Acute Coronary Syndromes Flashcards
Three types of acute coronary syndrome?
unstable angina/ STEMI/ NSTEMI
What is acute coronary syndrome?
thrombus forming from rupture of atherosclerotic plaque blocking coronary artery
Presentation of acute coronary syndrome?
central constricting chest pain with:
Pain radiating to the jaw or arms
Nausea and vomiting
Sweating and clamminess
A feeling of impending doom
Shortness of breath
Palpitations
How long do symptoms occur for?
more than 15 mins at rest
What is a silent myocardial infarction and who are at highest risk?
no typical chest pain
diabetics at high risk
ECG changes for STEMI?
ST-segment elevation
New left bundle branch block
ECG changes for NSTEMI
ST segment depression
T wave inversion
What are pathological Q waves?
suggest deep infarction of full thickness of heart muscle
appear 6 hours or more after symptoms
What is troponin?
protein from damaged myocardial infarction raised in blood
for diagnosis of NSTEMI
Dangers of interpreting a troponin result?
Troponin is non-specific
raised also due to:
Chronic kidney disease
Sepsis
Myocarditis
Aortic dissection
Pulmonary embolism
How to avoid incorrect interpretation of troponin?
repeat troponin 3hrs after baseline
high or rising troponin = NSTEMI
Investigations for acute coronary syndrome?
Baseline bloods: FBC, U&E, LFT, lipids and glucose
Chest x-ray
Echocardiogram
How to classify and diagnose a STEMI?
ST elevation and new LBBB
How to classify and diagnose a NSTEMI?
raised troponin
normal ECG or other changes (ST depression/ T wave inversion)
How to classify and diagnose a unstable angina?
normal troponin
normal ECG or other changes (ST depression/ T wave inversion)
Initial management for acute coronary syndrome?
CPAIN
C – Call an ambulance
P – Perform an ECG
A – Aspirin 300mg
I – Intravenous morphine for pain if required (with an antiemetic, e.g., metoclopramide)
N – Nitrate (GTN)
If patient is pain free but chest pain was within last 72 hours, how to manage?
refer to same day assessment unit
How to manage a STEMI?
PCI and angioplasty
thrombolysisH
How to manage NSTEMI?
BATMAN
B – Base the decision about angiography and PCI on the GRACE score
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel if high bleeding risk, or prasugrel if having angiography)
M – Morphine titrated to control pain
A – Antithrombin therapy with fondaparinux (unless high bleeding risk or immediate angiography)
N – Nitrate (GTN)
Do you give oxygen to manage an MI?
NO - only if sats drop below 95% (non-COPD pts)
How to determine if a NSTEMI is for immediate angiography?
if unstable –> GRACE score (6 month probability of death after having NSTEMI)
<3% - low risk
>3% med to high risk
3 main ways for ongoing management for ACS?
Echo
Cardiac rehab
secondary prevention
What is the secondary prevention with someone with ACS?
6As
Aspirin 75mg once daily indefinitely
Another Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months
Atorvastatin 80mg once daily
ACE inhibitors (e.g. ramipril) titrated as high as tolerated
Atenolol (or another beta blocker – usually bisoprolol) titrated as high as tolerated
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
What must you monitor when patients are on ACE inhibitors or aldosterone antagonists?
bloods for potassium
can cause hyperkalaemia (can be fatal)
