Acute Coronary Syndrome Management Flashcards
What are some symptoms of acute coronary syndrome?
- Acute central or left chest pain >20 minutes (+/- radiation to left jaw/arm)
- Nausea and vomiting (Bezold-Jarisch reflex (INF infarction irritates the diaphragm)
- Diaphoresis
- Dyspnoea
- Palpitations
- Silent MI may present with syncope, delirium, hypotension, or oliguria
Silent myocardial infarction (MI) is more common in elderly and diabetics.
What are the modifiable risk factors for acute coronary syndrome?
- Hypertension (HTN)
- Diabetes Mellitus (DM)
- Hyperlipidaemia
- Smoking
- Obesity/sedentary lifestyle
- Cocaine use
Modifiable risk factors are lifestyle or health issues that can be changed to reduce risk.
What are the non-modifiable risk factors for acute coronary syndrome?
- Family history
- Previous myocardial infarction (MI)
Non-modifiable risk factors are inherent traits that cannot be changed.
List some differential diagnoses (DDx) for chest pain.
- Cardiac: Stable angina, pericarditis, myocarditis, aortic dissection, Takotsubo cardiomyopathy
- Respiratory: Pulmonary embolism (PE), pneumothorax, pneumonia
- Gastrointestinal: GORD, diffuse oesophageal spasm, perforated peptic ulcer disease (PUD), pancreatitis
- Other: Anaemia, anxiety, costochondritis
Differential diagnoses help rule out other potential causes of chest pain.
What are the signs of acute coronary syndrome during a focused exam?
- Anxious and sweaty appearance
- Pallor
- Levine’s sign (clenched fist over chest)
- Vital signs: tachycardia or bradycardia, hypertension or hypotension
- Cardiac exam: 4th heart sound, signs of left ventricular failure, pansystolic murmur
Signs can indicate the severity and nature of the cardiac issue.
What is the first-line test for acute coronary syndrome?
Immediate 12-lead ECG
ECG may be initially normal in ~20% of myocardial infarctions.
What are common findings on an ECG for STEMI?
- ST elevation
- Hyperacute T waves
- Q waves indicate a full-thickness infarct
STEMI is characterized by specific changes in the ECG that indicate severe heart damage.
What are common findings on an ECG for STEMI?
■ ST depression
■ T wave inversion
What laboratory tests are important in the evaluation of acute coronary syndrome?
- Full blood count (FBC)
- Urea and electrolytes (U&E)
- Liver function tests (LFTs)
- C-reactive protein (CRP)
- Glucose and HbA1C
- Lipids
- Coagulation tests
- Troponin (T and I)
Troponin is the most specific biomarker for heart damage.
Troponin levels are elevated at ______ hours post-MI.
Other biomarkers?
3-12 hours
Troponin peaks at 24 hours and returns to baseline in 5-14 days.
● Myoglobin (1st biomarker to rise)
● CK-MB (assess for reinfarction as it normalises in 2-3 days)
What is the role of antiplatelet therapy in the treatment of acute coronary syndrome?
- Aspirin 300 mg PO
- Second antiplatelet: Ticagrelor 180 mg, or prasugrel/clopidogrel
Antiplatelet therapy is crucial for preventing further clot formation.
How to treat chest pain associated with MI?
Start with 1-2 sprays 0.4 mg/spray of sublingual GTN - can repeat every 3-5 minutes
IV morphine 2 mg, titrate to effect (5-10 mg)
What are the contraindications for using sublingual GTN?
- Hemodynamically unstable (BP <90/60 mmHg)
- Inferior MI
- Aortic stenosis
- Use of sildenafil
Sublingual GTN is a common treatment for chest pain but has specific contraindications.
What is the primary reperfusion therapy for STEMI?
Primary PCI (Percutaneous Coronary Intervention)
PCI should be performed within 120 minutes of symptom onset.
Contraindications for STEMI Thrombolysis?
AGAINST24:
● Aortic dissection
● GI bleeding
● Allergic reaction (previously)
● Iatrogenic (recent surgery 2-3 weeks, relative C/I)
● Neuro: CVA Hx (stroke in last 3 months), cerebral neoplasm
● Severe HTN (200/120)
● Time >24 hours
Management of an NSTEMI?
The GRACE score helps determine the urgency of intervention.
What lifestyle changes are recommended after an acute myocardial infarction?
- Smoking cessation
- Mediterranean low glycemic index diet
- Regular exercise (30 minutes moderate intensity 5 days a week)
- Reduce/eliminate alcohol
- Mental health support
Lifestyle modifications can significantly improve prognosis post-MI.
What medications are recommended for secondary pharmacological prevention after MI?
- ACE inhibitors
- Beta-blockers
- Dual antiplatelet therapy (DAPT)
- High-dose statins
These medications are critical for reducing the risk of future cardiovascular events.
True or False: DAPT should be continued for life after an acute coronary syndrome event.
False
DAPT is typically recommended for 6-12 months, with aspirin continued for life.
