acute coronary syndromes Flashcards
what presentations does ACS cover
STEMI, NSTEMI, unstable angina
how is an NSTEMI differentiated from unstable angina
no rise in troponin + no ECG changes
basic pathophsiology of atherosclerosis
endothelial dysfunction –> oxidaisation + phagocytosis of LDLs –> foam cells –> fibrous capsule over plaque
how do fatty plaques lead to IHD
narrowing of coronary vessels // rupture –> occlusion
presentation ACS
central chest pain // radiate to jaw or left arm // heavy pain // sweating // SOB
invx for ACS
ECG + troponin
who is an atypical presentation of ACS more common in (ie less pain)
elderly, diabetics, women
inital mx for all ACS patients
aspirin 300mg // nitrates // O2 if sats <94% // Morphine if needed
when in ACS would nitrates need to be held
hypotensive
how is STEMI diagnosed
symptoms >20 mins + ECG features >2 mins in at least 2 leads
when is PCI considered for STEMI
first line if present within 12 hours and PCI can be delivered in 120 mins
what artery is accessed for PCI and what stent is used
radial > femoral // drug-eluting stent
what is done if PCI cannot be offered within 120 minutes
fibrinolysis
prior to PCI what antiplatelets are given
aspirin + prasugrel (if not on anticoag) or clopidogrel (if on anticoag)
what medication is given during PCI
heparin + bailout GPI
what mediation should be given at the same time as fibrinolysis in a STEMI
antithrombin eg dabigatran, faundiparux
when should an ECG be repeated after fibrinolysis + what should be done if symptoms persist
ECG after 60-90 mins –> PCI
when would PCI be considered in NSTEMI or unstable angina
if risk assessment = 3%> (eg GRACE assessment)
if PCI or angiography is not planned in NSTEMI/ unstable angina what drug should be given
antithrombin eg fondaparoux + (aspirin + tricagrelor)
which patients with NSTEMI/ unstable angina should recieve immediate angio (+/- PCI)
clinically unstable eg hypotensive
which patients with NSTEMI/ unstable angina should recieve angio (+/- PCI) within 72 hours
GRACE score >3%
for those at low risk after NSTEMI/ unstable angina, and LOW risk of bleeding, what conservative treatment is given
aspirin + ticagrelor
for those at low risk after NSTEMI/ unstable angina, and HIGH risk of bleeding, what conservative treatment is given
aspirin + clopidogrel
what does the Killip class determine
30 day mortality post MI
what is Killip class 1
no signs of heart failure
what is Killip class 2-3
2 = lung crackles // 3 = frank pulm oedema
what is killip class 4
cardiogenic shock (80% mortality)
what 3 things make typical angina
constricting chest, neck, shoulder, jaw pain + exacerbated by exercise + relieved by GTN
what makes atypical angina
2/3 things
if clinical assessment not enough for stable angina, what is 1st line invx
CT coronary angio
2nd and 3rd line invx stable angina
2nd = non invasive imaging (eg SPECT, echo, MRI) // 3rd = invasie
2nd and 3rd line invx stable angina
2nd = non invasive imaging (eg SPECT, echo, MRI) // 3rd = invasie
what initial mx should all patients presenting with chest pain get
GTN + 300mg aspirin
what should all patients with stable angina be started on
aspirin + statin
1st line drugs for stable angina
beta blocker or CBB (verapmil or diltiazem)
if monotherapy not working what mx is done for stable angina
max dose monotherapy –> CCB + beta blocker
if dual therapy is used in stable angina what CCB must be used
amlodopine or nifedepine (verapamil + BB –> heart block)
if dual therapy cannot be tolerated in stable angina what drugs should be considered
long acting nitrate eg isosorbide mononitrate // ivabrandine // nicorandil
what dosing is required with isosorbide mononitrates
asymmetric dosing so there is a nitrate free period of 10-14 hours to prevent tolerance
what should all patiens with STEMI recieve
aspirin + tricagrelor/ clopidogrel (or prasugrel if going for PCI)
what drug is given to STEMI patients during PCI
unfractionated heparin (if unsuitable LMW heparin)
when is O2 given in a STEMI
<94%
1st line mx STEMI
PCI within 2 hours
what drug is given during thrombolysis
tissue plasminogen activator (tPa) eg alteplase
contraindications to thrombolysis
active or recent haemorrhage // coag or bleeding disorders // brain tumur // recent stroke
after an MI what drugs shuld all patients recieve (4)
dual antiplatelet (aspirin +…) // ACEi // BB // statin
what antiplatelets are commonly given after a medically managed ACS
aspirin (lifelong) + tricegrelor (12 months)
what antiplatelets are commonly given after a PCI managed MI
aspirin + tricegrelor (or prasufel) (12 months)
what drug can be given post MI for patietns with HF and left ventricular dysfunction
eplerenone started 3-14 days after
most common cause of death following an MI
v fib –> arrest
what type of MI can cause bradyarrhythmias
inferior MIs
when is pericarditis common post MI + symptoms
48 hours –> pericardial rub + effusion (ECHO)
what is dresslers syndrome
2-6 weeks post MI –> fever, pleuritic pain, effusion, raised ESR
how is dresslers syndrome managed
NSAIDs
how would left ventricular aneurysm present afer an MI
persistent ST elavation + LV failure
how would LV rupture present post MI
1-2 weeks later –> tamponade (raised JVP, pulsus paradoxus, reduced heart sounds)
how would ventricular septal defect present post MI
1st week –> acute HF, pansystolic murmur (ECHO)
how can acute mitral regurg occur post MI
ischaemia or rupture of papilliary muscle
how can acute mitral regurg present
acute hypotension + pulmonary oedema
how does a posterior MI present on an ECG
ST depression not elevation
what ECG changes could indicate a STEMI
ST elevation or new LBBB
what ECG changes could indicate a NSTEMI
ST depression // deep T wave inversion // pathological Q waves
what leads + artery indicate an anteroseptal MI
V1-V4 + LAD
what leads + artery indicate an inferior MI
II, III, aVF + right coronary
what leads + artery indicate an anterolateral MI
V1-6, I, aVL (LAD)
what leads + artery indicate an lateral MI
I, aVL, V5-6 (left circumflex)
what leads + artery indicate an posterior MI
changes in V1-3 (orV7-9) (usually ST depression) // left circumflex or right coronary
