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Year 6 Cardiology > Acute Coronary Syndrome NEW > Flashcards

Acute Coronary Syndrome NEW Flashcards

1
Q

What is acute coronary syndrome (ACS)?

A

ACS is an umbrella term covering a number of acute presentations of ischaemic heart disease.

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2
Q

What are the presentations included in ACS?

A

The presentations include ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina.

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3
Q

What is ischaemic heart disease?

A

Ischaemic heart disease describes the gradual buildup of fatty plaques within the walls of the coronary arteries, leading to reduced blood flow and oxygen to the myocardium.

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4
Q

What are the two main problems caused by ischaemic heart disease?

A
  1. Gradual narrowing of arteries leading to angina. 2. Risk of sudden plaque rupture causing occlusion.
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5
Q

What are unmodifiable risk factors for ischaemic heart disease?

A

Unmodifiable risk factors include increasing age, male gender, and family history.

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6
Q

What are modifiable risk factors for ischaemic heart disease?

A

Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolaemia, and obesity.

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7
Q

What triggers initial endothelial dysfunction in ischaemic heart disease?

A

Factors such as smoking, hypertension, and hyperglycaemia trigger initial endothelial dysfunction.

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8
Q

What happens to monocytes in the development of atherosclerosis?

A

Monocytes migrate from the blood and differentiate into macrophages, which phagocytose oxidized LDL and turn into foam cells.

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9
Q

What complications can develop from atherosclerosis?

A

Complications include physical blockage of the coronary artery causing angina and plaque rupture leading to myocardial infarction.

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10
Q

What are common symptoms of acute coronary syndrome?

A

Common symptoms include chest pain, dyspnoea, sweating, and nausea/vomiting.

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11
Q

What is the classic feature of ACS?

A

The classic feature of ACS is chest pain, typically central or left-sided, often described as ‘heavy’ or constricting.

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12
Q

What are the two most important investigations for chest pain?

A

The two most important investigations are ECG and cardiac markers (e.g., troponin).

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13
Q

What does the mnemonic MONA stand for in ACS management?

A

MONA stands for Morphine, Oxygen, Nitrates, and Aspirin.

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14
Q

What is the priority management for a patient with STEMI?

A

The priority is to reopen or revascularise the blocked coronary artery.

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15
Q

What lifelong drug therapy is required after an ACS event?

A

Lifelong therapy includes aspirin, a second antiplatelet, a beta-blocker, an ACE inhibitor, and a statin.

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16
Q

What is the role of coronary angiography in NSTEMI management?

A

Coronary angiography is performed for high-risk or unstable patients; lower risk patients may have it later.

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17
Q

What are the features of acute coronary syndrome (ACS)?

A

Features of ACS include chest pain, dyspnoea, nausea and vomiting, sweating, and palpitations.

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18
Q

Where is chest pain classically located in ACS?

A

Chest pain is classically on the left side of the chest.

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19
Q

Can chest pain in ACS radiate to other areas?

A

Yes, it may radiate to the left arm or neck.

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20
Q

Is chest pain always present in ACS?

A

No, chest pain may not always be present.

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21
Q

What factors make an atypical presentation of ACS more likely?

A

Being elderly, diabetic, or female makes an atypical presentation more likely.

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22
Q

What is acute coronary syndrome (ACS)?

A

ACS is a very common and important presentation in medicine.

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23
Q

What are the classifications of acute coronary syndrome?

A
  1. ST-elevation myocardial infarction (STEMI)
  2. Non ST-elevation myocardial infarction (NSTEMI)
  3. Unstable angina
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24
Q

What are the criteria for STEMI?

A

Clinical symptoms consistent with ACS (≥ 20 minutes) with persistent ECG features in ≥ 2 contiguous leads of:
- 2.5 mm ST elevation in leads V2-3 in men under 40 years
- 2.0 mm ST elevation in leads V2-3 in men over 40 years
- 1.5 mm ST elevation in V2-3 in women
- 1 mm ST elevation in other leads
- New LBBB.

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25
Q

What is the initial drug therapy for ACS?

A
  1. Aspirin 300mg
  2. Oxygen if saturations < 94%
  3. Morphine for severe pain
  4. Nitrates for ongoing chest pain or hypertension.
26
Q

What are the two types of coronary reperfusion therapy for STEMI?

A
  1. Percutaneous coronary intervention (PCI)
  2. Fibrinolysis.
27
Q

When should PCI be offered for STEMI?

A

If presentation is within 12 hours of symptom onset and PCI can be delivered within 120 minutes.

28
Q

What is dual antiplatelet therapy prior to PCI?

A

Aspirin + another drug (prasugrel if not on anticoagulant; clopidogrel if on anticoagulant).

29
Q

What should be done if fibrinolysis fails in STEMI?

A

Transfer for PCI should be considered if ECG shows persistent ST elevation after fibrinolysis.

30
Q

What is the management for NSTEMI/unstable angina?

A

Management depends on individual patient factors and risk assessment.

31
Q

What is the Global Registry of Acute Coronary Events (GRACE)?

A

A tool for risk assessment that considers age, heart rate, blood pressure, cardiac function, and troponin levels.

32
Q

What are the risk stratifications based on GRACE score?

A
  1. 1.5% or below - Lowest
  2. > 1.5% to 3.0% - Low
  3. > 3.0% to 6.0% - Intermediate
  4. > 6.0% to 9.0% - High
  5. Over 9.0% - Highest.
33
Q

What is the recommended antithrombin treatment for NSTEMI?

A

Fondaparinux for low bleeding risk; unfractionated heparin if immediate angiography is planned.

34
Q

What further drug therapy is recommended for patients undergoing PCI with NSTEMI?

A

Unfractionated heparin and dual antiplatelet therapy (aspirin + another drug).

35
Q

What is the conservative management for NSTEMI/unstable angina?

A

Further antiplatelet therapy (aspirin + another drug), with ticagrelor for low bleeding risk and clopidogrel for high risk.

36
Q

What study was used to derive regression models for predicting death in patients with acute coronary syndrome?

A

The 2006 Global Registry of Acute Coronary Events (GRACE) study.

37
Q

What are some poor prognostic factors in acute coronary syndrome?

A
  1. Age
  2. Development (or history) of heart failure
  3. Peripheral vascular disease
  4. Reduced systolic blood pressure
  5. Killip class
  6. Initial serum creatinine concentration
  7. Elevated initial cardiac markers
  8. Cardiac arrest on admission
  9. ST segment deviation
38
Q

What is the Killip class system used for?

A

To stratify risk post myocardial infarction.

39
Q

What are the features and 30-day mortality rates for Killip class I?

A

Features: No clinical signs of heart failure
30-day mortality: 6%

40
Q

What are the features and 30-day mortality rates for Killip class II?

A

Features: Lung crackles, S3
30-day mortality: 17%

41
Q

What are the features and 30-day mortality rates for Killip class III?

A

Features: Frank pulmonary oedema
30-day mortality: 38%

42
Q

What are the features and 30-day mortality rates for Killip class IV?

A

Features: Cardiogenic shock
30-day mortality: 81%

43
Q

What is the most common cause of death following a myocardial infarction (MI)?

A

Cardiac arrest due to ventricular fibrillation.

Managed as per the ALS protocol with defibrillation.

44
Q

What is cardiogenic shock?

A

A condition that may develop if a large part of the ventricular myocardium is damaged, leading to a decreased ejection fraction.

Treatment may require inotropic support and/or an intra-aortic balloon pump.

45
Q

What can result from dysfunctional ventricular myocardium after MI?

A

Chronic heart failure.

Loop diuretics like furosemide can decrease fluid overload, and ACE-inhibitors and beta-blockers improve long-term prognosis.

46
Q

What are common arrhythmias following a myocardial infarction?

A

Tachyarrhythmias, including ventricular fibrillation and ventricular tachycardia.

47
Q

What is a common complication of inferior myocardial infarctions?

A

Bradyarrhythmias, specifically atrioventricular block.

48
Q

What is pericarditis and when does it commonly occur post-MI?

A

Pericarditis occurs in the first 48 hours following a transmural MI in about 10% of patients.

Symptoms include pain worse when lying flat, a pericardial rub, and pericardial effusion detectable by echocardiogram.

49
Q

What is Dressler’s syndrome?

A

An autoimmune reaction occurring 2-6 weeks post-MI characterized by fever, pleuritic pain, pericardial effusion, and raised ESR.

Treated with NSAIDs.

50
Q

What complication can arise from ischaemic damage to the myocardium?

A

Left ventricular aneurysm, which may lead to persistent ST elevation and left ventricular failure.

Patients are anticoagulated due to the risk of thrombus formation.

51
Q

What is left ventricular free wall rupture?

A

A complication seen in around 3% of MIs occurring 1-2 weeks post-MI, presenting with acute heart failure due to cardiac tamponade.

Requires urgent pericardiocentesis and thoracotomy.

52
Q

What is a ventricular septal defect?

A

Rupture of the interventricular septum usually occurring in the first week, seen in 1-2% of patients, presenting with acute heart failure and a pan-systolic murmur.

An echocardiogram is diagnostic, and urgent surgical correction is needed.

53
Q

What is acute mitral regurgitation and its common causes?

A

More common with infero-posterior infarction, potentially due to ischaemia or rupture of the papillary muscle, leading to acute hypotension and pulmonary oedema.

Treated with vasodilator therapy but often requires emergency surgical repair.

54
Q

What are the key drugs offered to all patients after a myocardial infarction?

A

Patients should be offered dual antiplatelet therapy (aspirin plus a second antiplatelet agent), an ACE inhibitor, a beta-blocker, and a statin.

55
Q

What dietary advice is given to patients after a myocardial infarction?

A

Advise a Mediterranean style diet, switching butter and cheese for plant oil-based products. Do not recommend omega-3 supplements or eating oily fish.

56
Q

What is the recommended exercise duration for patients after a myocardial infarction?

A

Advise 20-30 minutes of exercise a day until patients are ‘slightly breathless’.

57
Q

When can sexual activity resume after an uncomplicated myocardial infarction?

A

Sexual activity may resume 4 weeks after an uncomplicated MI. Reassure patients that sex does not increase their likelihood of a further MI.

58
Q

What are the recommendations for PDE5 inhibitors after a myocardial infarction?

A

PDE5 inhibitors (e.g., sildenafil) may be used 6 months after a MI, but should be avoided in patients prescribed either nitrates or nicorandil.

59
Q

What is the current recommendation for dual antiplatelet therapy (DAPT) after an acute coronary syndrome?

A

Post-acute coronary syndrome (medically managed): add ticagrelor to aspirin, stop ticagrelor after 12 months. Post-percutaneous coronary intervention: add prasugrel or ticagrelor to aspirin, stop the second antiplatelet after 12 months.

60
Q

What should be considered for patients at high risk of bleeding or further ischaemic events regarding DAPT?

A

The 12-month period for stopping the second antiplatelet may be altered for people at high risk of bleeding or those at high risk of further ischaemic events.

61
Q

When should aldosterone antagonists be initiated after a myocardial infarction?

A

Aldosterone antagonists should be initiated within 3-14 days of the MI for patients who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, preferably after ACE inhibitor therapy.

Year 6 Cardiology (36 decks)

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