovolaemia
Head trauma
Cerebral haemorrhage
Sidenafil (viagra) or related drug taken within 24 hours
Unconscious patients

Question 25

What are the side effects of GTN?

Answer 25

Throbbing headache
Flushing
Dizziness
Postural hypotension
Tachycardia

Question 26

What is the dose and how do you administer GTN?

Answer 26

1 x 400mcg spray
Sprayed under the tongue

The effect of the first dose should be assessed over 5 mins, further doses can be administered provided the systolic blood pressure is less than 90mmHg