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Year 3 - CR > Acute coronary Syndrome and Myocardial infarction > Flashcards

Acute coronary Syndrome and Myocardial infarction Flashcards

1
Q

What is the definition of an MI

A

Rise and/or fall of troponin with at least one value >99th percentile of the URL, plus at least one of the following:

  • Cardiac chest pain
  • ECG changes (new ST-T change or new LBBB)
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2
Q

What are the two types of AMI

A
  • STEMI

- NSTEMI - unstable angina

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3
Q

Describe what happens in an NSTEMI

A
  • ruptured coronary plaque with subocclusvie thrombus

- ECG non diagnostic

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4
Q

Describe what happens in a STEMI

A
  • Ruptured coronary plaque with occlusive thrombus

- ECG diagnostic

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5
Q

What troponin is used in to see if you have an MI

A

Troponin I and T

- specific to the heart

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6
Q

What are the classifications of AMI

A

Type 1

  • spontaneous AMI
  • due to plaque rupture

Type 2

  • ischaemic imbalance
  • due to coronary spasm, embolism , dissection, hypotension

Type 3

  • cardaic death
  • due to presumed AMI

Type 4a

  • related to PCR
  • greater than 5 times URL for troponin

Type 4b

  • caused by stent thrombosis
  • confirmed at angiography or autopsy

Type 5

  • related to CABG
  • greater than 10 times URL for troponin
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7
Q

how many people die from AMI before they reach to hospital

A

33% of people who die from AMI do so before they reach hospital

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8
Q

who delays in calling for help with an AMI

A
  • Older people
  • Women
  • Nocturnal or w/e pain
  • No previous AMI
  • People with diabetes
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9
Q

what are the determinants of infarct size

A

Anatomical

  • distribution of occluded artery
  • proximity of coronary occlusion
  • collateralization of occluded artery

Physiological

  • thrombotic response to plaque rupture
  • effectiveness of endogenous thrombolysis

Therapeutic

  • reperfusion therapy
  • antiplatelet drugs
  • drugs to protect against LV remodelling

Logistical

  • time to call for help
  • time to arrive at hospital
  • time to delivery of reperfusion therapy
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10
Q

If the

  • circumflex
  • RCA
  • LAD

is damaged where is the STEM on the ECG

A
  • circumflex = lateral STEMI
  • RCA = Inferior STEMI
  • LAD - anterior STEMI
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11
Q

What is the pathway when a patient comes in complaining of chest pain

A
  1. Do an ECG = if it is diagnostic then Admit
  2. if ECG is non diagnostic then do a clinical assessment = if there is typical chest pain or heart failure or unstable rhythm then admit
  3. if there is atypical Chest Pain and rhythmically and haemodynamically stable then look at biomarkers
  4. if biomarkers are troponin positive then admit
  5. if biomarkers are troponin negative then the patient is a low risk patient
    - send them home and consider a further out patient investigation
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12
Q

how is troponin used to rule out AMI in A and E

A
  1. Allows diagnostic thresholds to be set at very low levels
  2. Improves diagnostic sensitivty
  3. Endorsed by NICE for accelerating diagnostic pathways and reducing pressure on beds
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13
Q

How do you treat a STEMI

A
  • Aspirin and ticagrelor (P2Y12 receptor antagonists)
  • GpIIb/IIIa inhibitor
  • unfractionated/LMWH
  • PPCI
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14
Q

What type of drug is ticagrelor

A

P2Y12 receptor antagonists

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15
Q

What is the guidelines for treating a NSTEMI

A 
Low risk 
- aspirin 300mg 
- fondaparinux 
- ticagrelor 300mg 
Then conservative management

Intermediate risk 3-6%

  • aspirin 300mg
  • fondaparinux
  • ticagrelor 300mg
  • consdier tirofiban/eptifibatide for intermiediate or high risk groups
  • Coronary angiogram within 96 hours or earlier for unstable patients - PCI or CABG

High risk greater than 6%

  • aspirin 300mg
  • fondaparinux
  • ticagrelor 300mg
  • consdier tirofiban/eptifibatide for intermiediate or high risk groups
  • Coronary angiogram within 96 hours or earlier for unstable patients - PCI or CABG
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16
Q

If you have a STEMI what do you get immediately

A
  • Coronary angiography - then PCI or CABG
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17
Q

What are the two important complications in an MI (IMPORTANT - IN EXAM)

A
  • Heart failure

- Arrhythmia

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18
Q

How do you treat heart failure

A

Diuretics
• IV frusemide
• Haemofiltration if
diuretic resistant

RAS Inhibition
• ACE-I or ARB
• Eplerenone

Inotropes
• Noradrenaline
• Dobutamine

LV support device
• Balloon pump?
• LVAD?

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19
Q

name the two types of Arrhythmia

A

Bradyarrhythmias

Tachyarrhythmias

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20
Q

Describe how an AV node block and complete AV node block

A

rate of depolarisation goes from fast, slower, much slower as you get down

  • depending on where the conduction system is damaged it determines how serious it is
  • if you have a block at the AV node that is not a DT - pacemaker in the bundle of his will take over - the patient will feel fine - usually gets better on its own
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21
Q

How do you treat intermittent AV node block and complete AV node block

A
  • Atropine if rate slow
  • pacing rarely needed
  • sponteaneous recovery in less than 7 days
  • prognosis is good
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22
Q

What happens if both bundle branches blocked

intermittent block of both bundle branches and complete block of both bundle branches

A
  • large infarct
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23
Q

What causes blockage of the AV node

A

inferior MI

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24
Q

How do you treat intermittent block of both bundle branches and complete block of both bundle branches

A
  • Pacing mandatory
  • no spontaneous recovery
  • prognosis poor
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25
Q

Name some types of tachyarrythmias

A
  • atrial fibrillation

- VT, VF

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26
Q

How do you treat an atrial fibrillation

A
  • Beta blocker
  • DV cardioversion if haemodynamic compromise
  • if arrhythmia persists needs anticoagulation with later consideration of rate vs rhythm control
27
Q

What is the difference between early and late ventricular tachyarrhythmias

A
  • ventricular tachyarrhythmias that complicate AMI usually occur in the first 12-24 hours when if corrected they have only minor prognostic impact
  • but if late VT/VF after 24 hours presentation are a bad prognostic sign are predictive of sudden death in the first year
28
Q

what treatment is for life expect

A

except P2Y12 receptor antagonist = ticagrelor

29
Q

what is the prevention lifestyle

A
  • smoking
  • diet
  • exercise
30
Q

What are the prevention drugs

A
  • aspirin 75mg and a second antiplatlet e.g. clopidogrel for at least 12 months to decrease stroke
  • P2Y12 receptor antagonist
  • statin
  • beta-blocker - reduce myocardial oxygen demand
  • ACE-I - in patients with LV dysfunction, hypertension or diabetes unless not tolerated
31
Q

Name prevention devices

A

ICD

32
Q

Name the life saving strategies in AMI

A
  1. Pre-hospital death from 1° VF–33% of all deaths
     get the patient to a defibrillator ASAP
  2. Hospital death from LVF–directly related to infarct size
     initiate reperfusion therapy ASAP
  3. Late deaths–variably related to infarct size a) Recurrent ischaemic events
     2° prevention therapy

b) Lethal arrhythmias
 implantable defibrillator in selected cases

33
Q

What is the definition of acute coronary syndrome

A

The term ‘acute coronary syndromes’ (ACS) encompasses a range of conditions including unstable angina, non-ST-segment-elevation myocardial infarction (NSTEMI) and ST-segment-elevation myocardial infarction (STEMI) that are due to a sudden reduction of blood flow to the heart.

34
Q

What conditions can acute coronary syndrome include

A

includes unstable angina and MIs, which share a common underlying pathology – plaque rupture, thrombosis and inflammation

35
Q

What leads to a diagnosis of an Acute coronary syndrome

A
  • increase in cardiac biomarkers (troponin)

Either

  • symptoms of ischaemia
  • ECG changes of new ischaemia
  • development of pathological Q waves
  • loss of myocardium
  • regional wall motion abnormalities on imaging
36
Q

What are the symptoms of acute coronary syndrome

A
  • acute central chest pain lasting longer than 20 minutes
  • nausea
  • sweating
  • dyspnoea
  • palpitations

ACS without chest pain mostly seen in diabetic patients

  • syncope
  • pulmonary oedema
  • epigastric pain
  • vomiting
  • post op hypotension or oliguria
  • acute confusional state
  • stroke
  • diabetic hyperglycaemic states
37
Q

What are the signs of acute coronary syndrome

A
  • distress
  • anxiety
  • pallor
  • sweatiness
  • pulse raised or not
  • BP either hypertensive or hypotensive
  • 4th heart sound

May be signs of

  • heart failure = Raised JVP, 3rd heart sound, basal crepitations
  • pan systolic murmur
  • low grade fever
38
Q

What are differential diagnosis for retrosternal chest pain

A
  • GORD
  • Biliary colic
  • pancreatitis
  • MI
39
Q

List the investigations that can be used to confirm the diagnosis of ACS

A
  • ECG
  • CXR
  • Blood
  • Cardiac enzymes
  • Echo
40
Q

What does an ECG look like in a STEMI

A 
STEMI 
within hours 
- hyper acute tall T waves 
- ST elevation 
- new LBBB
hours to days 
- pathological Q wave 
- T wave inversion
41
Q

What does an ECG look like in an NSTEMI

A
  • ST depression
  • T wave inversion
  • non specific changes or normal
42
Q

Name 5 cardiac enzymes

A
  • Creatine kinase
  • CK cardiac isoenzyme
  • Aspartate transaminase
  • lactate dehydrogenase
  • cardiac troponin
43
Q

Name when the cardiac enzyme rises and for how long they remain high

A

Troponin

  • goes to x50 of normal in first few hours
  • remains high for 3 days and then starts to decrease until day 10 when it is normal

CK-MG

  • goes high and peaks in 1 and a half days since MI
  • falls to normal by half way through 2nd day

CK
- goes high and peaks around 2 days and then is normal by 3rd day

AST
- increases after 1 day and is normal by day 3

LDH
- increases from day 2 and slowly decreases till normal at day 10

44
Q

IN terms of revascualrisation what is the difference between STEMI and NSTEMI

A
  • STEMI - receive immediate angiography and PCI
  • NSTEMI who are at high risk have angiography within 24 hours, immediate risk within 3 days and low risk may be considered for non invasive testing
45
Q

What are the indications for CABG

A

Improve survival

  • left main stem disease
  • triple-vessel disease involving proximal part of the LAD

Relieve symptoms

  • angina unresponsive to drugs
  • unstable angina
  • if angioplasty is unsuccessful
46
Q

How does CABG work

A
  • heart is stopped
  • cardiac bypass
  • patients own saphenous vein or internal mammary artery is used as the graft
47
Q

What vessels are used as the graft in CABG

A
  • saphenous vein

- internal mammary artery

48
Q

How do you take a sublingual GTN

A
  • used under the tongue
  • either in tablet or spray form

Tablet
- 1 tablet under tongue as soon as possible, if still in pain 5 minutes later put another tablet and then if still in pain after 5 more minutes put another tablet

Spray
- 1 or 2 sprays under your tongue. If you’re still in pain after 5 minutes you can have a second dose of 1 or 2 sprays under your tongue. If you’re still in pain after 5 minutes you can have a third and final dose

49
Q

What are the side effects of sublingual GTN

A
  • headaches

- hypotension

50
Q

What are the indications of coronary interventions in acute coronary syndrome

A
  • high risk patients with ACS

- multi vessel lesion

51
Q

What life style modification should you take if you are post ACS

A
  • dietary recommendations including calorie control of obesity
  • alcohol consumption maintained within safe limits
  • patients should be physically active
  • patients should stop smoking
  • a healthy weight
  • blood pressure should be reduced
  • patients with diabetes need treatment
52
Q

define a STEMI

A

ACS with ST elevation or new onset LBBB

53
Q

Define a NSTEMI

A
  • troponin-positive ACE without ST elevation, ECG may show ST depression, T wave inversion, non=specific changes or be norma
54
Q

What is the management of acute STEMI

A

Dual oral antiplatelet therapy: Aspirin 300mg PO + Ticagrelor 180mg PO or Prasugrel 60mg PO if no Hx of stroke/TIA and <75yrs
- Previously: clopidogrel

Analgesia: Morphine 5-10mg IV + antiemetic (1st) Metoclopromide 10mg IV or (2nd) Cyclizine 50mg IV

Oxygen recommended if SaO2 <94%, breathless or acute LVF

Reperfusion therapy – must be early!

Anticoagulation – injectable anticoagulant must be used in primary PCI: Bivalirudin preferred, if not available use Enoxaparin ± GP IIb/IIIa blocker (eg Tirofiban)

Beta-blockers – eg Bisoprolol 2.5mg od; provide benefit if used early
CI: cardiogenic shock, HF, asthma/COPD or HB

55
Q

What is the criteria for reperfusion therapy

A
  1. Typical clinical symptoms of MI
  2. ECG criteria - either of the following
    - ST elevation>1mm in 2 or more adjacent limb leads or >2mm in 2 or more adjacent chest leads
    - LBBB
    - posterior changes: deep ST depression and tall R-waves in V1-V3
56
Q

Name the types of reperfusion therapy

A
  • 1st choice: Primary PCI

- 2nd choice: Thrombolysis

57
Q

Describe when you should use primary PCI

A
  • Should be offered to all patients presenting within 12h of symptom onset with a STEMI who either are at or can be transferred to a primary PCI centre within 120min of first medical contact
  • If not possible thrombolyse & transfer patient after infusion for either rescue PCI (if residual ST elevation) or angiography (if successful)
  • PCI use >12h from symptom onset requires specialist advice
58
Q

When should you use thrombolysis

A
  • benefit reduces steadily from onset of pain; target time is <30 minutes from admission
  • thrombolysis use is >12 hours from symptom onset requires specialist advice
59
Q

When do you not thrombolyse

A
  • ST depression alone
  • T wave inversion alone
  • Normal ECG
60
Q

Name the absolute contraindications to thrombolysis

A
  • previous intracranial haemorrhage
  • ischameic stroke < 6 months
  • c cerebral malignancy or arteriovenous malformations
  • recent major trauma/surgery/head injury less than 3 weeks ago
  • GI bleeding less than 1 month ago
  • known bleeding disorder
  • aortic dissection
  • non-compressible punctures < 24 hours e.g. liver biopsy, lumbar puncture
61
Q

Name the relative contradinications to thrombolysis

A
  • TIA less than 6 months ago
  • anticoagulant therapy
  • pregnancy or 1 week post party
  • refractory hypertension
  • advanced liver disease
  • infective endocarditis
  • active peptic ulcer
  • prolonged/traumatic resuscitation
62
Q

What is the long term symptom control of ACS

A
  • manage chest pain with PRN GTN and opiates
  • if insufficient consider GTN infusion
  • if deteriorating seek senior help
63
Q

What risk factors do you have to modify in long term management of ACS

A
  • stop smoking
  • identify and treat DM, HTN, hyperlipidaemia
  • dietary advice: oily fish, fruit, vegetables fibre, decreased saturated fats
  • encourage daily exercise; refer to cardiac rehab programme
  • mental health: fall to GP if depression or anxiety present
64
Q

What is the complication of ACS

A
  • Cardiac Arrest
  • Cardiogenic Shock
  • LVF

Year 3 - CR (44 decks)

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