Acute coronary syndromes Flashcards
What is an acute coronary syndrome?
Which conditions are included?
A range of conditions associated with a sudden, reduced blood flow to the heart.
The conditions included are:
- Unstable angina
- nSTEMI
- STEMI
Definition of unstable angina
o An unprovoked or prolonged episode of chest pain- raising suspicion of acute myocardial infarction
o Without definite ECG or lab evidence
Definition of nstemi
o Chest pain suggestive of AMI
o Non-specific ECG changes (ST depression/ T inversion/ normal)
o Lab tests showing release of troponins
o Not necessarily caused by stenosis/ occlusion (e.g., sepsis, hypotension)
Definition of STEMI
o Sustained chest pain suggestive of AMI
o Acute ST elevation or new LBBB
Pathophysiology- atherosclerosis
- Epithelial injury
- Migration of monocytes/ macrophages
- LDL lipids consumed transition to foam cells
- Release of growth factors smooth muscle changes from contractile phenotype to secretory phenotype, collagen deposition
- Atheromatous plaque forms within intima
- Plague ruptures and prothrombotic factors are released (plaque and stenosis grows or emboli forms)
Risk factors
Modifiable risk factors of acute coronary syndrome
Smoking
Obesity
Diet
Lack of exercise
High serum cholesterol
Hypertension
Diabetes
Postcode
Non- modifiable risk factors of acute coronary syndrome
Increasing age
Gender (male)
Ethnicity
Family history
Diabetes
Pre-eclampsia
Cardiac differentials for ACS
o MI
o Angina
o Pericarditis
o Aortic dissection
Respiratory differentials for ACS
o PE
o Pneumothorax
o Pneumonia
GI differentials for ACS
o Oesophageal spasm
o GORD
o Pancreatitis
MSK differentials for ACS
o Osteochondrosis
o Trauma
Clinical features (SOCRATES)
o Site- central/ left sided
o Onset- often sudden
o Character- crushing
o Radiation- left arm, neck and jaw
o Associated symptoms- nausea, sweating, clamminess, SOB, vomiting, syncope, confusion
o Timing- constant
o Exacerbating symptoms/ relieving factors- worsened by exertion, relieved by GTN spray
o Severity- often very severe
Distinguishing features between stable and unstable angina
- Stable angina- cardiac chest pain + abnormal/ normal ECG + normal troponin precipitated by stress or exertion+ <20 mins + relieved by GTN
- Unstable angina- cardiac chest pain + abnormal/ normal ECG + normal troponin + occurs at rest + >20 mins + poor GTN relief
Distinguishing between NSTEMI and STEMI
NSTEMI- cardiac chest pain + abnormal/ normal ECG (but not ST elevation) + raised troponin
SETMI- cardiac chest pain + persistent ST-elevation/ new LBBB (no need for raised troponin)
Diagnosis criteria for NSTEMI
2 of the following:
• Cardiac chest pain
• Newly abnormal ECG which is NOT ST-elevation
• Raised troponin
Diagnosis criteria for STEMI
ST elevation >2mm in ADJACENT chest leads
ST elevation >1mm in adjacent limb leads
New LBBB with chest pain or suspicious MI
Investigations for suspected MI
- ECG- looking for ST elevation, LBBB or T wave inversion (most important investigation)
- Bloods- FBC and CRP to rule out infective causes of chest pain
- Troponin- done at least 3 hours after pain starts
- Renal function
- Blood glucose
- Lipid profile
- D-dimer may be appropriate to rule out PE
- CXR- look for pulmonary causes of angina
Results of troponin and ECG for unstable angina
Normal troponin
ECG normal
possible ST depression
Results of troponin and ECG for NSTEMI
raised troponin
ST depression
can be normal ECG
possible T wave inversion
Results of troponin and ECG for STEMI
raised troponin
ST elevation
hyperacute T waves
new LBBB
T inversion (hrs)
Q waves (days)
Draw and label a normal ECG
draw the ECG of a STEMI
draw an ST depression
draw t wave inversion
What is the progression of the ECG of a STEMI?
localization of an infarct
which part of the heart would an MI in lead 1 present in? which artery supplies here?
which part of the heart would an MI in lead 2 present in? which artery supplies here?
3
aVR
aVL
aVF
V1
V2
V2
V4
V5
V6
From which leads would you get an inferior view of the heart? associated artery supplies inferior aspect?
lateral
anterior
posterior
relevance of troponin to MIs
A myocardial protein released inot the bloodstream when cardiac myocytes are damaged. Serum levels raise 3 hours after Mis begin. Troponin can also be raised due to other conditions (pericarditis, arrhythmias, defibrillation, PE, CKD, sepsis)
Common ACS management
MONAC
Morphine- 5/10mg slow injection
Oxygen
Nitrates- GTN spray (1 spray or tablet)
Aspirin- (loading dose 300mg chewed)
Clopidogrel-
+ an anti-emetic (e.g., metoclopramide)
Unstable angina and NSETMI management (OSTABLN)
all patients should be referred for what kind of imaging
all patients sould b e referred to
consider what kind of treatment within 72 hrs
- Oxygen
- Statin- Atorvastatin
- Ticagrelor 180mg loading dose
- Aspirin + Fondaparinux
- ACEi- Ramipril
- Beta blocker- bisoprolol
- LMWH i.e. fondaparinux 2mg OD
- Nitrates- IV infusion if severe pain with hypertension
All patients should get an ECHO performed to assess systolic function
All patients should be referred to cardiac rehab
consiuder PCI/ coronary angiography
name 2 scoring systems for ACS
grace scoring and TIMI
what is the grace scoring
Predicts 6/12 mortality in NSTEMI patients
- Age
- HR and systolic BP
- Killip class (CCF, pulmonary oedema, shock)
- Cardiac arrest on admission
- Elevated cardiac markers
- ST segment change
what is the TIMI scoring system
Risk of cardiac events in the next 30 days
- Age >65
- Known coronary heart disease
- Aspirin in last 7/7
- Severe angina (>2 in 24 hours)
- ST deviation >1mm
- Elevated troponins
- > CAD risk factors
STEMI treatment- PTA-B
time is muscle
MONAC short term
-
Percutaneous coronary intervention
- “Diagnosis to balloon time” of 120 minutes
- Ballion and stent
- Treat as ACS
- Possible PCI after failed thrombolysis
-
Thrombolysis
- Streptokinase/ Alteplase
-
ACEi
- E.g., ramipril
-
Beta Blocker
- E.g., bisprolol
Longer-term management OF acs
Longer-term management
- Continuous ECG monitoring as an inpatient/ ICU
- Aspirin
- Ticagrelor (NOAC???)
- Beta blocker
- ACEi
- Statin
- Modification of risk factors
- Driving??
Complications of ACS
long term short term
- Early
- Death
- Cardiogenic shock
- Heart failure
- Ventricular arrhythmia
- Thromboembolism
- 2nd or 3rd degree heart block
- Late
- Wall rupture
- Valvular regurg
- Cardiac tamponade
- Dressler’s syndrome- post infarct pericarditis presenting with fever and pleuritic chest pain 2-3 weeks after MI
typical history of someone with ACS
