Acute Coronary Syndrome (pathology)

Question 1

What are acute coronary syndromes?

Answer 1

Collection of symptoms related to a problem with the coronary arteries

Question 2

What causes acute coronary syndromes?

Answer 2

Caused by unstable coronary lesions

Question 3

What are examples of acute coronary syndromes?

Answer 3

MI (STEMI and NSTEMI)
Unstable angina
Sudden cardiac death

Question 4

What differentiates STEMI, NSTEMI and unstable angina? (ECG and troponin)

Answer 4

ST elevation = STEMI
No ST elevation + troponin = NSTEMI
No ST elevation + no high troponin = unstable angina

Question 5

What are the 2 types if myocardial infarction?

Answer 5

Type 1:
Ischaemia + plaque rupture, erosion, fissuring, dissection = thrombosis

Type 2:
Supply demand imbalance —> ischaemia without thrombosis

Question 6

What are the non-modifiable risk factors for Acute coronary syndrome (2)?

Answer 6

Male sex

Age

Question 7

What are the modifiable risk factors for Acute coronary syndrome (7)?

Answer 7

Smoking 
Lifestyle (diet, exercise)
Diabetes mellitus 
Hypertension
Hyperlipidaemia 
Family history of premature heart disease
Known heart disease

Question 8

What are the symptoms for Acute coronary syndrome?

Answer 8

Ischaemic sounding chest pain:

- radiates to neck/arm
- described as discomfort, tightness, heaviness
- may be associated with nausea, sweating, SOB

Question 9

What are the complications of MI?

Answer 9

Arrhythmic:
- Ventricular fibrillation
Mechanical:
- myocardial rupture —> cardiac tamponade
- acute ventricular septal defect
- papillary muscle rupture —> mitral regurgitation
CHECK FOR NEW MURMURS

Question 10

What are the signs and symptoms for Acute coronary syndrome (4)?

Answer 10

Very unwell if STEMI
May look fine once in hospital 
Check for:
	- HR, BP both arms
Murmurs + crackles

Question 11

What are the diagnosis/investigations for Acute coronary syndrome?

Answer 11

Bloods:
- cardiac biomarkers (troponin)
- Hb, kidney function, cholesterol
12 lead ECG:
- complete occlusion —> STEMI —> Q waves after 3 days
- partial occlusion —> ST depression, T wave inversion —> no Q waves after 3 days

Question 12

What indicates there has been new ischaemic damage?

Answer 12

Cardiac cell death (+ve biomarkers - troponin)
AND one of:
	- symptoms of ischaemia 
	- new ECG changes 
	- Evidence of coronary obstruction

Question 13

What are the mechanical therapy/management options for STEMI (+NSTEMI)?

Answer 13

STEMI:
- Cath lab balloon & stents (PCI + coronary angiogram)
NSTEMI:
- angiogram within 48hrs
Thrombolysis given if can’t get to Cath lab within 2hrs

Question 14

What are the pharmacological therapy/management options for STEMI?

Answer 14

Increase O2 supply:
- thrombolysis - good if given within 1-2hrs
- converts plasminogen into plasmin
- (fibrin specific alteplase)
&
- dual antiplatelet therapy (aspirin 300mg + ticagrelor 180mg)

Question 15

What are the pharmacological therapy/management risks for STEMI?

Answer 15

Bleeding

- NO if recent stroke or intercranial bleed
- caution if recent surgery, on warfarin, severe hypertension

Question 16

What are the observation & treatment options for ACS?

Answer 16

Hospital admission
- if uncomplicated discharged in 2-3 days
Serial ECGs and cardiac monitor
IV access
O2 if low
Organise echo
Secondary prevention medication (statins, beta-blockers, anticoagulants)

Question 17

What are the pharmacological therapy/management options for ACS?

Answer 17

B: beta-blockers (unless contraindicated)
A: aspirin (300mg start dose)
T: Ticagrelor (180mg start dose)
- clopidogrel (300mg) alternative if higher bleeding risk
M: Morphine titration to control pain
A: anticoagulant (Fondaparinux - unless high bleeding risk)
N: nitrates (e.g. GTN) to relieve coronary artery spasm

Give oxygen only if their saturations are dropping (<95%)

Question 18

What are the secondary therapy/management options for ACS?

Answer 18

Aspirin (75mg)
Another antiplatelet (clopidogrel/ricagrelor) for up to 12 months
Statins
ACEi (ramipril)
Beta blocker (atenolol)
Aldosterone antagonists - if with heart failure (eplerenone)