Acute coronary syndrome - Cardiology Flashcards
Definition of Acute coronary syndrome (A+++++)
Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations that occur on top of acute coronary ischemic event (mostly thrombosis)
1- ST-segment elevation myocardial infarction (STEMI)
o ST segment elevation in ECG
o Positive cardiac enzymes
2- non–ST segment elevation myocardial infarction (NSTEMI)
o No ST segment elevation in ECG
o Positive cardiac enzymes
3- unstable angina
o No ST segment elevation in ECG
o Negative cardiac enzymes
Diagnosis of Acute coronary syndrome (Short note) (A++)
A. Presentation
- Typically it presents with continuous retrosternal compressing anginal PAIN which occurs at rest for longer than 20 minutes and does not relieve with rest or sublingual nitrates.
- Variations in presenting Pain:
a) Character: Compressing, Burning, tightness and constricting. Could also be stitching or stabbing pain.
b) Site: Retrosternal, Left side, jaw, one or both arms, one or both shoulders, epigastric and in the back.
c) Radiation: Localized or radiating pain
d) Association: Nausea, vomiting and sweating.
-Other presentations of ACS:
a) Attacks of anginal pain of increasing frequency, intensity and durations (Crescendo angina or unstable angina)
b) New onset angina (de novo angina)
c) Post-infarction angina
d) Syncopal attacks as a complication
e) Acute dyspnea (Acute HF)
F) Cardiac arrest as complication
B. Physical examination
- Normal in most cases (ABCDE used)
- Airway
- Breathing: Course crepitations and Desaturation referring to Acute pulmonary edema (Common complication of ACS)
- Circulation:
1- Pulse: Tachyarrhythmia (Ventricular tachycardia) Or Bradyarrhythmia ( Complete heart block)
2-Bp: Hypertensive emergency (Cause of ACS) or Cardiogenic shock (Complication of ACS)
3- ABG: Respiratory acidosis ( Acute HF) or Metabolic acidosis (Cardiogenic shock)
- Disability:
1- Consciousness level: Disturbed in Stroke and Cardiogenic shock
2- Random blood sugar test: Diabetic ketoacidosis in Acute MI
- Exposure and examination: Systolic murmur due to either Acute mitral regurge or Ventricular Septal rupture
C- Investigations
1- ECG: Done as early as possible. May show any changes of the following and they must be in 2 or more contiguous lead:
a) ST segment elevation (≥1mm) + Pathological Q waves (If STEMI)
b) ST segment depression
c) T wave inverted or biphasic
d) Normal ECG does not exclude ACS if there is typical clinical picture. At this time follow up ECG, Full investigations and monitoring should be done.
e)Electrical complications: Atrioventricular block, Supraventricular arrhythmia (AF) or Ventricular Tachyarrhythmia.
2- Echocardiography
- It should not delay revascularization in STEMI in acute setting
- Helpful in uncertain diagnosis and in patients with hemodynamic compromise and pick up:
a) Evidence of New regional wall motion abnormality
b) Mechanical complications -> MR and Ventricular septal rupture
c) Other causes of chest pain -> Aortic dissection, Cardiac tamponade, Pulmonary embolism
3- Chest x-ray
-Should not delay revascularization in STEMI in acute setting, however helpful in uncertain diagnosis. Pick up any of the following:
a)Ischemic related left sided heart failure ( Pulmonary congestion)
b) Other causes of chest pain (Pneumothorax, Aortic dissection and pulmonary embolism)
4- Lab tests
a) Elevated cardiac biomarkers (STEMI AND NSTEMI)
b) Lipid profile (within 24hrs of acs onset)
c) CBC (Anemia and platelets)
d) Kidney function tests (Adjust medication doses)
e) HBAC1 (DM and if controlled)
DD of acute chest pain (b)
Cause and Clue in ABCDE approach
Cardiac causes:
Pericarditis. Pericardial rub
Myocarditis. Pericardial rub
Pulmonary embolism. Tachycardia, desaturation, and clear back
Chest causes
Tension pneumothorax. Diminished air entry on one side
Pleuritis. Diminished air entry on one side if with effusion
Vascular Causes
Aortic dissection. Unequal pulse and BP
GIT causes
Cholecystitis. Epigastric tenderness
Pancreatitis. Epigastric tenderness
Esophageal spasm. No ABCDE approach :/
Chest wall causes
Myositis. Tenderness
Chest wall trauma. Tenderness and visible injury
Herpes zoster infection. Rash on the skin
Complications of myocardial infarction (B)
1) Acute severe mitral regurgitation: Due to infarction of the papillary muscles.
2) Ventricular septal rupture.
3) Ventricular free wall rupture.
4) Ventricular aneurysm.
5) Cardiogenic shock.
6) Acute heart failure.
7) Pericarditis.
8) Arrythmias: e.g., Ventricular tachycardia which may cause sudden cardiac arrest.
Emergency treatment of Acute coronary syndrome (B)
A. In severe intolerable pain give opioids ( IV morphine)
B. Immediate loading doses of antiplatelet drugs
1- Aspirin ( 300mg loading, 75mg rest of life / Daily)
2- P2Y12 inhibitors:
- Ticagrelor ( 180mg loading, 90mg x 2 daily for 1 year) (Preferred unless unavailable or CI -> On anticoagulants, advanced liver disease or previous intracranial hmg)
- Clopidogrel (300mg or 600mg (PCI) loading, 75mg daily for 1 year)
C. Loading doses of statin therapy
1- Atorvastatin (80mg loading, 80mg daily for life)
2- Rosuvastatin (40mg loading, 40mg daily for life
-Target LDL level should be below 55mg/dl (With or Without use of ezetimibe or PCSK9 inhibitors)
D. Intravenous nitroglycerine
- 5-20ug/min to help with controlling ischemic pain with close monitoring of blood pressure
- Dose can be adjusted according blood pressure
E. Anticoagulants (one of the following)
1- Unfractionated heparin
2- LMW heparin
3- Fondaparinux (not used in PCI)
F. Reperfusion therapy (in detail)
G. Others:
1- ACEI or ARBs for life with:
-Hypertension
-Diabetes mellitus
-Anterior wall STEMI
-Reduced left ventricular systolic function
2- BB for life (Target HR -> 50-60 at rest)
3- Proton pump inhibitors if
- Patient on dual antiplatelets therapy after first year of ACS
- GERD
- High risk of git-bleeding
- history of peptic ulcer
4- Lifestyle modifications (As chronic angina)
Mention reperfusion therapy in ACS (A++)
1- STEMI patients (Done asap)
A) Fibrinolytic therapy :
-Given in first 12 hours of chest pain if catheterization lab is unavailable
- Then immediate transfer to PCI capable center
B) Primary percutaneous coronary intervention
- Preferred in first 24hrs of STEMI (Can be done after 48hrs of chest pain onset)
- Should be done if late presentation after 48hrs if there are electrical or mechanical complications.
C) Surgery;
- Coronary artery bypass surgery if
1- Multivessel coronary disease after opening of infarcted related artery with balloon dilatation.
2- Surgical repair of a mechanical complication (Ventricular septal rupture)
2- For NSTE-ACS
A) Very high risk patient: PCI done within 2 hours
- Hemodynamic instability
- Electrical instability
- Refractory chest pain
B) High risk patient: PCI within 24hrs
- Elevated cardiac biomarkers
- Dynamic changes in ST segment or T wave in ECG
C) Low risk patient: Selective PCI considered if patient has one or more of the following ->
- Prior PCI within 6 months
- Prior CBAG
- DM
- CKD
- LVEF <40%
- Early post-infarction angina
Fibrinolytic therapy Absolute and relative Contraindications (A)
Absolute (Hackrig)
- Hemorrhagic stroke or stroke of unknown origin
- Aortic dissection
- Central nervous system damage, neoplasm or structural vascular lesions (AVM)
- Known bleeding disorder
- Recent major trauma/Surgery/Head injury
- Ischemic stroke (preceding 6 months)
- Gastrointestinal bleeding within last month
Relative (TOP TRAAIN)
- Transient ischemic attack in preceding 6 months
- Oral anticoagulant therapy
- Pregnancy within 1 week post partum
- Traumatic resuscitation
- Refractory hypertension
- Advanced liver disease
- Active peptic ulcer
- IE (Infective endocarditis)
- Non-compressible punctures
