Acute coronary syndrome - with ST elevatiob Flashcards
clinical prestenation of STEMI
angina duration more than 30!!!!! mins NOW unlike nstemmi
Very severe accompanied by abundant vegetative nervous system symptoms – sweating, nausea, vomiting
UNAFFECTED BY NITROGLYCERIN
specific ECG changes
and lab consolation
what are the ECG changes we see in stemi ?
CRITERIA
ecg
we see a ST – elevation:
- ST elevation is equal or > 1 mV (mm) in at least two peripheral leads
OR
ST elevation is equal to or > 2 mV (mm) in at least two precordial leads
acute stage -
infraction or myocardial damage going on
>hyper acute T waves (physiological in high vagal tone , or hyperkalemia )
>ST elevation
intermediate stage -Myocardial necrosis present
> absence of r waves
> ST elevation with T wave inversions (first few days)
> pathological q wave with t wave inversion - week to months
( it is any q wave with duration of more than or equal to 0.04s or more than or an amplitude of equal to 1/4 of preceding r wave, or any q wave seen in lead V1-V3 (seen in hypertrophic cardiomyopathy) )
chronic stage - permanent scarring
>perisirant , broad and deep q waves
> incomplete recovery of R waves
> and permanent t wave inversion can be possible
pathologic Q-waves remain forever
!!!
if there is ST elevation for more than 2 months what is this a sign for ?
aneurysm
other than ECG what other modes of diagnosis are used
troponin I (cTnI) troponin T (cTnT) - lasts the longest up to 5-14 days
begin to rise 3 to 4 hours after the onset of chest discomfort, achieve a peak level between 18 and 36 hours,
Elevation of CK-MB
ratio of CK-MB to total CK. The ratio is usually greater than 2.5% in the setting
of myocardial injury
peak time at 12 or more hours
MB2 isoform
what is the differential diagnosis of ST elevation ?
NEW LEFT BUNDLE BRANCH BLOCK
early depolarisation
pericardtis / myocarditis
takotsubo cardiomyopathy
brugada syndrome
left and right bundle branch block associated with repolarisation abnormalities
hyperkalemia , hypothermia
through ECG how would you know there is a right ventricular infraction ?
Confirm by demonstrating ST elevation in rV3/4 and/
or echo. NB: rV4 means that V4 is placed in the right 5th intercostal space in the
midclavicular line.
dd for troponin increase?
Myocarditis Decompensated congestive heart failure Pulmonary embolism Cardiac arrhythmia Takotsubo cardiomyopathy
Noncardiac causes
Renal failure
Stroke
what is the management of STEMI ?
A-E
2 large bore iv acess!!! - Bloods for FBC, U&E, glucose, lipids, troponin
oxygen - s recommended if patients have SaO2 <95%, are breathless or in acute LVF
check glucose levels
12 ECG lead and telemetry
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bedside troponins
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dual anti platelet therapy
aspirin load 300mg PO
plus an adp inhibitor r prasugrel (60mg PO if no history of stroke/TIA and <75yrs)
TICAGRELOR-180mg
as newer alternatives to clopidogrel (300mg PO)
(should be continues after 12 months after PCI )
• Morphine: 5–10mg IV (repeat after 5min if necessary). Give anti-emetic with the 1st
dose of morphine: metoclopramide 10mg IV (1st line), or cyclizine 50mg IV (2nd line)
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GP 2b and 3a receptor antagonist should be considered in precatherisation setting
abciximab, eptifibatide
we need to do immediate revascularisation and initiation of other therapies should not delay this step in management.
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emergency coronary angiography with PCI ideally less than 90 minutes and should not exceed the 120 minutes given
: An injectable anticoagulant must be used in primary PCI. Bivalirudin (direct thrombin inhibitor ) is preferred, if not available use enoxaparin ± a GP IIb/IIIa blocker.
if PCI cannot be performed under 120 minutes or if PCI is not successful we start with
thrombolytic therapy = tPA , reteplase / streptokinase
should be administered in less than 30 minutes of arrival into the hospital , it is contraindicated to administer it 24 hours after the symptoms
PCI should be performed even if the symptoms go away
we can also do a CABG - coronary artery bypass grafting
- indicated only when PCI is unsuccessful
anatomy not suitable
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• ß-blockers provide additional benefit when started early, eg bisoprolol 2.5mg PO OD.
Ensure no evidence of cardiogenic shock, heart failure, asthma/COPD, or heart block
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Patients with STEMI who do not receive reperfusion (eg presenting >12h after
symptom onset) should be treated with fondaparinux, or enoxaparin/unfractionated heparin if not available.
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Mild and moderate heart failure
• Furosemide 20-40 mg i.v. slowly, when no effect – new dosing in 2-4 h
• When the result is not sufficient – Nitroglycerin i.v. infusion with dose titration every 5 min
management of RV infarction?
Treat hypotension and oliguria with fluids (avoid nitrates and diuretics). Monitor BP carefully, and assess early signs of pulmonary oedema.
Intensive
monitoring and inotropes may be useful in some patients
further pharmacological therapy can you go to ?
statins
loop diuretics
ACE or ARB
what is the contraindication of thrombolytic therapy ?
•Previous intracranial haemorrhage. •Ischaemic stroke <6months. •Cerebral malignancy or AVM. •Recent major trauma/surgery/ head injury (<3wks). •GI bleeding (<1 month). •Known bleeding disorder. •Aortic
what are the complication 3-14 days post infraction ?
papillary muscle rupture - in 2-7 days
lead to mitral regurgitation
rupture of the posteromedial papillary muscle due to occlusion of the posterioir descending artery is very common
New holosystolic, blowing murmur over the 5th ICS on the midclavicular line
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ventricular septal rupture - in 3-5 days
holosystolic murmur is heard
treatment - emergency surgery and revascularisation
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left ventricular free wall rupture - 5-14 days
LV hypertrophy and tissue fibrosis of previous MI decreases the risk - this leads to another complication which is CARDIAC TAMPOADE
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left ventricular pseudo aneurysm
out pouching of the ventricular wall rupture
what are the complications for 2 weeks to months post infraction ?
atrial and ventricular aneurysms
= perisistate st elevation and t wave inversion 3 weeks post MI
- further complication of arrhythmia , rupture and cardiac tamponade and mural thrombus formation leading to thromboembolism - stroke and mesenteric eschemia , and renal infraction
treatment : anticoagulation
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DRESSLER syndrome
pericarditis occurring 2-10 weeks post MI
due to circulating antibodies against cardiac ,muscle cells
leading pleuritic chest pain , dry cough , friction rub can be heard , fever ,
serum troponin levels continue to remain highh
and on ECG diffuse ST elevations
= treatments of NSAID , COLCHINE
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arrhythmia
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congestive heart failure
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rein fraction
how do you know through egg if there is posterior myocardial infraction ?
• Posterior changes: deep ST depression and tall R waves in leads V1 to V3
